Female infertility

Disease Description (Causes and Symptoms)

• Definition: Infertility refers to a condition in which pregnancy does not occur for more than 1 year despite maintaining regular sexual intercourse without contraception (occurring in approximately 10–15% of couples of reproductive age). If pregnancy has never occurred, it is called primary infertility; if there is a history of previous pregnancy, it is called secondary infertility.
• Main causes and pathophysiology
  • Ovulatory disorders (most common): Ovulation does not occur or is irregular due to polycystic ovary syndrome (PCOS), premature ovarian insufficiency, hyperprolactinemia, thyroid disease, and other conditions.
  • Tubal factors: Fallopian tube obstruction or dysfunction (pelvic inflammatory disease, adhesions after surgery for ectopic pregnancy, etc.).
  • Uterine and cervical factors: Endometriosis, uterine fibroids, congenital malformations, intrauterine adhesions, abnormalities of cervical mucus, etc.
  • Peritoneal and pelvic factors: Pelvic adhesions and inflammatory diseases (e.g., pelvic inflammatory disease).
  • Male factors (partner evaluation required): Abnormal sperm count, motility, or morphology.
  • Unexplained infertility: In some cases, the cause cannot be identified even after all tests have been performed.
• Main symptoms
  • Infertility itself (failure to become pregnant)
  • Menstrual abnormalities: Irregular menstruation, amenorrhea, heavy menstrual bleeding, etc.
  • Pelvic or abdominal pain (when there is an underlying cause such as endometriosis)
  • Other: Dyspareunia and abnormal vaginal discharge (infection-related)

Treatment Methods

• Diagnostic-based treatment principle: Identify the cause and then provide treatment according to the cause.
• Evaluation and diagnosis (summary)
  • Women: Blood hormone tests (follicular-phase FSH/LH, prolactin, TSH, luteal-phase progesterone, etc.), pelvic and ovarian ultrasound, hysterosalpingography (HSG) or tubal evaluation (laparoscopic evaluation in selected cases), and endometrial testing when necessary.
  • Men: Semen analysis (at least once, with two tests recommended).
• Medication treatment
  • Ovulation induction: Menopausal hormone analog (clomiphene), aromatase inhibitor (letrozole — the first-line recommended medication for patients with PCOS), follicle-stimulating hormone for ovulation stimulation (injectable medication).
  • Treatment of hormonal abnormalities: Correction of thyroid disease and hyperprolactinemia.
• Assisted reproductive technology (ART)
  • Intrauterine insemination (IUI): Performed for mild male-factor infertility or after ovulation induction.
  • In vitro fertilization (IVF)/ICSI: Indications include tubal obstruction, severe male-factor infertility, or failure of IUI.
  • Egg and sperm cryopreservation may be considered when fertility preservation is needed.
• Surgical treatment
  • Laparoscopic or hysteroscopic surgery: Correction of underlying causes, such as endometriosis, adhesiolysis, tubal reconstruction, and uterine fibroid removal.
• Conservative treatment and lifestyle management
  • Weight management: Correcting overweight or underweight (particularly important in PCOS).
  • Stop smoking, limit excessive alcohol consumption, exercise regularly, and manage stress.
  • Minimize environmental exposures (harmful chemicals, high temperatures, etc.).
• Precautions and risk of complications during treatment
  • Use of follicle-stimulating drugs increases the risk of ovarian hyperstimulation syndrome (OHSS) and multiple pregnancy.
  • Adhesions may recur after surgery.
  • ART can impose a significant financial and psychological burden, so psychosocial support is needed.
• Prognosis
  • Age dependence: The likelihood of natural pregnancy decreases with increasing age (fertility declines rapidly after age 35). Depending on age, diagnosis and treatment may need to be initiated earlier.

Checklist Before an Outpatient Visit (Including Sample Questions)

• Items and records to prepare
  • Duration of attempts (how many months/years since stopping contraception), and history of previous pregnancies or miscarriages (if applicable, the number and timing)
  • Menstrual cycle records from the past 6–12 months (cycle length, menstrual volume and pattern, signs of ovulation)
  • List of medications and supplements currently being taken (contraceptives, antipsychotic medications, anticancer drugs, etc.)
  • History of major surgery, pelvic infections, or sexually transmitted infections, and frequency of sexual intercourse and related problems (e.g., retrograde ejaculation)
  • Bring the partner's (husband's) semen analysis results, if available
  • Results of previous tests (hormone tests, ultrasound, HSG, etc.)
• Key information to provide to the doctor during the outpatient visit
  • Age (female and male), weight and BMI, smoking and alcohol history, and occupational exposure to substances
• Sample questions patients may want to prepare in advance
  • When did you start trying to become pregnant (the exact duration)?
  • What is your menstrual cycle like, and are there any notable features (irregularity, heavy bleeding, amenorrhea)?
  • Has the partner undergone semen analysis?

Examples of General Questions to Ask the Doctor

• What are the possible causes of this condition? Which tests should I have first?
• At my age, how long can I wait before undergoing evaluation and treatment? (e.g., the 1-year vs. 6-month 기준)
• What treatment options are recommended, and what are their success rates? What are the costs and side effects?
• What are the major side effects of medications such as letrozole and clomiphene?
• Which would be more suitable for my situation, intrauterine insemination (IUI) or in vitro fertilization (IVF)?
• Are there any lifestyle changes I should make immediately? (Weight, smoking, alcohol consumption, etc.)
• What complications may occur during treatment, and how should they be managed?

Examples of Condition-Specific Questions

• If menstruation is irregular: "My menstrual cycle is irregular. What tests should be performed to determine whether I am ovulating (a luteal-phase progesterone test, an ultrasound test for ovulation, or an ovulation test kit), and when should they be performed?"
• If tubal or uterine factors are suspected: "If tubal obstruction is confirmed, which would have a higher success rate and lower risk in my situation: surgical restoration (tubal reconstruction) or proceeding directly to IVF?"