Differential Diagnosis for Infertility in a 29-year-old Woman
- The patient's symptoms and history suggest a complex etiology for her infertility. The following differential diagnoses are considered:
Single most likely diagnosis
- Pelvic Inflammatory Disease (PID) with Adhesions and Potential Asherman's Syndrome: The patient's history of gonococcal cervicitis, severe lower abdominal pain, and a small uterus with a laterally displaced cervix suggest PID, which can lead to adhesions, scarring, and potential Asherman's syndrome. These conditions can cause infertility, menstrual irregularities, and pelvic pain.
Other Likely diagnoses
- Endometriosis: The patient's severe lower abdominal pain, dysmenorrhea, and infertility are consistent with endometriosis. The pain with cervical manipulation also supports this diagnosis.
- Adenomyosis: Similar to endometriosis, adenomyosis can cause severe pelvic pain, dysmenorrhea, and infertility. The patient's symptoms and age are consistent with this diagnosis.
- Polycystic Ovary Syndrome (PCOS): Although the patient's menstrual cycle is regular, her BMI and infertility suggest PCOS. However, the absence of other typical PCOS symptoms, such as hirsutism or acne, makes this diagnosis less likely.
Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Ovarian Cancer: Although rare in this age group, ovarian cancer can cause pelvic pain, infertility, and abdominal symptoms. A thorough evaluation, including imaging and potentially a CA-125 screening, is essential to rule out this diagnosis.
- Ectopic Pregnancy: The patient's history of PID and infertility increases her risk for ectopic pregnancy. Although she has not become pregnant, it is essential to consider this diagnosis if she were to become pregnant in the future.
Rare diagnoses
- Uterine Anomalies (e.g., Unicornuate or Bicornuate Uterus): The patient's small uterus and laterally displaced cervix may suggest a uterine anomaly, which can cause infertility and obstetric complications.
- Tuberculosis: Although rare in developed countries, tuberculosis can cause PID, infertility, and pelvic pain. The patient's history of gonococcal cervicitis and severe abdominal pain make this diagnosis a consideration, especially if she has traveled to or lived in areas with high TB prevalence.