Reproductive health encompasses fertility awareness, infertility evaluation and treatment, reproductive life planning, and management of pregnancy loss. Infertility affects 8-12% of couples worldwide.

Reproductive health checkup — Reproductive health encompasses fertility awareness, infertility evaluation and treatment, reproductive life planning, and management of pregnancy loss. Source: Unsplash.

Fertility Awareness

Fertility awareness methods (FAM) involve tracking physiologic markers to identify the fertile window (approximately 6 days per cycle — 5 days before ovulation and ovulation day). Methods include basal body temperature (BBT — temperature rises 0.5-1 degree F after ovulation, confirming ovulation retrospectively), cervical mucus monitoring (peak mucus — clear, stretchy, like raw egg white — correlates with the fertile window), calendar-based methods (Standard Days Method for cycles 26-32 days, Calendar Rhythm Method), and ovulation predictor kits (urine LH surge detection, positive 24-48 hours before ovulation). Apps (Clue, Flo, Natural Cycles) use algorithms combining cycle tracking and temperature data. FAM is 75-88% effective with typical use but 95-99% effective with perfect use for pregnancy prevention. FAM can also be used to optimize timing for conception: intercourse every 1-2 days during the fertile window maximizes pregnancy rates.

Infertility

Infertility is defined as failure to achieve pregnancy after 12 months of regular unprotected intercourse (women under 35), or 6 months (women 35 and older). Immediate evaluation is indicated for women over 40 or those with known risk factors (amenorrhea, oligomenorrhea, known uterine or tubal disease, endometriosis, prior pelvic surgery, or male factor issues — partner history of cryptorchidism, radiation, chemotherapy, prior infertility in a different partnership).

Pelvic exam — Infertility evaluation includes assessment of ovulatory function, tubal patency, and semen analysis. Source: Unsplash.

Etiology

Causes of infertility include female factor (30-40%): ovulatory dysfunction (40% — PCOS, hypothalamic amenorrhea, POI, anovulation), tubal disease (20% — PID, previous ectopic, endometriosis, prior pelvic surgery), uterine factors (5-10% — fibroids, polyps, Asherman syndrome, Müllerian anomalies), and peritoneal factors (endometriosis). Male factor accounts for 30-40% (oligospermia, asthenospermia, teratospermia, azoospermia). Unexplained infertility accounts for 10-20%.

Evaluation

Female: medical history (cycle history, prior pregnancies, prior STIs, pelvic surgery, medications), physical exam (BMI, thyroid, signs of androgen excess, pelvic exam), ovulatory assessment (day 3 FSH, LH, estradiol; anti-Müllerian hormone — AMH, the most important single test of ovarian reserve; mid-luteal progesterone 7 days before menses to confirm ovulation), hysterosalpingography (HSG — X-ray with contrast to assess tubal patency and uterine cavity), and transvaginal ultrasound (antral follicle count, uterine and ovarian evaluation). Male: semen analysis (volume, sperm count, motility, morphology — two abnormal samples confirm male factor). Additional male evaluation if indicated: hormonal testing (FSH, LH, total and free testosterone), genetic testing (Y-chromosome microdeletions, CFTR for congenital bilateral absence of the vas deferens), and testicular biopsy.

⚠ Clinical Correlation

Ovulation induction (OI) with oral agents: clomiphene citrate (CC) 50-150 mg on days 3-7 of the cycle (60-80% ovulation rate, 10-20% pregnancy rate per cycle). Clomiphene is anti-estrogenic at the level of the endometrium and cervical mucus — 5-10% of cycles have thin endometrium. Letrozole (an aromatase inhibitor) is now first-line for PCOS — superior live birth rates to CC and lower multiple pregnancy rates (3-4% vs 8-10%). Gonadotropins (injectable FSH and LH) are used for OI when oral agents fail or in IVF. Risks of OI include multiple pregnancy (10-30% with gonadotropins — 80% twins, 20% triplets or higher) and ovarian hyperstimulation syndrome (OHSS — severe in 1-2% of gonadotropin cycles). Intrauterine insemination (IUI) — washed, concentrated sperm placed directly into the uterine cavity via a catheter, timed to ovulation. IUI with OI yields 10-20% pregnancy rate per cycle. In vitro fertilization (IVF) is indicated for tubal factor, severe male factor, endometriosis, ovulatory dysfunction not responsive to OI, and unexplained infertility after 3-6 cycles of OI/IUI. IVF involves controlled ovarian hyperstimulation (gonadotropins for 10-14 days with GnRH antagonist or agonist protocol), oocyte retrieval (transvaginal ultrasound-guided aspiration, IV sedation), fertilization (conventional insemination or ICSI — intracytoplasmic sperm injection for male factor), embryo culture (day 3 cleavage stage or day 5-6 blastocyst), and embryo transfer (fresh or frozen). The live birth rate per IVF cycle is 30-50% depending on maternal age. Preimplantation genetic testing for aneuploidy (PGT-A) may be offered in selected cases (advanced maternal age, recurrent pregnancy loss, severe male factor) — the debate continues about PGT-A’s universal benefit, but it is clearly beneficial for these specific indications.

