Infertility in Primary Care: A Practical Guide With Dr. Brindha Bavan

Defining and Understanding Infertility

• 🎯 Infertility is defined as the inability to conceive after 12 months of regular, unprotected intercourse for women under 35, or six months for those 35 and older.
• ⚠️ This definition is adjusted for medical conditions impacting fertility, such as PCOS or ovulatory dysfunction, allowing for earlier intervention.
• 💡 A more inclusive definition acknowledges the need for donor gametes for same-sex couples or single parents, emphasizing that everyone deserves help building a family.
• 📈 Approximately 12-15% of couples, or about one in six to one in eight, face infertility, a common issue that is often underdiagnosed due to patient reluctance to discuss it.

Male Factor Infertility Workup

• 🔬 The initial step for the male partner is a semen analysis, ideally after 2-5 days of abstinence, assessing volume, concentration, motility, and morphology.
• ⚠️ Sexual function issues like erectile or ejaculatory dysfunction are not directly correlated with semen analysis results and require specific patient history to assess.
• 🧬 Beyond semen analysis, a thorough medical history, screening for chronic conditions, surgeries, and medications is crucial, with optional preconception genetic carrier screening available.
• 💡 Lifestyle factors such as avoiding tobacco, marijuana, excessive alcohol, and heat exposure to the testes are important considerations.

Female Factor Infertility Evaluation

• 🔄 An anatomical approach is used, examining the vagina, cervix, uterus (for fibroids, polyps, or anomalies), fallopian tubes (for patency), and ovaries (for ovulation and egg quality).
• 🥚 Ovarian reserve is assessed through Anti-Müllerian Hormone (AMH) levels and antral follicle count (AFC) via transvaginal ultrasound, with FSH and estradiol levels checked around cycle day three.
• ⚠️ Shorter cycles might prompt thyroid function tests, while longer cycles may warrant prolactin checks; PCOS is diagnosed using Rotterdam criteria.
• 🩺 For patients with regular cycles, AMH, cycle day three FSH/estradiol, and AFC are key initial tests, while HSG (hysterosalpingogram) is crucial for assessing uterine and tubal patency.

Treatment Options and Unexplained Infertility

• 🧩 Unexplained infertility is diagnosed when all initial tests are reassuring, affecting about one-third of infertile couples.
• 🚀 First-line treatment for unexplained infertility is often superovulation with IUI (intrauterine insemination), typically attempted for three to six cycles.
• 🧬 For patients planning multiple children or with concerns about declining egg quality with age, IVF (in vitro fertilization) may be considered earlier to bank embryos.
• 📊 Success rates for IUI range from 8-15% per cycle, while IVF success is age-dependent, with all-comer rates around 30% per cycle.

Navigating Costs and Access to Care

• 💰 The high cost of fertility treatments is a significant barrier, with many patients incurring debt; coding medical diagnoses correctly is vital for insurance coverage.
• 🏥 System-level changes, such as mandated infertility coverage by states, are crucial for improving access.
• 🗣️ Primary care providers can support patients by screening for infertility, normalizing the conversation, and providing initial workup, thereby facilitating a smoother transition to specialists.
• ❄️ Fertility preservation options like egg or embryo freezing should be discussed, especially for individuals in their early to mid-30s considering future family building.