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  • Print publication year: 2009
  • Online publication date: May 2010

Chapter 19 - Evaluation of female infertility for the non-gynecologist


An evaluation of the reproductive endocrine status is an essential component in the investigation of all male partners with either an abnormal physical examination suggestive of a disorder in testosterone production and action, an abnormal semen examination, or evidence of impaired sexual function. Initial laboratory assessment of the hypothalamic- pituitary-testicular axis includes the measurement of circulating levels of LH, FSH, and testosterone. The differential diagnosis and treatment of endocrine- dependent male-factor infertility is based on the history, physical examination, and reproductive hormone levels. Hypogonadotropic hypogonadism, also referred to as secondary hypogonadism, can occur as the congenital condition idiopathic hypogonadotropic hypogonadism (IHH). Androgen receptor abnormalities are rarely amenable to hormone therapy. Testosterone replacement therapy available in the United States includes oral, intramuscular, transdermal, and buccal preparations. A number of non-FDA-approved drugs and supplements are marketed as alternative therapies for declining androgens and decreasing libido and potency in older men.


[1] GuttmacherAF. Factors affecting normal expectancy of conception. JAMA 1956; 161: 855–60.
[2] CollinsHA. Unexplained infertility. In: KeyWR, ChangRJ, RebarRW, SoulesMR, eds. Infertility: Evaluation and Treatment. Philadelphia, PA: Saunders, 1995: 249–62.
[3] World Health Organization. Recent advances in medically assisted conception. World Health Organ Tech Rep Ser 1992; 820: 1–111.
[4] American Society for Reproductive Medicine. Optimal evaluation of the infertile female: a Practice Committee report. Birmingham, AL: ASRM, 2000.
[5] BarbieriRL. Female infertility. In: StraussJF, BarbieriRL, eds. Yen & Jaffe’s Reproductive Medicine Endocrinology. St. Louis, MO: Saunders, 2004: 633–88.
[6] LeridonH, SpiraA. Problems in measuring the effectiveness of infertility therapy. Fertil Steril 1984; 41: 580–6.
[7] EversJ. Female subfertility. Lancet 2002; 360: 151–9.
[8] Centers for Disease Control, and Prevention. 2004 Assisted Reproductive Technology Success Rates: National Summary and Fertility Clinic Reports. Atlanta, GA: CDC, US Department of Health and Human Services, 2006.
[9] ZinamanMJ, CleggED, BrownCC, O’ConnorJ, SelevanSG. Estimates of human fertility and pregnancy loss. Fertil Steril 1996; 65: 503–9.
[10] SteinZ. A woman’s age, childbearing and child rearing. Am J Epidemiol 1985; 121: 327–42.
[11] MetcalfM. Incidence of ovulatory cycles in women approaching the menopause. J Biosoc Sci 1979; 11: 39–48.
[12] MenkenJ, TrussellJ, LarsenU. Age and infertility. Science 1986; 233: 1389–94.
[13] TietzeC. Reproductive span and rate of reproduction among Hutterite women. Fertil Steril 1957; 8: 89–97.
[14] SchwartzD, MayauxMJ. Female fecundity as a function of age: results of artificial insemination in 2193 nulliparous women with azoospermic husbands. Federation CECOS. N Engl J Med 1982; 306: 404–6.
[15] BalmacedaJ, BernardiniL, CiuffardiI, et al. Oocyte donation in humans: a model to study the effect of age on embryo implantation rate. Hum Reprod 1994; 9: 2160–3.
[16] BattagliaD, KleinNASoulesMR. Changes in centrosomal domains during meiotic maturation in the human oocyte. Mol Hum Reprod 1997; 2: 845–51.
[17] BattagliaD, GoodwinP, KleinN, SoulesM. Influence of maternal age on meiotic spindle assembly in oocytes from naturally cycling women. Human Reprod 1996; 11: 2217–22.
[18] PellestorF, AndreoB, ArnalF, HumeauC, DemailleJ. Maternal aging and chromosomal abnormalities: New data drawn from in vitro unfertilized human oocytes. Hum Genet 2003; 112: 195–203.
[19] PlatteauP, StaessenC, MichielsA, et al. Preimplantation genetive diagnosis for aneuploidy screening in women older than 37 years. Fertil Steril 2005; 84: 319–24.
[20] HookE. Rates of chromosomal abnormalities at different maternal ages. Obstet Gynecol 1981; 58: 282–5.
[21] de La RochebrochardE, de MouzonJ, ThepotF, ThonneauP, French National Ivf Registry (FIVNAT) Association. Fathers over 40 and increased failure to conceive: the lessons of in vitro fertilization in France. Fertil Steril 2006; 85: 1420–4.
[22] YenSSC, TsaiCC, NaftolinF, VandenBergG, AjaborL. Pulsatile patterns of gonadotropin release in subjects with and without ovarian function. J Clin Endocrinol Metab 1972; 34: 671.
[23] KleinN, BattagliaD, FujimotoV, et al. Reproductive aging: accelerated follicular development associated a monotropic follicle stimulating hormone rise in normal older women. J Clin Endocrinol Metab 1996; 81: 1038–45.