Treatment

Treatment depends on etiology: ovulatory dysfunction (ovulation induction with letrozole or clomiphene), tubal disease (tubal surgery for mild disease, IVF), endometriosis (laparoscopic excision plus OI/IUI or IVF), male factor (donor sperm for severe azoospermia/no viable sperm on TESE, and IVF-ICSI for other male factor), and unexplained infertility (OI/IUI for 3-6 cycles, then IVF). The cumulative live birth rate after 3 IVF cycles is 60-70% for women under 38, declining with age.

Reproductive Life Planning

Reproductive life planning is a framework for helping individuals and couples make informed decisions about pregnancy timing, spacing, and prevention. The CDC recommends that all women of reproductive age have a reproductive life plan (RLP) — a set of personal goals about whether and when to have children. Preconception counseling should address: folic acid supplementation (400 mcg daily for all reproductive-age women, 4 mg daily for those with prior neural tube defect or on anticonvulsants), optimization of chronic diseases (diabetes — HbA1c under 7% before conception; hypertension — optimize BP with pregnancy-safe agents; thyroid disease — TSH between 0.5-2.5 mIU/L; epilepsy — adjust anticonvulsants to minimize teratogenic risk; autoimmune disease — optimize disease control), medication review (stop teratogenic medications — ACE inhibitors, statins, isotretinoin, valproate, mycophenolate, warfarin — and switch to pregnancy-safe alternatives), weight optimization (BMI 18.5-24.9 — obesity increases miscarriage, gestational diabetes, preeclampsia, and congenital anomalies), smoking cessation (35-40% of smokers stop during pregnancy — smoking increases miscarriage, placental abruption, preterm birth, and SIDS), alcohol avoidance (no safe level in pregnancy; FASD is the leading preventable cause of birth defects and intellectual disability), genetic carrier screening (cystic fibrosis, spinal muscular atrophy, hemoglobinopathies — offered to all; expanded carrier screening in some populations), and immunization update (MMR — check rubella immunity and vaccinate if non-immune, varicella if non-immune, Tdap in each pregnancy, influenza vaccine in pregnancy).

Miscarriage and Recurrent Pregnancy Loss

Miscarriage (spontaneous abortion) affects 15-20% of recognized pregnancies. The risk increases with maternal age: 10% at age 20, 20% at age 35, 40% at age 40, and 80% at age 45. Chromosomal abnormalities account for 50-60% of first-trimester miscarriages (most commonly trisomies — trisomy 16 is the most common autosomal trisomy in miscarriages). Other causes include maternal factors: uterine anomalies, endometrial dysfunction (thin endometrium, chronic endometritis), endocrine factors (poorly controlled diabetes, thyroid dysfunction), luteal phase deficiency (controversial), and antiphospholipid syndrome (aPL — the most important treatable cause of recurrent miscarriage).

Recurrent pregnancy loss (RPL) is defined as 2 or more (ASRM) or 3 or more (ACOG) clinical pregnancy losses. Evaluation: karyotyping of products of conception (if available), parental karyotyping (balanced translocation in 3-5% of RPL couples), hysterosonography or hysteroscopy (uterine cavity evaluation — 15% of RPL patients have a structural abnormality), antiphospholipid antibody testing (lupus anticoagulant, anticardiolipin antibodies, beta-2 glycoprotein I antibodies — 5-15% of RPL), and thyroid function and HbA1c. Treatment of RPL: structural anomalies (hysteroscopic resection of septum, polyps, fibroids, or lysis of adhesions — 60-80% live birth rate), antiphospholipid syndrome (aspirin 81 mg daily plus prophylactic low molecular weight heparin — enoxaparin 40 mg daily — starting at positive pregnancy test until 6 weeks postpartum — live birth rate improves from 10-20% to 70-80%), luteal phase support (progesterone — vaginal, oral, or intramuscular — may reduce miscarriage in women with RPL and bleeding in early pregnancy; the PRISM trial suggests benefit in those with a history of RPL). The prognosis after three losses with no identifiable cause is 60-70% live birth in a subsequent pregnancy with supportive care alone.

Summary

Fertility awareness tracks BBT, cervical mucus, and cycle length. Infertility is 12 months of unprotected intercourse without pregnancy (6 months if over 35). Evaluation includes female (ovarian reserve, HSG, ultrasound) and male (semen analysis) components. Treatment includes OI (letrozole, clomiphene), IUI, and IVF (30-50% live birth per cycle). Reproductive life planning starts with folic acid, chronic disease optimization, medication review, and genetic screening. Miscarriage affects 15-20% of pregnancies; RPL evaluation identifies a cause in 50-60% of cases. Supportive care alone provides 60-70% live birth rate in unexplained RPL.