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Figure 4-1

Changes in the ovarian follicle, endometrial thickness, and serum hormone levels during a 28-day menstrual cycle. P, progesterone; E2, estradiol; LH, luteinizing hormone; FSH, follicle-stimulating hormone. (Used with permission from Hoffman BL, et al. Chapter 15. Reproductive endocrinology. In: Hoffman BL, et al., eds. Williams Gynecology. 2nd ed. New York, NY: McGraw-Hill; 2012)

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  • Infertility: Inability to conceive after 1 year of frequent unprotected intercourse (evaluation recommended after 6 months if age is over 35)

  • Primary Infertility: When a woman has never been pregnant

  • Secondary Infertility: Infertility after a prior pregnancy




  • Affects 7% of married couples in which female partner is of reproductive age

  • One-year prevalence of infertility is approximately 15%

  • Infertility affects men and women equally

    • 20% of infertility cases can be attributed to male factors

    • 38% of infertility cases can be attributed to female factors

    • 27% of infertility cases combined male/female

    • 15% are unexplained

  • Infertility and childlessness increase with age (Table 4-1)

  • Risk of spontaneous abortion (SAB) also increases with age (Table 4-2)

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Table Graphic Jump Location



Male Factor Infertility


  • Incidence: 20%

  • Etiology

    • Hypothalamic pituitary disease (secondary hypogonadism): 1–2%

      • Mechanism: Deficiency of GnRH or gonadotropin

      • Congenital: Kallman syndrome, Prader–Willi syndrome

      • Acquired: Pituitary/Hypothalamic tumors, sarcoidosis, tuberculosis (TB), trauma, aneurysm, infarction, hyperprolactinemia, estrogen or cortisol excess, medications

      • Systemic: Chronic illness, nutritional deficiency, obesity

    • Primary Hypogonadism: 30–40%

      • Congenital: Klinefelter syndrome, cryptorchidism, androgen insensitivity

      • Acquired: Varicocele, orchitis, medication (alcohol, tetrahydrocannibol (THC), ketoconazole, spironolactone, histamine antagonists, calcium-channel blockers, steroids), environmental toxins, trauma, torsion, systemic illness (renal failure, cirrhosis, cancer, sickle cell)

    • Post-testicular defects (disorders of sperm transport): 10–20%

      • Congenital: Absence of vas deferens (check for Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) mutation)

      • Acquired: Infection, spinal cord disease, erectile dysfunction, premature ejaculation, retrograde ejaculation, vasectomy

      • Obstruction: Benign prostatic hyperplasia (BPH), infection, and scarring

    • Unexplained: 40–50%

  • Evaluation: Semen ...

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