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MKSAP Quiz: Unable to achieve pregnancy

A 37-year-old woman is unable to achieve pregnancy despite 7 months of unprotected intercourse. Her menstrual cycles are normal, occurring every 28 days with associated breast tenderness and bloating. There have been no prior pregnancies or attempts to achieve pregnancy by either the patient or her male partner. Following a physical exam, what is the most appropriate management?


A 37-year-old woman is unable to achieve pregnancy despite 7 months of unprotected intercourse. Her menstrual cycles are normal, occurring every 28 days with associated breast tenderness and bloating. There have been no prior pregnancies or attempts to achieve pregnancy by either the patient or her male partner. There is no history of previous sexually transmitted infections. She is otherwise healthy.

Medical history is significant for appendicitis at age 26 for which she had an uncomplicated appendectomy. Her only medication is a prenatal vitamin.

On physical examination, vital signs are normal. She has a well-healed abdominal scar. Thyroid, skin, and pelvic examinations are all unremarkable. There is no elicitable breast discharge, no signs of hyperandrogenism, and no visual field cuts.

Which of the following is the most appropriate management?

A. Obtain midluteal phase serum progesterone level
B. Obtain semen analysis
C. Recommend an additional 5 months of unprotected intercourse
D. Refer for laparoscopy

Reveal the Answer

MKSAP Answer and Critique

The correct answer is B. Obtain semen analysis. This content is available to MKSAP 18 subscribers as Question 45 in the Endocrinology and Metabolism section. More information about MKSAP is available online.

When evaluating infertility, both female and male factors should be considered concurrently. Thus, semen analysis is part of the initial diagnostic evaluation. Collection should occur after 2 to 3 days of sexual abstinence, but no longer to avoid decreased sperm motility. If semen analysis is abnormal, it should be repeated at least 2 weeks later, and if results are abnormal, referral to a reproductive endocrinologist is recommended.

Given that this patient has regular menses every 28 days with molimina symptoms (breast pain and bloating), her cycles appear to be ovulatory. Thus, laboratory assessment of ovulatory function is not needed at this time. In patients who do not have normal menstrual cycles with ovulation, laboratory assessment should be performed. A midluteal phase serum progesterone level, obtained approximately 1 week before the expected menses, is an effective way to assess ovulatory status. A progesterone level above 3 ng/mL (9.5 nmol/L) is evidence of recent ovulation. Measurement of serum thyroid stimulating hormone and prolactin levels is appropriate to exclude thyroid disease and hyperprolactinemia as causes of oligo-ovulation.

In women over the age of 35 years, an infertility evaluation is initiated after 6 months of unprotected intercourse; in women under the age of 35, an infertility evaluation is initiated after 1 year of regular unprotected intercourse. Recommending an additional 5 months of unprotected intercourse is unnecessary for this 37-year-old woman.

Laparoscopy for evaluation of pelvic adhesions or mild endometriosis may be warranted in patients with dysmenorrhea, history of sexually transmitted infections, or previous pelvic surgery. While assessment of tubal patency may be indicated in this patient given her prior history of appendicitis and abdominal surgery (putting her at risk for adhesions), laparoscopy is not indicated at this immediate time prior to moving forward with an initial noninvasive diagnostic evaluation.

Key Point

  • When evaluating infertility, both female and male factors should be considered concurrently; semen analysis is part of the initial diagnostic evaluation.