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Basic Infertility Evaluation

The evaluation of infertility is very straightforward and may be completed over a period of about one month. Both the man and the woman should be evaluated. It is reasonable to begin the evaluation after 1 year of attempting to conceive if the woman is less than 35 years of age and after 6 months of unprotected intercourse if she is above the age of 35. As you can see below, age play a role in conception rates.

Conception Rates-Fertile

Age % Conceive in
12 Months
20-24 86
25-29 78
30-34 63
35-39 52

The causes of infertility are broadly categorized as follows, and the evaluation addresses each of these. The frequencies may vary from population to population, but this serves as a useful guideline.

Cause %
Tubal pathology 35%
Male 35%
Ovulatory 15%
Cervical 5%
Idiopathic 10%

The evaluation should begin with a detailed medical history and physical examination. The age of menarche (age menses began) should be noted. The length of the menstrual cycle (normal approximately 25-35 days), and the amount of bleeding should be reported. It is important to know if the patient has painful periods (dysmenorrheal) or painful intercourse (dyspareunia). These could be signs of endometriosis or pelvic adhesions. Irregular menstrual cycles may be a sign of an ovulation disorder. A common ovulation disorder is PCOS. Please see other parts of web site that review PCOS in detail. It is important to know if the patients have a history of STDs, tobacco or marijuana use, or has a job where environmental factors could affect reproductive capacity. Patients with prior abdominal surgery (i.e. ruptured appendix, caesarian section) may have pelvic adhesions and patients with a prior cone biopsy may have cervical factor infertility that would benefit from an intrauterine insemination. A family history of birth defects, early menopause, mental retardation may also be important. The physical examination should include body mass index, thyroid palpation, signs of androgen excess like hirsutism and pelvic examination with reference to uterine size, position, tenderness, and ovarian enlargement or tenderness.

Diagnostic Tests

Semen Analysis

The semen should be collected on site or at home if the sample can be delivered within one hour. It is important to have 2-3 days of abstinence. Too frequent intercourse may lower an already low sperm count and too infrequent intercourse may lead to decreased motility.

volume 1.5-5.0 cc
sperm density >20 million / ml
percent motility >50%
forward progression >2  (scale 1-4)
morphology >50% normal

And

no significant agglutination
no significant pyospermia
no hyper-viscosity
Strict morphology-normal smooth contour, head, acrosome 40%-70% of distal head, NL mid-piece & tail, no cytoplasmic droplets (NL=4%-14%).

Newer tests under development include assessing the amount of sperm DNA damage (i.e. sperm chromatin assay, DNA fragmentation assay, etc.). These tests may have some utility, but the tests are not widely used in the United States and have not been replicated in many labs. As a basic evaluation, the standard semen analysis should be considered the ‘gold standard’, at present.

Assessment of fallopian tubes

The status of the fallopian tubes may be evaluated with a hystersosalpingogram (HSG) or with a diagnostic laparoscopy. If the patient has signs and symptoms of endometriosis or pelvic pain, the laparoscopy may help treat as well as diagnose the condition. The diagram below shows an HSG. A balloon catheter is now used rather then the device shown;

The HSG may show occlusion of the fallopian tubes and uterine cavity defects like scar tissue, polyps or sub-mucosal myomas. The HSG below shows bilateral hydrosalpinges (blocked tubes) most likely due to a previous pelvic infection.

Assessment of ovulation

Several methods are available to assess if the patient is ovulating. A serum progesterone level on cycle day 21-23 (>2 ng/ml) may be used. Ovulation predictor kits are widely available for self-testing. These have the advantage of predicting ovulation and helping the patient time intercourse well. Patients may do a basal body temperature chart by taking their temperature each morning upon awakening. A chart with is biphasic is consistent with ovulating. A monophasic or flat chart is consistent with not ovulating.

Other methods to assess ovulation include trans-vaginal ultrasound exams at the time of ovulation to see if a dominant follicle has developed. In the past, endometrial biopsy was used to assess the development of the endometrium in response to progesterone. The endometrium undergoes a specific series of changes during the luteal phase, and the biopsy may be used to ‘date the endometrium’. If the endometrial date is > 2 days from the appropriate date based upon ovulation, a luteal phase defect may be present. The concept of luteal phase defect is controversial with respect to it being a cause of infertility. Additionally, most of our treatment will correct any potential luteal phase problem so endometrial biopsies are not commonly done.

Ovarian reserve testing

Women have a finite number of eggs. When a women is 5 months along inside her mothers uterus, she has 5 million eggs in her ovaries. When she is born she has about 1 million eggs and when she has her 1st period at the age of about 12 years of age about 200,000 eggs are in the ovaries. At menopause, there are essentially no eggs left in the ovaries. This is the basis of the age related decline of fertility. In order to assess ovarian function, an FSH level is checked on the 3rd day of the menstrual cycle. If the FSH is high (>20 mIU/ml), ovarian reserve may be significantly compromised. In general, we consider testing all patients 35 years of age and older. Please see more information on this topic in the patient education part of our web site.
 

 

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