Recallab › Question bank › Gynaecology › #50008
Infertility: definition and first steps
A 24-year-old woman attends with her husband because they have not conceived after seven months of regular unprotected intercourse. Her cycles are regular at 29 days. General and pelvic examination are normal and she has no history of pelvic infection, surgery or chronic illness. What is the most appropriate next step?
- correctA. Reassure the couple and review after 12 months of trying
- B. Send the husband for a semen analysis now
- C. Arrange a hysterosalpingogram
- D. Arrange a diagnostic laparoscopy and dye test
Explanation
Key fact
Infertility is 12 months of regular unprotected intercourse without conception - or 6 months if the woman is over 35.
Reassure and review after 12 months. She does not yet meet the definition of infertility, and investigating early only creates anxiety and cost.
Why
About 85% of couples conceive within 12 months of trying.
Roughly half of those still trying at 6 months will conceive in the next six.
She is 24, cycling regularly, and has no risk factor that would justify starting early.
Nothing in the history or examination points to tubal, ovulatory or uterine disease.
The correct advice is timing of intercourse, folic acid, and review at 12 months.
Most couples conceive inside the twelve months
Why not the others
- B. Semen analysis now — is the right first test once the couple qualifies - it is cheap and non-invasive - but they do not qualify at seven months.
- C. Hysterosalpingogram — is a tubal test used after the definition is met and semen analysis and ovulation have been assessed.
- D. Laparoscopy and dye — is invasive and needs anaesthesia. It is reserved for suspected endometriosis or adhesions, or for an abnormal HSG.
Remember
Twelve months, or six over thirty-five. The age cut-off is the only thing that shortens the wait.
Go deeper
Evaluate immediately, whatever the duration, if there is amenorrhoea or oligomenorrhoea, known tubal disease, prior pelvic infection or surgery, stage III-IV endometriosis, or a partner with known subfertility.
When the workup does begin, it runs in parallel: semen analysis, confirmation of ovulation, and tubal patency.
Williams Gynecology, 4th ed. (McGraw Hill, 2020); DC Dutta's Textbook of Gynecology, 9th ed. (Jaypee, 2023).