Evaluation of Infertility

Infertility is a complex disease and is often due to numerous factors. A woman who suspects she is infertile must have a thorough examination by a specialist.

The first office visit will consist of a history and physical. The physician will ask questions regarding frequency of intercourse, regularity of periods, general health, etc. The doctor will also want to know about any pelvic infections, endometriosis, surgeries, ectopic pregnancies, or social habits (such as smoking) that may negatively affect fertility.

You will be screened for rubella (measles) and venereal disease. The hormones that affect reproductive capability (DHEA, testosterone, progesterone, follicle stimulating hormone, and leutinizing hormone) will be measured and evaluated as appropriate.

It is very important that the male partner be evaluated during the initial workup. A history of genital infections, trauma, or environmental exposure to toxins can reduce male fertility. Disorders of the endocrine system (hypothalamus, pituitary gland), structural dysfunction (such as obstruction of the vas deferens), or numerous other conditions can cause male infertility. In addition, the male may experience sexual dysfunction and/or retrograde ejaculation.

One of the first tests will be the semen analysis. No treatment of the female will prove effective unless the male produces enough viable sperm to cause fertilization.

The semen analysis determines the number, shape, and swimming ability of the sperm. Healthy sperm have a characteristic structure and tend to swim in straight lines. A normal male will produce over 20 million sperm per milliliter of semen.

Ovulation Evaluation

Ovulation must occur for an egg to be released. The graphic depicts the expulsion of the ovum from the ovary and its progress through fertilization to the blastocyst stage. Ovulation will be documented during the early stages of the evaluation through the use of basal body temperature monitoring (BBT) or, in most cases, a urine ovulation detection kit (LH kit). The LH kit is far more accurate, and less intrusive, than the BBT.

Ovulation may be tested with a serum progesterone level done in the mid-luteal phase (last part of your cycle). Progesterone is a naturally occurring hormone needed for proper preparation of the lining of the uterus (endometrium) for acceptance of the embryo. High levels of progesterone indicate that ovulation has occurred.

An endometrial biopsy may be required. This is an office procedure. A small segment of tissue is removed from the endometrial lining of the uterus a few days prior to menses. The development of this tissue indicates the readiness of the endometrium (lining of uterus) to support a developing embryo.

An ultrasound will document the proper development of the follicle and egg release. The ultrasound passes sound waves (nontoxic) through organs and allows the doctor to differentiate structures. A probe is placed in the vagina and the ovary is examined.

This picture demonstrates the use of the ultrasound probe in the retrieval of eggs for an assisted reproductive technique, such as IVF. The ultrasound view shows several developing follicles (dark circles). No needle is needed for a routine vaginal probe ultrasound.

Cervix Evaluation

A postcoital test may be ordered. The postcoital test determines if the sperm can survive in the cervical mucus. The mucus is the transport medium that allows sperm to reach the egg. A sample of the cervical mucus is taken after intercourse and examined to determine if mobile sperm are present. If healthy sperm are not found in the mucus, fertilization is unlikely.

During the periovulatory period the cervical mucus should be profuse, thin, clear, and contain no blood cells. The presence of abundant high quality mucus is one indicator of appropriate female hormone function.

The functional properties attributable to the cervix are:

1. It must be receptive to sperm penetration.
2. It must serve as a sperm reservoir.
3. It protects sperm from the vaginal environment.
4. It filters out unfit sperm so they do not reach the egg. The cervix is the gate though which the sperm must pass to reach the egg.

Evaluation of Uterus and Fallopian Tubes

In some cases a hysterosalpingogram (HSG) will be ordered. The HSG and the laparoscopy are considered the second stage of the infertility workup. Both of these tests are done as hospital outpatient procedures.

The HSG determines if the fallopian tubes are open, thus allowing the transport of the egg from the follicle to the fimbria (end of the tubes). Factors which are known to affect the patency of the fallopian tubes are:

1. A history of pelvic inflammatory disease.
2. A previous ectopic pregnancy.
3. Prior use of an intrauterine device for contraception.
4. A history of appendicitis.

The HSG also illustrates the contour and shape of the uterus. Dye is used to elucidate the fallopian tubes and uterus during X-rays. In some cases, the HSG has a therapeutic effect, probably by opening or straightening clogged tubes. There is an average threefold rise in conception after this procedure.

Evaluation of Pelvis

Laparoscopy is considered to be the final diagnostic procedure as it allows the physician to directly visualize many of the reproductive organs. Two small openings are made in the abdomen and the laparoscope is inserted. This procedure is very effective for identifying and treating endometriosis and obstructive diseases.

Reproductive specialists receive many hours of advanced training in the use of the laparoscope and can often correct problems duirng thelaparoscopic examination.

Even after testing, no cause for infertility can be found in 10 percent of cases. These percent patients' best chance for conception is usually through IVF. Statistics demonstrate that well over three-fourths of couples who seek appropriate help will conceive. Regardless of the cause of infertility, a thorough evaluation by an experienced infertility specialist will yield the best chance for success.

For additional information, see Tests for Infertility.