EVALUATION OF

INFERTILE COUPLE
BY
DR NDENWANEKU JULIET
20/6/2023
Supervisors: Drs Danyaro/Salisu
• A 27-Year-Old Woman Comes to Your Officewith Her HusbandA 27-
year-old nulligravida woman comes to your office with her husband.
They are concerned about not having conceived after a year of
regular, unprotected intercourse. The patient denies any major
medical illnesses, and she takes no medications. The husband reports
he is healthy and has never fathered a child. Both thepatient and her
husband are visibly upset and somewhat tearful while discussing their
frustrations about not being pregnant yet. They express that they are
anxious to begin “all the tests necessary” as soon as possible so they
can have a child without further delay
• 1. What is the most appropriate diagnosis for this
• couple’s condition?
• a. primary sterility
• b. secondary sterility
• c. primary infertility
• d. secondary infertility
• e. diminished fecundity
• 2. Infertility is defined as failure to conceive with regular unprotected sexual
intercourse after:
• a. 1 month
• b. 3 months
• c. 6 months
• d. 1 year
• e. 2 years
• 3. What is the most appropriate initial step in this couple’s evaluation?
• a. basal body temperature (BBT) charting
• b. history and physical examination of both
• partners
• c. semen analysis
• d. referral to a reproductive specialist
• e. urine ovulation predictor kit testing
• 4 All of the following may be direct causes of female infertility except:
• a. previous uncomplicated abortion
• b. pelvic inflammatory disease (PID)
• c. endometriosis
• d. polycystic ovary syndrome (PCOS)
• e. hyperprolactinemia
• 5. Evaluation for tubal patency or “pelvic factor” is best accomplished by:
• a. transvaginal ultrasound
• b. hysteroscopy
• c. hysterosalpingogram (HSG)
• d. pelvic magnetic resonance imaging (MRI)
• e. pelvic computed tomography (CT) scan

• 6. Appropriate initial screening for male infertility includes which of the following?
• a. two semen analyses done at least 3 month apart
• b. serum testosterone and FSH levels
• c. postejaculatory urinalysis
• d. scrotal ultrasonography
• e. transrectal ultrasonography
• 6. It is appropriate to initiate an infertility evaluation after 6 months of
trying to conceive in which of the following conditions?
• a. the woman is older than age 35 years
• b. the man is older than age 40 years
• c. the woman has used Depo-Provera within the previous year
• d. the woman has used oral contraceptive pills for at
• least 10 years
• e. the woman has a history of recurrent vaginitis
OUTLINE
• DEFINITION
• EPIDEMIOLOGY
• AETIOLOGY
• EVALUATION – MALE, FEMALE
• INVESTIGATIONS
• MANAGEMENT
• PSYCHOSOCIAL PROBLEMS ASSO WITH INFERTILITY
INTRODUCTION
Childlessness is regarded as a curse in this environment. People often
see child bearing as an essential aspect of keeping a marriage.
A woman will go to any length to look for a child to keep her marriage
intact.
Family Physicians as frontline doctors and gate keepers of the health
system would be confronted with these issues.
It is important for primary care physicians to be familiar with the
workup and prognosis for infertile couples.

A British study found that patients valued primary care physicians

who were well informed about infertility and the treatment process.

Because anxiety over infertility may cause increased stress and

decreased libido, further compounding the problem, formal
counseling is encouraged for couples experiencing infertility
DEFINITION
Is the inability of the couple to achieve conception after at least one
year of
• Regular (≥ 3 X weekly)
• Unprotected (without contraception)
• orgasmic/ejaculatory
• Vaginal sexual intercourse
• With an adult of the opposite sex
Definition of Terms
Fertility: Is defined as the capacity to reproduce or the state of being
fertile.

Fecundability: Is the probability of achieving a pregnancy each

month.

Fecundity: Is the ability to achieve a live birth within 1 menstrual

cycle.
• Sterility is a permanent state of infertility.

• Time to pregnancy refers to the length of time, usually measured in

months, that it takes a couple to conceive. This parameter is often
used in epidemiological studies as a measure of subfecundity
The fecundability rate in the general reproductive-aged population is
fairly constant and is approximately 0.22 per month. Is higher in
young women and lower in the old.

The estimated fecundity rate is 0.15-0.18 per month, representing a

cumulative pregnancy rate of 90% per year.
• The probability of getting pregnancy per a reproductive cycle is about
20% to 25% in young, fertility-focused, healthy couple.

