# Situation: A nurse assists in the genetic counseling and fertility clinic of a medical center, where couples come for preconception advice. A 36-year-old woman has a 5-year-old child born after an uncomplicated pregnancy. Two years ago she had a tubal ectopic pregnancy that was treated with medication. For the past 7 months she and her husband have had regular unprotected intercourse without conceiving. She has regular cycles. How should the nurse classify her situation?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629501  
> language: ko  
> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: A nurse assists in the genetic counseling and fertility clinic of a medical center, where couples come for preconception advice.

A 36-year-old woman has a 5-year-old child born after an uncomplicated pregnancy. Two years ago she had a tubal ectopic pregnancy that was treated with medication. For the past 7 months she and her husband have had regular unprotected intercourse without conceiving. She has regular cycles. How should the nurse classify her situation?

## 보기

1. Primary infertility that warrants evaluation now
2. Primary infertility that warrants evaluation at 12 months
3. Secondary infertility that warrants evaluation at 12 months
4. Secondary infertility that warrants evaluation now **✔ 정답**

**정답: 4**

## 해설

Primary infertility means the woman has never conceived; secondary infertility follows a previous pregnancy, and she has had a previous pregnancy and birth. Under the ASRM 2023 definition, infertility in a woman 35 or older is recognized after 6 months, and evaluation begins then instead of at 12 months. Her prior tubal pregnancy is also a known risk for tubal disease, which supports prompt evaluation.

## 심화 해설

Classifying the infertility

The first step is to decide whether this is primary or secondary infertility. Primary infertility is defined as never having achieved a clinical pregnancy, while secondary infertility means the woman has conceived before, regardless of whether that pregnancy ended in a live birth, miscarriage, or ectopic pregnancy. This client has a 5-year-old child from a previous pregnancy and also had a tubal ectopic pregnancy two years ago. Therefore, she has clearly conceived before, which makes this secondary infertility, not primary. Options 1 and 2 are eliminated.

Timing of evaluation

The standard benchmark for initiating an infertility evaluation is 12 months of regular unprotected intercourse without conception for women under 35. However, for women 35 or older, the timeline is shortened. The client is 36 years old, so she falls into the older age category.

Women older than 35 years should receive an expedited evaluation after 6 months of failed attempts to conceive, or earlier if clinically indicated. This recommendation reflects the reality that fecundity declines gradually but significantly beginning around age 32 and drops more rapidly after age 37 [1][2]. The finite ovarian reserve and reduced oocyte quality with advancing age mean that waiting a full 12 months could cost valuable reproductive time [3].

This client has already been trying for 7 months, which exceeds the 6-month threshold for her age group. Therefore, evaluation is warranted now, not at 12 months. Option 3 is incorrect because it applies the 12-month rule that is appropriate only for younger women.

Why the ectopic pregnancy history matters

The client’s prior tubal ectopic pregnancy is not just a historical footnote. It is a known risk factor for tubal factor infertility. An ectopic pregnancy often indicates underlying tubal pathology, such as scarring, adhesions, or impaired tubal motility, which can interfere with normal transport of the embryo into the uterus. Even though the ectopic pregnancy was treated medically rather than surgically, the underlying tubal environment may still be compromised.

Key point! A history of ectopic pregnancy, pelvic inflammatory disease, endometriosis, or prior pelvic surgery should lower the threshold for early infertility evaluation, regardless of age. In this case, the ectopic history reinforces the decision to evaluate now rather than waiting longer.

Putting it together

| Classification | Definition | Evaluation timing (age 35+) | This client |
| --- | --- | --- | --- |
| Primary infertility | Never conceived | After 6 months | Does not apply (has prior pregnancy) |
| Secondary infertility | Prior pregnancy regardless of outcome | After 6 months | Applies (prior live birth and ectopic) |

The client has secondary infertility because she has a previous pregnancy and birth. Because she is 36 years old and has been trying for 7 months—beyond the 6-month threshold for women 35 or older—evaluation should begin now. The prior tubal ectopic pregnancy adds further clinical justification for prompt assessment of tubal patency and overall fertility status [1][2][3].References (research sources)

- [1]Female age-related fertility decline. Committee Opinion No. 589.Research articleAmerican College of Obstetricians and Gynecologists Committee on Gynecologic Practice and Practice Committee (2014) · DOI: 10.1016/j.fertnstert.2013.12.032

- [2]Female age-related fertility decline. Committee Opinion No. 589.Research article(2014) · DOI: 10.1097/01.AOG.0000444440.96486.61

- [3]Age-Related Fertility DeclineResearch articleCarlson K, Sparzak PB. (2026)

## 임상 시나리오

Infertility Classification and Evaluation TimingASRM 2023 criteria for women 35 and older
Secondary infertility is defined by any prior clinical pregnancy, including live birth, miscarriage, or ectopic pregnancy. This client has a 5-year-old child and a prior tubal ectopic pregnancy, so primary infertility is ruled out.

For women 35 years or older, the ASRM 2023 guideline shortens the evaluation threshold to 6 months of regular unprotected intercourse without conception. This client is 36 years old and has been trying for 7 months, so evaluation is indicated now.

CautionA prior tubal ectopic pregnancy raises concern for tubal disease, which further supports prompt evaluation rather than waiting the full 12-month standard used for women under 35.

## 핵심 개념

- **Primary infertility** — Inability to conceive in a woman who has never achieved a clinical pregnancy.
- **Secondary infertility** — Inability to conceive after a previous clinical pregnancy, regardless of pregnancy outcome.
- **ASRM 2023 definition** — Infertility recognized after 6 months of failed attempts in women 35 or older, prompting earlier evaluation.
- **Tubal ectopic pregnancy** — A pregnancy implanted outside the uterus in the fallopian tube; a risk factor for tubal disease and subsequent infertility.
- **Fecundity** — The biologic capacity for reproduction; declines gradually after age 32 and more rapidly after age 37.

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