Hard to Conceive

A CLINICAL PROBLEM-SOLVING article by Julie Levison from Brigham and Women's Hospital, Boston.
A 31-year-old woman reported to her primary care physician that she and her husband had been unable to conceive a child since abstaining from all contraception 18 months earlier. One year before presentation, she had been evaluated by her physician for abdominal pain in the left lower quadrant. She reported having received BCG vaccination against tuberculosis as an infant. She was born and raised in Kathmandu, Nepal, and had moved to the United States 4 years earlier with her husband. As part of the immigration process, she underwent screening for latent tuberculosis infection and received a “borderline positive” result on a tuberculin skin test with a purified protein derivative. She was told that this result was due to her BCG vaccination and did not receive treatment for latent tuberculosis infection.
The patient and her husband had no apparent current or past medical conditions that explained their infertility. and they were seen by an obstetrical–gynecologic fertility specialist.
A hysterosalpingogram revealed a normal uterus and endometrial cavity without synechiae. Both fallopian tubes filled with contrast medium and were of normal caliber. However, there was no distal spill of contrast medium from either fallopian tube.
After the two unsuccessful cycles of IVF, an endometrial biopsy was performed. An Interactive Medical Case related to this article is available at NEJM.org. [Original Article]