• The probability is 60% within the first 6 months

• It becomes 84% within the first year

• And 92% within the second year

EPIDEMIOLOGY
• Globally, prevalence of infertility among couples is between 8-12% .

• Infertility prevalence rates in African among married couples ranges between 15% to 30%

• Nigerian prevalence is about 15.7%

• The prevalence is found to be less in developed countries and more in developing countries

• In a study in Northwest Nigeria, primary infertility constituted 32.8%, while secondary

infertility was 67.2%.

• About 30% of infertility cases is attributed to female factors, 30% to male factors, 20- 30%
to combined male and female factors while 10% is unexplained origin
Types of Infertility
• Primary - Primary infertility refers to the inability to conceive or
achieve a successful pregnancy after at least one year of regular,
unprotected sexual intercourse in couples who have never had a child

• Secondary - This refers to the inability to conceive or carry a

pregnancy to term after having previously given birth to a child.

• Unexplained Infertility: In some cases, the cause of infertility cannot

be identified even after a comprehensive evaluation of both partners.
This is known as unexplained infertility.
CAUSES OF MALE INFERTILITY
Problems with spermatogenesis:
• Rise in scrotal temperature eg. Undescended testes, varicoceles, hot
baths, tight underwear.

• Infections (e.g. mumps, STD orchitis & epididymitis)

• Testicular inflammation, trauma and torsion

• Aneuploidy of sex chromosomes eg. Klinefelter syndrome XXY

• Endocrine issues eg. hypogonadotropic hypogonadism,

hyperprolactinemia, hypothyroidism

• Microdeletions of the azoospermic factor regions of the Y

chromosome

• Exposure to chemicals, toxins (glycol ethers), radiation, drugs

Problems with ejaculation;
• Erectile dysfunction (stress > decreased libido)
• Ejaculatory failure
• From metabolic & systemic disease eg Diabetes, multiple sclerosis

Problems with sperm transport;

• Vasectomy
• Epididymal obstruction due to inflammation or congenital
• Immotile cilia syndrome, cystic fibrosis

Problems due to immunological and infective factors;

• Antisperm antibodies (IgA or IgG)
• Primary hypogonadism (this is as a result of testicular problems (primary testicular
failure) as seen in 30 to 40 % of male infertility). This is seen in the following
situations:
• Androgen insensitivity

• Congenital or developmental testicular disorder (e.g., Klinefelter syndrome)

• Cryptorchidism
• delay surgery beyond 2yrs
• Risk of cancer 4-10 fold

• Medication such as antiandrogens, cimetidine, ketoconazole, spironolactone

• Mumps Orchitis
• after puberty- bilateral in 17% Can lead testicular atrophy
• Radiation

• Systemic disorder like diabetes mellitus

• Testicular trauma

• Varicocele

• Y chromosome defect
• Altered sperm transport (as seen in 10 to 20 % of male ifertility)
• Absent vas deferens or obstruction

• Epididymal absence or obstruction

• Erectile dysfunction

• Retrograde ejaculation

• Vasectomy
• Secondary hypogonadism which is a problem with
pituitary/hypothalamic problem as seen in 1 - 2 % of male infertility.
Conditions which result into this include:

• Androgen excess state e.g in anabolic abuse

• Congenital idiopathic hypogonadotropic hypogonadism

• Oestrogen excess state

• Infiltrative disorder (e.g., sarcoidosis, tuberculosis)

• Medication effect

• Multi-organ genetic disorder

• Pituitary adenoma

• Trauma
CAUSES OF FEMALE INFERTILITY
• Ovulation disorders which results from:
• Advancing age.

• Diminished ovarian reserve due to advancing age, some medications,

radiations

• Endocrine disorder such as thyroid diseases, hyperprolactinemia by

reducing the gonadotrophins
• Polycystic ovary syndrome: Ovulation is irregular as the ovaries
produce excessive amounts of androgens. Increased androgen
production results in high levels of LH and low levels of FSH resulting
in follicles not undergoing maturation, which then swells with fluid
and form into cysts.

• The elevated levels of androgens can also produce obesity, hirsutism,

acne as well as insulin resistance, which is associated with type 2
diabetes.