[24] JordanJ, CraigK, CliftonDK, SoulesMR. Luteal phase defect: the sensitivity and specificity of diagnostic methods in common clinical use. Fertil Steril 1994; 62: 54–62.
[25] JohnsonN, VandekerckhoveP, WatsonA, et al. Tubal flushing for subfertility. Cochrane Database Syst Rev 2005; (2): CD003718.
[26] JohnsonNP, FarquharCM, HaddenWE, et al. The FLUSH trial: flushing with lipiodol for unexplained (and endometriosis-related) subfertility by hysterosalpingography. A randomized trial. Hum Reprod 2004; 19: 2043–51.
[27] StrandellA, WaldenstromU, NilssonL, HambergerL. Hydrosalpinx reduces in-vitro fertilization/embryo transfer pregnancy rates. Hum Reprod 1994; 9: 861–3.
[28] CamusE, PonceletC, GoffinetF, et al. Pregnancy rates after in-vitro fertilization in cases of tubal infertility with and without hydrosalpinx: a meta-analysis of published comparative studies. Hum Reprod 1999; 14: 1243–9.
[29] GomelV, McCombPF. Microsurgery for tubal infertility. J Reprod Med 2006; 51: 177–84.
[30] JohnsonNP, MakW, SowterMC. Surgical treatment for tubal disease in women due to undergo in vitro fertilisation. Cochrane Database Syst Rev 2001; (3): CD002125.
[31] Braun-QuentinC, BillesC, BowingB, KozotD. MURCS association: case report and review. J Med Genet 1996; 33: 618–20.
[32] GougeonA, EcochardR, ThalabardJ. Age-related changes of the population of human ovarian follicles: increase in the disappearance rate of non-growing and early-growing follicles in aging women. Biol Reprod 1994; 50: 653–63.
[33] RichardsonS, SenikasV, NelsonJ. Follicular depletion during the menopausal transition: Evidence for accelerated loss and ultimate exhaustion. J Clin Endocrinol Metab 1987; 65: 1231–7.
[34] LentonE, LandgrenB, SextonL, HarperR. Normal variation in the length of follicular phase of the menstrual cycle: effect of chronological age. Br J Obstet Gynaecol 1984; 91: 681–4.
[35] LeeS, LentonE, SextonL, CookeI. The effect of age on the cyclical patterns of plasma LH, FSH, oestradiol and progesterone in women with regular menstrual cycles. Hum Reprod 1988; 3: 851–5.
[36] ChangMY, ChiangCH, HseihTT, SoongYK, HsuKH. Use of the antral follicle count to predict the outcome of assisted reproductive technologies. Fertil Steril 1998; 69: 505–10.
[37] FrattarelliJL, Lauria-CostaDF, MillerBT, BerghPA, ScottRT. Basal antral follicle number and mean ovarian diameter predict cycle cancellation and ovarian responsiveness in assisted reproductive technology cycles. Fertil Steril 2000; 74: 512–17.
[38] SchipperI, de JongFH, FauserBC. Lack of correlation between maximum early follicular phase serum follicle stimulating hormone concentrations and menstrual cycle characteristics in women under the age of 35 years. Hum Reprod 1998; 13: 1442–8.
[39] van RooijIA, BancsiLH, BroekmansFJ, et al. Women older than 40 years of age and those with elevated follicle-stimulating hormone levels differ in poor response rate and embryo quality in in vitro fertilization. Fertil Steril 2003; 79: 482–8.
[40] TanboT, DalePO, LundeO, NormanN, AbyholmT. Prediction of response to controlled ovarian hyperstimulation: a comparison of basal and clomiphene citrate-stimulated follicle-stimulating hormone levels. Fertil Steril 1992; 57: 819–24.
[41] LockwoodG. The diagnostic value of inhibin in infertility evaluation. Semin Reprod Med 2004; 22: 195–208.
[42] VisserJA, de JongFH, LavenJS, ThemmenAP. Anti-Mullerian hormone: a new marker for ovarian function. Reproduction 2006; 131: 1–9.
[43] Scheffer, GJ, Broeksmans, FJ, DorlandM, et al. Antral follicle counts by transvaginal ultrasonography are related to age in women with proven natural fertility. Fertil Steril 1999; 72: 845–51.
[44] KweeJ, SchatsR, McDonnellJ, LambalkCB, SchoemakerJ. Intercycle variability of ovarian reserve tests: Results of a prospective randomized study. Hum Reprod 2004; 19: 590–5.
[45] NahumR, ShifrenJL, ChangY, et al. Antral follicle assessment as a tool for predicting outcome in IVF: is it a better predictor than age and FSH? J Assist Reprod Genet 2001; 18: 151–5.
[46] BancsiLF, BroekmansFJ, EijkemansMJ, et al. Predictors of poor ovarian response in in vitro fertilization: A prospective study comparing basal markers of ovarian reserve. Fertil Steril 2002; 77: 328–36.
[47] El-ToukhyT, KhalafY, HartR, TaylorA, BraudeP. Young age does not protect against the adverse effects of reduced ovarian reserve: an eight year study. Hum Reprod 2002; 17: 1519–24.
[48] HendriksDJ, MolBW, BancsiLF, te VeldeER, BroekmansFJ. Antral follicle count in the prediction of poor ovarian response and pregnancy rate after in vitro fertilization: a meta-analysis and comparison with basal follicle-stimulating hormone level. Fertil Steril 2005; 83: 291–301.