Action 2: Causes and Outcomes


2. Outline causes and outcomes: The PCP should outline the causes of the infertility based on history, physical examination and available diagnostic tests. Treatment resources should be explained to the patient along with potential outcomes, which should be quantified where possible.

In order to advise on treatment, service providers should be familiar with common causes of infertility and their impact on the likelihood of pregnancy and birth within two or three years. In 20 follow-up studies involving more than 14,000 infertile couples, who had only non-ART treatments, the average likelihood of live birth was 31% (Collins and Van Steirteghem, 2004).

The three most common causes of infertility are problems with ovulation, sperm quality and tubal patiency (The Male Infertility Best Practice Policy Committee of the American Urological Association and Practice Committee of the American Society for Reproductive Medicine, 2006; ASRM, 2012c). It is less clear how endometriosis and peritubal adhesions might cause infertility. In a small fraction of couples, severe endometriosis and extensive tubal adhesions may distort the relationship between ovarian follicles and tubal fimbria (Giudice and Kao, 2004). Although abnormal production of cervical mucus could cause infertility, the associated diagnostic test (postcoital test) is no longer recommended (ASRM, 2012c). While large fibroids can distort the uterine cavity, fibroids and congential abnormalities of the uterus are uncommon causes of infertility. Their importance can be evaluated by means of a hysterosalpingogram when that test is available (ASRM, 2012c). In some couples more than one apparent cause of infertility may exist.

Common abnormalities associated with infertility
Infrequent or absent menses indicating problems with ovulation
Low sperm count or low sperm motility or abnormal sperm shape
Fallopian tube obstruction or adhesions surrounding the tube
Severe endometriosis

Even after a complete diagnostic assessment, however, reasons for the infertility may not be found. Thus, unexplained infertility may be a common diagnosis (Maheshwari, 2008). Where fewer tests are available to be done, it follows that more couples will fall into the unexplained category.

Without treatment, the likelihood of pregnancy within two or three years is close to zero when there is complete lack of ovulation, absence of sperm, or tubal obstruction. When ovulation does occur, but infrequently, or when there is tubal patency despite the presence of tubal disease such as adhesions, pregnancy rates are lower than in normal couples but still more than 20% within one year, which is far from zero (Hunault, 2004). Also, if sperm are present but the count is below normal, if the sperm have low motility or abnormal shape, average pregnancy rates are also lower than in normal couples but again far from zero (Hunault, 2004).

With unexplained infertility, mild endometriosis and mild oligospermia, live birth rates over two to three years are similar to the 31% average rates noted above (Collins and Van Steirteghem, 2004; ASRM,2012c). Mild endometriosis, if suspected, can generally be treated in a similar fashion to unexplained infertility, although the relationship of endometriosis to infertility is complex and poorly understood. Patients often also suffer from pelvic pain. (Johnson, 2013) (Dunselman, 2014) In all types of infertility, age of the female partner, previous pregnancy and duration of infertility affect pregnancy rates.