• Premature ovarian failure from early menopause and hormonal

imbalance

• Tobacco use
CAUSES OF FEMALE INFERTILITY
Problems with ovulation;
• polycystic ovary syndrome (commonest cause)

• Hypothalamic disorder eg. Hypothalamic hypogonadism

• Pituitary disease eg. Hyperprolactinemia

• Thyroid diseases (hypo/hyper)

• Adrenal diseases eg. Cushing’s syndrome, congenital adrenal hyperplasia

• Substance abuse, severe stress (decreased libido), smoking

WHO CLASSIFICATION OF OVULATION
DISORDERS
• Group I: Hypothalamic pituitary failure (hypothalamic amenorrhoea
or hypogonadotrophic hypogonadism)

• Group II: Hypothalamic-pituitary-ovarian dysfunction (mainly

polycystic ovary syndrome)

• Group III: Ovarian failure

Problems with implantation/ uterus;
• Uterine pathologies eg fibroids, endometrial polyps, endometrial scarring
(asherman’s syndrome) from surgery (D&C) or infections, septum
anomalies at birth

Problems with the fallopian tubes;

• Tubal blockage from pelvic inflammatory disease usually chlamydia and
gonorrhea, endometriosis, previous pelvic or abdominal surgery

Problems due to egg number and quality;

• Age related decline >40yrs
• Premature ovarian failure, resistant ovary syndrome, irradiation
• Abnormalities in sex chromosomes eg. Turner’s syndrome
• Tubal factors from :
• tubal occlusion secondary to past pelvic inflammatory disease which
results from sexually transmitted infections

• Occlusion from tubal surgery

• Also about 15% of cases of female infertility is from endometriosis

It affects fertility indirectly by blockage of the fallopian tubes when it
implants in the tube, or by preventing the release of eggs (when
implanted on ovaries) or it may result in adhesions.
• Uterine/cervical factors as seen in the following conditions:
• Congenital uterine anomaly

• Uterine Fibroids : when it blocks the fallopian tube or distorts the shape
of the uterine cavity. It may also result in reducing blood flow to the
uterine lining

• Cervical Polyps

• Poor cervical mucus quantity/quality as caused by smoking, infection,

some medications

• Uterine synechiae as seen in Ashermans

EVALUATION OF INFERTILITY
• When to evaluate:
• In young, healthy couple: evaluation for infertility is commenced after
12 months of regular unprotected sexual intercourse

• However, situation when evaluation is commenced by 6 months

include:

• When the woman is older than 35 years

• When either partner has a known risk for infertility ( evaluation is

immediately)
HISTORY TAKING - Male
• The history taking should be done separately as well as together in order to
bring out important facts that a partner does not wish to disclose to the
other.
• This includes:

• Age

• Details regarding the type of infertility 1° or 2° and its duration

• Fathered any previous pregnancies

• Hx of previous infertility evaluation/treatment

• Current medication history in relation to known aetiologies if female
infertility
• Contraceptive history: previous use of any contraceptive method, or
vasectomy.

• Sexual history: Coital frequency and timing as it relates to the menstrual

cycle, use of vaginal lubricant before intercourse, sexual dysfunctions

• Past medical history: medical or surgical history as pelvic infection, ovarian

cyst,( mumps in men), hypertension or diabetes mellitus. Bilateral inguinal
herniorrhaphy, undesended testis in men, Spinal cord, multiple sclerosis,
previous chemotherapy or pelvic radiotherapy, any genetic anomaly

• Family history: of similar problem among the family members,

consanguinity, diabetes mellitus, hypertension, breast cancer
• Hx of sexually transmitted diseases and it management

• Hx of testicular trauma, testicular torsion & undescended testis

• Hx of mumps or measles eg. Orchitis, epididymitis, prostatitis, seminal

vesiculitis
• Surgical Hx eg hernia repair, genitourinary surgery, vasectomy

• Occupation Hx eg exposure to chemicals, radiation, paints, ethylene

glycol, athlete (anabolic steroid use)

• Family/social Hx – substance use, heavy smoking, excessive alcohol,

fertility status of the pt’s siblings

• Drug Hx – current medication & it reason of use, allergy hx

HISTORY TAKING - FEMALE PARTNER
• Age (Single most important factor in prognosis)

• Details regarding the type of infertility 1° or 2° and its duration

• Menstrual history: for age of menarche, cycle characteristics, cycles of

22 to 35 days suggests ovulatory cycles. History of primary or
secondary amenorrhoea (six months of amenorrhoea) or
oligomenorrhoea (>45 days of amenorrhoa)

