Table of contents


    • Fertility drops >32yo
    • Defined as inability to conceive after 1yr, but realistically


    • History
      • Previous surgery
      • Past PID
      • Past surgeries (
      • Thyroid (Thyroid binding globulin goes up, demand goes up)


    Female Partner
    1. Egg quality problem / Age / FSH
      • Age (decr at 35y and significantly after 40)
      • Check FSH at day 3: Normal is <10 mIU/L
      • Antral follicle counts (day 3-6)
      • Clomifene challenge test (100mg day 3-7 and check FSH on day 10)
        • Clomifene increases FSH by >50%
    2. Ovulation Defect
      • Menstrual Hx (cycle length etc... 24-35d normal)
      • Sx of ovulation: breast tenderness, moodiness, bloating
      • Basal Body Temperature
      • Serum Progesterone (to monitor ovulation induction)
      • Urine LH kits
      • PCOS: 2000-2500mg metformin, stop at 12 weeks because women with PCOS have high risk of first trimester loss
    3. Anatomical Problem
      • Do Hysterosalpingogram (HSG): tubal patency, contour of uterus, and 
      • sonohysterogram (SHG) U/S + saline
      • Hysteroscopy
    Male Partner
    1. Semen Analysis
    2. Hx or Surgery etc...
    3. Erectile Dysfunction
    4. Other: diabetes, HTN, medications (CCB, AntiCh, antideperssants)
    Intercourse Timing
    1. 2-3x/week
    2. Need to have sex mid-cycle
    3. Avoid lubricants, spermicides (egg white, canola oil ok
    1. Counselling
    2. Meds (clomiphene citrate vs gonadotropins), thyroid
    3. Intrauterine insemination
    4. IVF, IVF with intracytoplasmic sperm injection (ICSI), oocyte donation, sperm donation, embryo donation, gestational surrogate


    • Anovulation (irregular menses), testosterone signs (hair growth, acne, andogeneic alopecia), cystes in ovaries
    • PCOS causes abnormal GnRH secretion is changed leading to increase in LH, and low FSH.  LH causes theca cells to secrete androgens
    ...end of document
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