# Clinical Cases: Infertility

## Case 1: Tubal Factor Infertility

### Clinical Image
![Hysterosalpingography](case_01_image.jpg)
*Source: [Wikipedia - Hysterosalpingography](https://en.wikipedia.org/wiki/Hysterosalpingography) - CC BY-SA 3.0*

### Case Presentation
A 33-year-old G0 woman and her husband present for infertility evaluation after 18 months of unprotected intercourse without conception. Her menstrual cycles are regular at 28-30 days, suggesting normal ovulation. She has no history of sexually transmitted infections that she is aware of, but she was treated for pelvic inflammatory disease at age 21 while in college. She has no chronic medical conditions. Her husband's semen analysis is normal. Mid-luteal progesterone is 12 ng/mL, confirming ovulation. Day 3 FSH is 7 mIU/mL and AMH is 2.8 ng/mL, indicating adequate ovarian reserve. Hysterosalpingography (HSG) is performed, demonstrating a normal uterine cavity but bilateral tubal occlusion with proximal blockage on the right and a dilated, club-shaped left tube consistent with hydrosalpinx. No contrast spills into the peritoneal cavity bilaterally. The diagnosis is tubal factor infertility secondary to prior PID with bilateral tubal damage. Given the bilateral tubal disease and hydrosalpinx, IVF is recommended. She is counseled that the hydrosalpinx fluid is toxic to embryos and associated with reduced IVF success rates. Laparoscopic left salpingectomy is performed before IVF. She undergoes IVF with a good response to stimulation, and a single euploid blastocyst is transferred. She conceives on the first IVF cycle and delivers a healthy infant at term.

### Key Learning Points
- Tubal factor infertility accounts for 25-30% of female infertility; pelvic inflammatory disease (often from Chlamydia trachomatis) is the most common cause, with risk increasing with each episode of PID
- Hysterosalpingography (HSG) is the first-line test for tubal patency; it can identify tubal occlusion, hydrosalpinx, and uterine abnormalities
- Hydrosalpinx (dilated, fluid-filled fallopian tube) reduces IVF success by approximately 50%; salpingectomy or proximal tubal occlusion before IVF improves pregnancy rates
- IVF bypasses the fallopian tubes entirely and is the treatment of choice for bilateral tubal disease

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## Case 2: Male Factor Infertility with Varicocele

### Clinical Image
![Varicocele](case_02_image.jpg)
*Source: [Wikipedia - Varicocele](https://en.wikipedia.org/wiki/Varicocele) - CC BY-SA 3.0*

### Case Presentation
A 32-year-old man and his 30-year-old wife present for infertility evaluation after 14 months of trying to conceive. The wife has regular menstrual cycles, normal ovulation confirmed by ovulation predictor kits, normal HSG with bilateral tubal patency, and normal ovarian reserve testing. The husband's semen analysis reveals: volume 3.0 mL (normal), concentration 8 million/mL (low; normal >15 million/mL), motility 30% (low; normal >40%), and morphology 2% normal forms (low; normal >4%). The diagnosis is oligoasthenoteratozoospermia (OAT syndrome). Physical examination of the husband reveals a palpable left scrotal mass described as a "bag of worms" that increases with Valsalva maneuver. Scrotal ultrasound confirms a grade III left varicocele with veins measuring 4.5 mm. Hormonal evaluation shows normal testosterone, FSH, and LH. The couple is counseled about treatment options. The husband undergoes microscopic varicocelectomy. Repeat semen analysis 4 months post-surgery shows significant improvement: concentration 22 million/mL, motility 48%, morphology 6% normal forms. The couple conceives naturally 6 months after surgery.

### Key Learning Points
- Male factors contribute to approximately 35% of infertility cases as the sole cause and another 20% as a contributing factor; semen analysis is essential in all infertility evaluations
- Varicocele is the most common surgically correctable cause of male infertility, present in 15% of all men and 40% of men with infertility; it causes elevated testicular temperature, leading to impaired spermatogenesis
- WHO criteria for normal semen: concentration >15 million/mL, motility >40%, morphology >4% normal forms, volume >1.5 mL
- Varicocelectomy improves semen parameters in 60-80% of men and results in spontaneous pregnancy in 30-50% of couples

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## Case 3: In Vitro Fertilization for Unexplained Infertility

### Clinical Image
![IVF Embryo Transfer](case_03_image.jpg)
*Source: [Wikipedia - In vitro fertilisation](https://en.wikipedia.org/wiki/In_vitro_fertilisation) - CC BY-SA 4.0*

### Case Presentation
A 36-year-old G0 woman and her 38-year-old husband present after 2 years of infertility. Complete evaluation reveals: regular ovulatory cycles confirmed by mid-luteal progesterone of 14 ng/mL, normal ovarian reserve (AMH 2.2 ng/mL, day 3 FSH 8 mIU/mL, AFC 12), patent fallopian tubes on HSG, normal uterine cavity, and normal semen analysis. No cause for their infertility is identified. The diagnosis is unexplained infertility. They have already tried 3 cycles of ovulation induction with letrozole plus timed intercourse and 3 cycles of letrozole plus intrauterine insemination (IUI) without success. Given her age (36 years) and the duration of infertility, they are counseled that IVF offers the highest per-cycle success rate. They proceed with IVF. She undergoes controlled ovarian hyperstimulation with gonadotropins. Fifteen oocytes are retrieved. Twelve are mature, and 10 fertilize normally with conventional insemination. Five blastocysts develop by day 5. Preimplantation genetic testing for aneuploidy (PGT-A) reveals 3 euploid embryos. A single euploid blastocyst is transferred, and she conceives. She delivers a healthy infant at 39 weeks. The remaining 2 euploid embryos are cryopreserved for potential future use.

### Key Learning Points
- Unexplained infertility (10-15% of cases) is diagnosed when standard evaluation (ovulation assessment, tubal patency, semen analysis) is normal; subtle factors not detected by routine testing may be present
- For unexplained infertility, treatment typically progresses from ovulation induction + IUI (3-4 cycles) to IVF, though proceeding directly to IVF may be more cost-effective, especially in women over 35
- IVF success rates are approximately 40% per transfer for women under 35 using fresh embryos, declining with age; PGT-A for aneuploidy screening can improve implantation rates per transfer
- Elective single embryo transfer in good-prognosis patients achieves similar cumulative pregnancy rates while dramatically reducing multiple pregnancy risk