• Obstetric history: previous pregnancies, if any, and its outcome,

recurrent pregnancy loss, induced abortion, post-abortive infection or
puerperal sepsis
• Hx of previous infertility evaluation/treatment

• Coital frequency, any changes in libido

• Hx of Sexually transmitted diseases/PID and it management

• Medical Hx eg Diabetics, hypertension, previous chemotherapy or

pelvic radiotherapy, any genetic anomaly (turner syndrome) or birth
defect, cervical smear hx
• Surgical Hx eg tubal ligation, previous pelvic/ abdominal surgery

• Occupation Hx eg exposure to chemicals, radiation, paints, ethylene

glycol, athlete (anabolic steroid use)

• Family/social Hx – substance use, heavy smoking, excessive alcohol,

fertility status of the pt’s siblings

• Drug Hx – current medication and it reason of use, allergy hx

PHYSICAL EXAMINATION OF THE COUPLE
• General Examination: blood pressure, body height and weight, BMI,
secondary sexual characters, hirsutism, acne, thyroid gland enlargement

• Breast Examination: galactorrhoea, (gnaecomastia in men)

• Genital Examination: evidence of Female Genital Mutilation, size and shape

of clitoris, adnexal mass, vaginal discharge, cervical excitation tenderness (
• Shape and size of penis as well as location of external urethral meatus,
testicular volume , palpation of epididymis and vas deferens, exclude
varicocele or hydrocele. Rectal examination for prostate enlargement.

• Other systemic examination for possible causes of infertility e.g CNS for
brain tumour
INVESTIGATIONS
• After a detailed history, the couple is investigated to determine the
possible cause(s) of the infertility

• Before any invasive procedure is carried out on the female, the male
partner should carry out a seminal fluid analysis
PARAMETERS OF SEMEN ANALYSIS WHO

• STANDARD TESTS
• Volume = ≥2mls
• Ph =7.2-8.0
• Semen Conc. = ≥20X106/ml
• Total sperm count = ≥40X106/ejaculate
• Motility =25%with rapid progression
• =50% with forward progression
• Vitality =75%alive
• =25%dead
• Morphology = 30%Normal
• Wbc = <1X106/ml
• Immunobead test = <50%
• Mixed Agglutination reaction= <50%
• The following conditions can be present in the SFA

• oligospermia = sperm count < 15 million per mL; Azoospermia =

complete absence of sperm cells in the ejaculate

• Asthenozoospermia = < 40% of the sperm are motile

• Teratozoospermia = normal morphology < 4%.

• If an individual has all three low sperm conditions, it is known as OAT

(Oligoasthenoteratozoospermia) syndrome
HOW TO CONDUCT A SFA
• Abstinence from ejaculation for several days (2-5 days) before the test as each
ejaculation can reduce the number of sperm by a third.

• Seminal collection is by masturbation either at home or at the doctor's office.

Proper collection procedure is important, since the highest concentration of
sperm is contained in the initial portion of the ejaculate.

• Also, special condoms without spermicides may be used during sexual

intercourse

• The sample are kept at body temperature with prompt delivery with analysis
carried out within 2 hours of collection.

• Two semen analyses performed at least 4-12weeks apart to confirm abnormality

IF SFA IS ABNORMAL, THEN THE FOLLOWING TESTS ARE INDICATED

• Serum testosterone

• Serum FSH

• Serum prolactin if low FSH and low testosterone

• A decreased testosterone level + increased FSH level = primary hypogonadism.

• A low testosterone level + low FSH level = a secondary hypogonadism.

• Transrectal ultrasonography can identify obstruction of the vas deferens

• Testicular biopsy
Female infertility testing
• Pelvic/transvaginal ultrasound to detect and structural abnormality
such as uterine fibroid distorting the uterus (cystic ovary in
transvaginal USS)

• Serum progesterone by day 21 (or 7 days before presumed onset of

menses in women with irregular cycles which is repeated weekly until
menses).

