Infertility and subsequent pregnancy

Although the incidence of fertility has not increased over the last several decades, the number of patients seeking treatment has increased, especially among older women who have delayed childbearing for various social reasons. During this postponement they are more likely to develop pelvic pathology including endometriosis and uterine myomas and to have been exposed to more encounters with sexually transmitted diseases, all of which contribute to infertility. In addition, it is now well recognized that natural fecundity declines rather dramatically after age 35 years, as a function of the natural depletion of oocytes and decreased ovarian follicular function. Modern endoscopic surgical procedures may be performed to remove myomas, uterine septa, and intrauterine adhesions, but obstetric complications following these operations can occur. Treatment of ovulatory dysfunction can result in multiple pregnancies despite careful monitoring. Patients who fail conventional infertility treatment may now successfully conceive using artificial reproductive techniques, including the use of donor oocytes. This may also result in multifetal gestations and their attendant clinical risks. These aggressive methods of treatment have also led to a marked increase in the occurrence of heterotopic pregnancies, which can be a diagnostic challenge. Infertility patients who conceive should be considered at higher risk for pregnancy complications. A careful history of their fertility treatment and the underlying factors should be reviewed by the obstetric team. Anticipation of known complications will usually result in timely intervention and the successful conclusion of the pregnancy.