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Case History

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Image not available. A 32-year-old woman attends clinic along with her partner. She is worried that after twelve months of trying, she has not become pregnant. Her cycle is fairly regular (every 29–32 days). Her only significant medical history is an episode of pelvic inflammatory disease (PID) seven years ago. Her partner is aged 33 years and is fit and well.

What would you advise them about the timing of intercourse?

How would you counsel them about the likelihood of a spontaneous conception?

What factors in the history would prompt you to investigate early?

What are the appropriate and relevant investigations?

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Background

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Image not available. Infertility may be defined as failure to conceive after two years despite frequent sexual intercourse. One in seven couples encounter problems with their fertility.1

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What would you advise them about the timing of intercourse?

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Questions as to the frequency of sexual intercourse should be asked. Intercourse every two or three days may improve the chance of spontaneous conception because sperm can survive for up to seven days in the female genital tract.2 Regular intercourse rather than timed intercourse should be advised because timed intercourse has been found to be emotionally stressful for couples.

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How would you counsel them about the likelihood of a spontaneous conception?

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The couple should be informed that although 84% of people who are trying to conceive will do so in one year, the cumulative pregnancy rate after two years of trying is 92%.3

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What factors in the history would prompt you to investigate early?

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Current guidelines suggest that, for most couples, investigation into infertility should begin after two years.1 There are, however, situations where early investigation is appropriate (Table 18.1).

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Table Graphic Jump Location
Table 18.1Reasons to prompt early referral for investigation into infertility
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Early investigation of tubal patency is appropriate in a woman with a history of pelvic inflammatory disease. It is also appropriate in women with specific risk factors for ovarian failure, such as previous chemotherapy during treatment for cancer. Other factors in the history that may prompt early investigation are a history of oligomenorrhoea, amenorrhoea or other clinical signs of polycystic ovary syndrome.

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Female fertility is known to decline significantly with age, especially after 35 years of age. In addition, the success rates of assisted reproduction methods decline steadily with age.4 Data have suggested that the average prevalence of infertility is 5.5% at ages 25–29 years, 9.4% at ages 30–34 and 19.7% at ages 35–39.5 Thus, investigation after one year of infertility may be appropriate in ...

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