• A progesterone level of 5 ng per mL (15.9 nmol per L) or greater

implies ovulation

• Serum estradiol
• Serum FSH

• Serum LH (high in luteal phase insufficiency) if progesterone level is

low

• Serum Prolactin

• TSH
• A high serum FSH level+ high LH + a low estradiol level = ovarian
failure

• Low or normal FSH level + low estradiol level = hypothalamic pituitary

failure

• High LH + low FSH may suggest polycystic ovary syndrome or luteal

phase defect

• A high serum estradiol level + normal FSH level has also been
associated with lower pregnancy rates.
Tubal factor investigation if progesterone is normal
• Hysterosalphingography – minimally invasive with some therapeutic
benefits

• Laparoscopy with dye test- more invasive and can also be used for
diagnosis of endometriosis

• Hysteroscopy: invasive
MANAGEMENT OF INFERTILITY BY FAMILY
PHYSICIAN
• Information and education on infertility and the detected cause of their
infertility

• Psychosocial support due to anxiety associated with infertility

• Sexual counselling in individuals with sexual dysfunction

• If no identified cause of infertility in the couple, they should be counselled on

timing of intercourse for the most fertile period which is five days preceding
ovulation and ovulatory day which can be monitored). High fertile days
known to be between day 10 and 17

• Encouraged on regular intercourse at about 2-3 times/week.

TREATMENT OF INFERTILITY BY FAMILY PHYSICIAN
• Lifestyle modification:
• Abstinence from tobacco use

• Limit alcohol and caffeine consumption

• Weight reduction through exercises and reduction in calorie intake to a body

mass index less than 30 kg per m2

• Weight gain in underweight women with hypothalamic amenorrhoea (low or

normal FSH and low estradiol)

• Reduce stress
OVULATION INDUCTION
• Ovulation induction in anovulatory women with use of :
• Clomiphene on day3 or 5 with 50mg daily.

• Can be increased to 100mg daily (used for a total of 3-6 months if it fails
after each use)

• Side Effects : increase the risk of multiple pregnancy, ovarian

hyperstimulation syndrome (OHSS), thrombosis, and increase risk of
ovarian cancer in women who remain nulliparous

• Other ovulation induction drugs include: menotropins; gonadorelin , a

synthetic gonadotropin-releasing hormone (Gn-RH), and bromocriptine .
REFERRAL TO FERTILITY CLINICS WHERE THE
FOLLOWING CAN BE OFFERED
• Tubal surgery: as laparoscopic adhesiolysis

• Hysteroscopic surgery: Resection of intrauterine adhesions or polyps

• Intra-uterine Insemination (IUI): which involves placing the sperm directly in the
cervix (called intracervical insemination) or into the uterus (called intrauterine
insemination. This can be used for unexplained infertility and female cases with
minimal endometriosis

• In-vitro Fertilisation (IVF) and Embryo transfer (ET): with either the couples own
egg/sperm or donor source.

• Surrogacy: In women with congenital absence of uterus or after surgical removal

TREATMENT OPTIONS CONTD
• Oocyte donation and Ovarian tissue transplantation: for premature
ovarian failure

• Donor insemination for male fertility: for azoospermia

• Surgical restoration of duct patency in men

• Surgical sperm retrieval

PSYCHOSOCIAL PROBLEMS ASSO. WITH INFERTILITY.
Prior to and during treatment;
• Anxiety and worry

• Depression

• Sexual anxiety

• Relationship problems with partner, family and friends at work

• Increased sense of self-blame

• Marital tension

• Financial issues, cost of treatment

• Cultural expectation & pressure

Sequel to unsuccessful treatment;
• Emotional stress

• Poor coping skills

• Low self-esteem

• Depression

• Increased marital tensions > marriage failure

• Heightened anger > domestic violence

• Divorce
MANAGING PSYCHOSOCIAL PROBLEMS ASSO. WITH
INFERTILITY.
EVERYTHING DONE IS COUPLE CENTERED
• Evaluation and psychological therapy intervention- is necessary at the
beginning of the infertility evaluation, when psychiatric indications are
obvious and at the termination of unsuccessful treatment or with a
pregnancy loss.

• Support groups- couples can get social support from other couples
with similar condition and couples who have overcome infertility.
These group of persons understand and have experienced the fear,
worry or expectation that comes with infertility.
• Counselling- this is usually considered in cases of depression, anxiety
and preoccupations. It might include individual or couple therapy. It
aims at providing sufficient emotional support and developing healthy
coping mechanisms.

