UBC Objectives: Maternity Care & Priority Topic: Infertility

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Educate and arrange initial investigations regarding infertility and difficulties conceiving
• Provide counselling around the potential for emotional, psychological, and financial stress associated with infertility and infertility treatment, and the potential subsequent effects on pregnancy
  

Key Feature 2: In patients with fertility concerns, provide advice that accurately describes the likelihood of fertility.
Skill: Clinical Reasoning
Phase: Treatment

Key Feature 3: With older couples who have fertility concerns, refer earlier for investigation and treatment, as their likelihood of infertility is higher.
Skill: Clinical Reasoning, Selectivity
Phase: Hypothesis generation, Referral

Key Feature 4: When choosing to investigate primary or secondary infertility, ensure that both partners are assessed.
Skill: Clinical Reasoning
Phase: Hypothesis generation

Key Feature 5: In couples who are likely infertile, discuss adoption when the time is right. (Remember that adoption often takes a long time.)
Skill: Patient Centered, Clinical Reasoning 
​Phase: Treatment

Key Feature 6: In evaluating female patients with fertility concerns and menstrual abnormalities, look for specific signs and symptoms of certain conditions (ex: polycystic ovarian syndrome, hyperprolactinemia, thyroid disease) to direct further investigations (ex: prolactin, thyroid-stimulating hormone, and luteal phase progesterone testing).
Skill: Clinical Reasoning
Phase: Hypothesis generation, History

Isn't it just the loveliest thing - being a hard-working and career-driven woman in medicine -  receiving regular reminders that while I slave away my eggs are eroding inside of me. This graphic information is best demonstrated in a graph, such as this one put out by the Society of Obstetricians and Gynaecologists of Canada (SOGC):

Over the next decade of my life, my fertility will drop precipitously. Fertility treatments help to offset this somewhat, for those who can afford their exceedingly prohibitive costs (it costs between $12,000 and $18,000 for a single cycle of in-vitro fertilization, as I learned today). However, not infrequently fertility treatments aren't successful and also can perpetuate psychological and emotional stress beyond financial hardship. For patients who present with concern about being able to conceive, it is important to be honest about the fertility trajectory, and the possibility that delaying having a family may mean never having a genetically same one. (If assisted reproductive techniques are not desirable, possible, or feasible, patients may consider adoption. An overview of the adoption process in Canada is provided by the Adoption Council of Canada. Consider dropping this seed early when options regarding assisted reproduced technology are first discussed. It does take some time to jump through the various steps to adopt a child, and it is probably best that patients are aware of this sooner rather than later so they can start contemplating if it would be a good fit for their family.)

The drop in fertility with age also means we have to put up an earlier fight depending on just how old the female who is trying to conceive is. Accepted medical practice is to evaluate couples for infertility according to the following guidelines:

If a woman is having irregular menstrual cycles, or one of the other reasons to initiate evaluation for infertility despite 6 months of unprotected and frequent intercourse (see table above), a more immediate workup is indicated. At this initial visit, if a woman presents with a history of oligomenorrhea or amenorrhea, then signs and symptoms to look for that could suggest an underlying disease process include elevated BMI and signs of androgen excess (hirsutism, acne, male pattern baldness, muscle bulk, deep voice). Although it would be thorough to look for signs of hyperprolactinemia and thyroid disease as well (galactorrhea, goiter, tachycardia, proptosis, etc.), in a woman presenting with concern about infertility and who has oligomenorrhea, I would assess for hyperprolactinemia and thyroid disease regardless of how the patient presented clinically. I would also test estrogen on day 3 of the woman's cycle and a mid-cycle progesterone level to see if she is ovulating.

While the instinct when assessing a women with infertility might be to consider what could be going awry within her body, it is important to remember that it takes two people and all of their necessary associated organs to make a baby. Fertility is complex, and requires a lot of working parts. On the flipside, infertility is also a common problem, which actually makes a lot of sense when you think of all of the parts that can get rusty. Always remember that when one person presents to clinic with a concern about not being able to get pregnant, there could be an issue with any of a number of their AND/OR THEIR PARTNER'S parts. With a complaint of infertility, the patient is the couple.