Optimising the management of patients with infertility.

The main causes of infertility are female factor (anovulation, tubal damage, endometriosis and ovarian failure), male factor (low or absent numbers of motile sperm in the ejaculate, and erectile dysfunction), or unexplained infertility. More than 80% of couples will conceive within one year if the woman is aged under 40 and they have regular sexual intercourse. Of those who fail to conceive in the first year, around half will do so in the second year, giving a cumulative pregnancy rate > 90%. A woman of reproductive age who has not conceived after a year of regular sexual intercourse, and has no known cause of infertility, should be offered referral for further clinical assessment and investigation with her partner. Women who have a BMI > or = 30 are likely to take longer to conceive. Those with a BMI < 19 who have irregular or absent menstruation should be advised that putting on weight is likely to improve their chance of conception. The best test of ovulation is an appropriately timed mid-luteal serum progesterone level. Women with irregular or absent menstrual cycles should be offered a blood test to measure serum gonadotrophin levels (FSH and LH). Women with no known comorbidities should be screened for tubal occlusion. Those who are thought to have comorbidities should be offered laparoscopy and dye testing.