Infertility

HISTORY:

Infertility for ‍ ‍monthsyears

Frequency of intercourse: ‍ times per ‍weekmonth

Menstrual cycles: ‍ days, ‍regularirregular

Previous children: ‍yesno

G‍01234 P‍01234 A‍01234

Fertility treatments: ‍none

Fertility investigations: ‍none

‍menstrual irregularity

‍amenorrhea

‍heavy periods

‍painful periods

‍pain during intercourse



Male partner:

Number of previous children: ‍01234



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Measurements: weight: ‍ kg, height: ‍ cm, waist: ‍ cm, BMI: ‍

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Breasts: -R: ‍normal, -L: ‍normal

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Anorectal: DRE ‍normal, anus ‍normal

Pelvic:

- External genitalia: ‍normal, ‍inguinal lymphadenopathy

- Vagina: ‍normal, discharge ‍normal, ‍malodorous

- Cervix: ‍normal

- Uterus: ‍normal, ‍no cervical motion tenderness

- Adnexa: -R ‍normal, -L ‍normal

- Tests performed: ‍Pap test, ‍HPV DNA, ‍vaginal culture, ‍chlamydia/gonorrhea, vaginal pH ‍< 4.5> 4.5, whiff test with KOH ‍negative

- Performed with chaperone

Skin: ‍no rash

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought process ‍organized, ‍no suicidal ideation, judgment ‍good



ASSESSMENT:

‍Infertility ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍FSH, ‍LH, ‍estradiol, ‍progesterone, ‍prolactin, ‍TSH, ‍AMH, ‍testosterone, ‍DHEAS, ‍βhCG

- Pelvic ultrasound

- Hysterosalpingogram

- Genetic testing

- Semen analysis

- Lifestyle modifications: ‍healthy diet, ‍regular exercise, ‍weight loss, ‍quit smoking, ‍limit alcohol, ‍reduce stress

- ‍Fertility medications

- ‍Metformin

- ‍Medroxyprogesterone

- Intrauterine insemination

- In vitro fertilization

- Intracytoplasmic sperm injection

- Donor eggs or sperm

- Referral to fertility specialist

- Referral to psychologist

- Follow-up in ‍ ‍weeksmonths

- Return if no pregnancy after 6 months of treatment, if new symptoms develop such as pelvic pain or irregular periods, or if emotional distress occurs