• Cognitive behavioral therapy- this is usually done to reduce anxiety,

depression and stress as well as increase self esteem. It also serves as
a source of support.
• Relaxation techniques- these are carried out to reduce stress and
they include; Yoga, meditation, acupuncture, breathing exercises.

• Religion- studies have shown that turning to religion and prayers have
been a good coping strategy and this helps in reducing despair.
• Pharmacotherapy- the use of antidepressants especially SSRIs has
shown significant effect on improving symptoms of depression found
in cases of infertility.
• Also anxiolytic agents are helpful for anxiety episodes.

• Non medical options- Help couples to consider non-medical options

such as adoption.
CONCLUSION
• Our society places a social stigma on infertile couples, hence psychosocial
problems trails infertility.

• Even couples with fewer children than wanted are still under this societal
distress.

• Although success rates vary by age and diagnosis, accurate diagnosis and
effective therapy along with shared decision-making can facilitate
achievement of fertility goals in many couples treated for infertility.

• It is important to manage not only the biomedical issues but also a

BIOPSYCHOSOCIAL APPROACH should be employed by Family Physicians in
managing infertile couples.
• A 27-Year-Old Woman Comes to Your Officewith Her HusbandA 27-
year-old nulligravida woman comes to your office with her husband.
They are concerned about not having conceived after a year of
regular, unprotected intercourse. The patient denies any major
medical illnesses, and she takes no medications. The husband reports
he is healthy and has never fathered a child. Both thepatient and her
husband are visibly upset and somewhat tearful while discussing their
frustrations about not being pregnant yet. They express that they are
anxious to begin “all the tests necessary” as soon as possible so they
can have a child without further delay
• 1. What is the most appropriate diagnosis for this
• couple’s condition?
• a. primary sterility
• b. secondary sterility
• c. primary infertility
• d. secondary infertility
• e. diminished fecundity
• 2. Infertility is defined as failure to conceive with regular unprotected sexual
intercourse after:
• a. 1 month
• b. 3 months
• c. 6 months
• d. 1 year
• e. 2 years
• 3. What is the most appropriate initial step in this couple’s evaluation?
• a. basal body temperature (BBT) charting
• b. history and physical examination of both partners
• c. semen analysis
• d. referral to a reproductive specialist
• e. urine ovulation predictor kit testing

• 4 All of the following may be direct causes of female infertility except:

• a. previous uncomplicated abortion
• b. pelvic inflammatory disease (PID)
• c. endometriosis
• d. polycystic ovary syndrome (PCOS)
• e. hyperprolactinemia
• 5. Evaluation for tubal patency or “pelvic factor” is best accomplished by:
• a. transvaginal ultrasound
• b. hysteroscopy
• c. hysterosalpingogram (HSG)
• d. pelvic magnetic resonance imaging (MRI)
• e. pelvic computed tomography (CT) scan

• 6. Appropriate initial screening for male infertility includes which of the following?
• a. two semen analyses done at least 3 month apart
• b. serum testosterone and FSH levels
• c. postejaculatory urinalysis
• d. scrotal ultrasonography
• e. transrectal ultrasonography
• 7. It is appropriate to initiate an infertility evaluation after 6 months of
trying to conceive in which of the following conditions?
• a. the woman is older than age 35 years
• b. the man is older than age 40 years
• c. the woman has used Depo-Provera within the previous year
• d. the woman has used oral contraceptive pills for at
• least 10 years
• e. the woman has a history of recurrent vaginitis
THANK YOU
REFERENCES
• Alfred FT, Joseph ES, Nancy WD. Infertility. In: Adity B editor. Swanson’s Family
Medicine Review: A problem-oriented approach. 9th edition. Philadelphia: Elsevier,
Inc.; 2022. P 426-429

• Wendy K, Mark DH. Overview of infertility[Internet]. Wolters Kluwer Health; 2023

[ updated Apr 24, 2023]. Availiable from:
https://www.uptodate.com/contents/overview-of-infertility#H7.

• Lindsay TJ, Vitrikas KR. Evaluation and treatment of infertility. Am Fam Physician.
2015 Mar 1;91(5):308-14. Erratum in: Am Fam Physician. 2015 Sep 15;92 (6):437.
PMID: 25822387.

• Mike A. EVALUATION OF THE INFERTILE COUPLE [lecture]. WACP update course

• Loto O.M. The Infertile Couple [Lecture]. FMCGP Revision course; June 23, 2008