Endgames Picture Quiz

Investigating fertility problems

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e6173 (Published 20 September 2012) Cite this as: BMJ 2012;345:e6173
  1. A Davis, specialist trainee year 2, radiology1,
  2. K Madhvani, specialist trainee year 5, obstetrics and gynaecology2,
  3. L Lee, specialist registrar, radiology1
  1. 1St George’s Hospital NHS Trust, London, UK
  2. 2Poole Hospital NHS Foundation Trust, Poole, UK
  1. Correspondence to: A Davis adavis{at}doctors.org.uk

A 29 year old nulliparous woman was referred to the radiology department by her gynaecologist for a hysterosalpingogram. She had been trying unsuccessfully to conceive for 15 months. She had no medical, surgical, or gynaecological history. She had never been pregnant. Her body mass index was normal and she was a non-smoker. She described a regular 28 day menstrual cycle, with periods—which were not heavy or painful—lasting between five and six days. She had no history of sexually transmitted diseases. Day 21 progesterone concentrations indicated that she was ovulating and her partner’s semen analysis was normal. The couple were having regular intercourse. A chlamydia test was negative. Hysterosalpingography was carried out (fig 1).


  • 1 What is infertility?

  • 2 How should a couple presenting with infertility be investigated?

  • 3 How would you interpret this image?

  • 4 What other imaging modalities can be used instead of the investigation shown?


1 What is infertility?

Short answer

Infertility (clinical definition) is currently defined as one year of unwanted non-conception with unprotected intercourse in the fertile phase of the menstrual cycle.1

Long answer

Couples who have not conceived after one year of regular unprotected sexual intercourse should be offered clinical investigation, including semen analysis and assessment of ovulation.

Offer earlier investigation if the woman is aged 35 years or there is a history of predisposing factors (such as amenorrhoea, oligomenorrhoea, pelvic inflammatory disease, or undescended testes).

Couples who are worried about their fertility should be informed that 84% of couples in the general population will conceive within one year if they do not use contraception and have regular sexual intercourse. Of those who do not conceive in the first year, about half will do so in the second year (cumulative pregnancy rate 92% after two years and 93% after three years).2 3

2 How should a couple presenting with infertility be investigated?

Short answer

Focused questioning to identify known risk factors; …

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