April 2002 · Vol. 14, No. 47 easy steps to evaluating subfertility
Before selecting a treatment strategy, the clinician should quantify a couple’s potential for live birth. Two experts outline the steps.
IAN
TUMMON,
MD
DANIEL
A.
DUMESIC,
MDDr. Tummon is senior associate consultant, department of OBG, at the Mayo Clinic in Rochester, Minn. Dr. Dumesic is professor of OBG, Mayo Medical School, and consultant, section of reproductive endocrinology and infertility, and director of the reproductive endocrinology and infertility fellowship training program at Mayo Graduate School of Medicine, also in Rochester. Dr. Dumesic also serves on OBG Management’s board of editors.
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Key points
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Diagnostic categories of subfertility include oligospermia; azoospermia; minimal/mild or moderate/severe endometriosis; bilateral tubal occlusion; partial tubal defects; and unexplained subfertility.
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The duration of a couple’s subfertility, the age of the female partner, and whether the partnership has produced a prior pregnancy form the basis of their prognosis for live birth independent of treatment.
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If a couple fails to conceive within 3 to 6 treatment cycles after ovulation induction, further diagnostic evaluation is recommended.
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The accurate assessment by endometrial biopsy of luteal-phase sufficiency may be impossible in some women.
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In most cases, postcoital testing should be abandoned.
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A 35-year-old nullipara who has not conceived after 2 years of unprotected intercourse presents for treatment. Her primary desire—apart from becoming pregnant—is obtaining a truthful estimate of her prognosis. Obviously, that is our priority as well, since appropriate treatment can be determined only when the prognosis is clearly defined.
Of course, we informally estimate patients’ prognoses every day based on their history, physical examination, and laboratory studies. But when it comes to fertility—particularly when the woman is over 30 years of age—a quantified estimate is vital. Here, we outline the steps involved in evaluating a couple for “subfertility” and offer a model for predicting prognosis as precisely as possible. We base our recommendations on guidelines from the American Society for Reproductive Medicine (ASRM) and the American Urologic Association (AUA).1,2 We also searched Cochrane systematic reviews and MEDLINE English-language articles published between October 1, 1991, and October 1, 2001 (using the key words “infertility,” “prognosis,” and “diagnosis”), as well as the November 8, 2001, issue of the New England Journal of Medicine. The prediction model itself originated with Collins and colleagues and Snick et al.
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