Model Answer
0 min readIntroduction
Infertility, defined as the inability to achieve a clinical pregnancy after 12 months of regular, unprotected sexual intercourse, affects approximately 15% of couples globally. Understanding the distinction between primary and secondary infertility is crucial for appropriate diagnosis and management. While both represent challenges in achieving pregnancy, their underlying causes and investigative pathways can differ. This answer will define both types of infertility and outline a comprehensive investigative approach for a case presenting with primary infertility, adhering to current best practices in reproductive medicine.
Defining Primary and Secondary Infertility
Primary Infertility refers to the inability to conceive after 12 months of regular, unprotected intercourse in couples who have *never* been able to achieve a pregnancy. This implies that neither partner has a history of prior conception.
Secondary Infertility, conversely, describes the inability to conceive after 12 months of regular, unprotected intercourse in couples who *have* previously conceived and carried a pregnancy to viability, regardless of the outcome (live birth, miscarriage, ectopic pregnancy).
Investigating a Case of Primary Infertility
A systematic approach is essential when investigating primary infertility. This involves a detailed history, physical examination, and a series of investigations for both partners.
1. History Taking
- Menstrual History (Female): Cycle regularity, duration, flow, dysmenorrhea, and any history of abnormal bleeding.
- Sexual History (Both): Frequency of intercourse, timing relative to ovulation, use of lubricants, and history of sexually transmitted infections (STIs).
- Past Medical History (Both): Chronic illnesses (diabetes, thyroid disorders, autoimmune diseases), surgeries, medications, and allergies.
- Obstetric History (Female): Although primary infertility implies no prior pregnancy, inquire about any history of ectopic pregnancy or miscarriage.
- Family History (Both): History of infertility, early menopause, genetic disorders, or recurrent miscarriages.
- Lifestyle Factors (Both): Smoking, alcohol consumption, caffeine intake, diet, exercise, and stress levels.
2. Physical Examination
- General Physical Examination (Both): Assess overall health status and identify any signs of underlying medical conditions.
- Pelvic Examination (Female): Assess the uterus, ovaries, and fallopian tubes for any abnormalities (fibroids, endometriosis, adhesions).
- Male Genital Examination (Male): Assess the testes, epididymis, and vas deferens for any abnormalities (varicocele, undescended testes).
3. Investigations – Female Partner
- Hormonal Assessment:
- FSH, LH, Estradiol (Day 2-5 of menstrual cycle): To assess ovarian reserve and function.
- Prolactin: Elevated levels can inhibit ovulation.
- Thyroid Stimulating Hormone (TSH): Thyroid disorders can affect fertility.
- Anti-Mullerian Hormone (AMH): A marker of ovarian reserve.
- Transvaginal Ultrasound: To assess the uterus and ovaries for structural abnormalities (fibroids, polyps, cysts).
- Hysterosalpingography (HSG): An X-ray procedure to evaluate the patency of the fallopian tubes.
- Hysteroscopy: A procedure to visualize the uterine cavity and identify any abnormalities.
- Laparoscopy: A surgical procedure to visualize the pelvic organs and diagnose conditions like endometriosis or adhesions (usually reserved for cases where other investigations are inconclusive).
4. Investigations – Male Partner
- Semen Analysis: The cornerstone of male infertility evaluation. Assesses sperm count, motility, morphology, and volume. Requires at least two samples, several weeks apart.
- Hormonal Assessment:
- FSH, LH, Testosterone: To assess testicular function.
- Prolactin: Elevated levels can affect sperm production.
- Ultrasound of the Scrotum: To assess the testes and epididymis for any abnormalities (varicocele, hydrocele).
- DNA Fragmentation Test: Assesses the integrity of sperm DNA.
5. Additional Investigations (Considered based on initial findings)
- Karyotyping: To identify any chromosomal abnormalities.
- Immunological Tests: To assess for anti-sperm antibodies.
- Infectious Disease Screening: To rule out STIs.
Conclusion
Investigating primary infertility requires a thorough and systematic approach, encompassing detailed history taking, physical examination, and targeted investigations for both partners. The initial focus should be on non-invasive tests like hormonal assessments and semen analysis. Further investigations, such as HSG, hysteroscopy, and laparoscopy, are reserved for cases where the diagnosis remains unclear. A collaborative approach involving both partners and a multidisciplinary team (gynecologist, andrologist, endocrinologist) is crucial for optimal management and achieving a successful pregnancy.
Answer Length
This is a comprehensive model answer for learning purposes and may exceed the word limit. In the exam, always adhere to the prescribed word count.