Infertility in an Otherwise Healthy Couple – What Steps Should Be Taken?

Mrs. D, a 36-year-old G0, comes in for a fertility evaluation. She and her husband have been attempting to conceive with regular unprotected intercourse for six months with no pregnancy. Mrs. D is uncertain about whether their timing is appropriate for conception. Her menstrual cycles average every 28 to 32 days, with no pain and a moderate-to-light cycle flow. 

HISTORY
Mrs. D is well groomed and conversant. Her past medical history is uneventful for conditions affecting fertility. She takes no medications. No history of STDs. One previous sexual partner.

EXAMINATION
On physical examination, Mrs. D’s vital signs were BP: 110/60; pulse 74bpm. She is 5’7” tall and weighs 140lbs.

ROS:
HEENT: NL
Thyroid: NL
Chest:
   Heart: RRR
   Lungs: CTA bilaterally
Abdomen:
   Soft;  + bowel sounds
External genitalia:
   Vulva: NL
   Vagina: Normal rogation; moderate clear/physiologic discharge
   Cervix: Clear
   Uterus: Anteverted, non-tender, mobile
   Adnexa: Ovaries palpable, normal

ASSESSMENT   
Normal physical exam. Mrs. D’s menstrual cycles are normal and painless, suggesting ovulation. No symptoms of endometriosis are noted. Possible infertility (Woman >35yrs attempting pregnancy for six months).

TREATMENT PLAN
Timing of ovulation (typically 14 days BEFORE onset of menses – for Mrs. D, Day 14 to 18.) is discussed with Mrs. D. She is informed that conception generally occurs due to coitus before ovulation. A semen analysis is suggested for her husband. Day 3 FSH, AMH, and TSH tests are ordered. Mrs. D is prescribed to continue taking folic acid 1mg and to return to the clinic in three weeks to evaluate the lab test results.

Continue to Mr. D’s fertility evaluation and to view Mrs. D’s lab test results.