FACTS OF LIFE:

INFERTILITY FOR THE PRIMARY CARE PROVIDER

Supplemental handout to infertility.machealth.ca online program.

DEFINITION
One year of frequent, unprotected intercourse
during which time pregnancy has not occurred.
OR
Loss of 3 or more consecutive pregnancies.
PREVALENCE
Currently estimated to be between 11 and 16%.
PRECONCEPTION
Ensure immunizations are up to date.
(including rubella, pertussis, varicella, HepB, influenza)
Optimize treatment of any medical conditions.
(such as diabetes, hypothyroidism)
Review all medications and adjust those with
teratogenic risks.
(consult www.Motherisk.org as necessary)
Ensure Pap is up to date and perform swabs if
necessary.
Advise use of folic acid 0.4-1 mg a day.

CAUSES HISTORY
Couple
Cause may be with female partner, male
partner, both partners or indeterminant. History:
Previous fertility, STIs, genetic disease,
Female abdominal surgery, medications, environmental
• Ovulatory dysfunction exposure, menstrual history (females), history of
(polycystic ovarian syndrome (PCOS), premature mumps (males).
ovarian failure, endocrine disorders)
• Tubal obstruction Address lifestyle issues:
• Endometriosis Smoking, alcohol, substance abuse, obesity,
• Uterine/Cervical exercise.
(fibroids, polyps)
Counsel:
Male
Screen for any genetic disease specific to patient
• Altered sperm production
background (such as sickle cell, thalassemia, Tay-Sachs
• Altered sperm transport
disease) or to family history (such as cystic fibrosis).
• Structural abnormalities

Facts of Life: Infertility for the Primary Care Provider.

July 14, 2014, Version 1 © Risa Bordman and Deanna Telner, July 2014.
A course presented by machealth.ca, the Division of e-Learning Innovation, McMaster University, and the Ontario College of Family Physicians.
With support by the Government of Ontario.
PHYSICAL
Female Male
• Androgen excess (hirsutism, acne) • Androgen deficiency
• Breast development (↑body fat, ↓muscle mass/hair, small testes)
• Galactorrhea • Varicocele
• Thyroid • Testicular mass
• Abdomen • Digital rectal exam if prostatitis
• Pelvic (with Pap if due soon)

INVESTIGATIONS
Order bloodwork/investigations specific to
findings on history and exam.
Male:
Order one semen analysis taken directly to the
examining laboratory.
If oligospermia, sexual dysfunction or physical
findings of hypogonadism, order serum FSH
and testosterone.
If abnormal testicular exam order scrotal
ultrasound.
Female
Determine if ovulating by history.
Use luteal phase progesterone only if unsure
(>30 nmol/L indicates ovulatory cycles).
If not ovulating order FSH, free testosterone,
17αhydroxyprogesterone, TSH, and prolactin.
If ovulating order pelvic ultrasound and tubal
imaging to determine structural abnormalities.
TREATMENT
Treat any condition found in work-up for
infertility. For conditions not stated below, refer.
Male:
If abnormal semen analysis prescribe vitamin E
300-600 mg/day and zinc 500 mg/day.
Female:
If ovulatory dysfunction may prescribe
clomiphene citrate 50-100mg PO day 5-9.
If oligomenorrhea induce a withdrawal bleed
with Medroxyprogesterone 5-10 mg PO for 5-10
days.
Refer to local fertility centres for Assisted
Reproductive Technology therapies, if couple is
interested in pursuing this option.

KEY POINTS
Advancing maternal age is the most important risk factor for infertility.
•  Counsel women in their early 20s about risks of delay.
•  Advancing maternal age is associated with obstetrical and fetal risks too.
•  Advancing paternal age is associated with some health risks too.
The prevalence of infertility is 15%.
The cause of infertility is 1/3 female, 1/3 male, 1/3 both.
Counsel couple together and begin the work-up simultaneously.
Ovulatory dysfunction is the most common female cause of infertility and the easiest to treat.
•  Many will respond to oral clomiphene citrate.
Abnormal semen analysis can be treated with antioxidants (vitamin E and zinc)
Refer early if endometriosis, abnormal tests or not responding to treatment.
The primary care provider is the ideal clinician to provide ongoing emotional support to the couple.