The basic elements of an infertility evaluation target ovarian function, tubal and uterine anatomy, ability of the sperm to reach the fallopian tube and male factor.
Improvments in diagnosis and treatment technology is changing the medical experience and chance of success for couples experiencing infertility. The efficiency and accuracy of the infertility work up is a key factor in developing the appropriate treatment plan to achieve the couple's ultimate goal, a healthy baby. Since women are often starting their families at later ages, the initial infertility evaluation in the female has evolved to focus more on ovarian function as an indicator of fertility potential. However, assessment of all the other factors are still important parts of the evaluation. Following a history and physical examination, the initial tests used to assess the major causes of infertility are:
In the majority of cases this information is enough to indicate the appropriate initial treatment plan. Today laparoscopy is not routinely indicated, because it has the risks of surgery and does not usually change the initial treatment plan. It may be recommended in specific cases if there is suspected endometriosis or tubal disease based on the history, physical findings, ultrasounds or if there are other specific gynecologic reasons to perform this procedure.
Evaluation of infertility is warranted for a couple when the female partner is older than 35 and has been trying to conceive for 6 months without success. It is also indicated if the female partner is 35 years of age or less after the couple has been trying to conceive for one year. Immediate evaluation and treatment of infertility is warranted in cases of known problems such as anovulation, tubal occlusion, or severe male factor infertility. We also must be aggressive in evaluating and treat women 40 years and greater because of the increased potential for significant loss of ovarian reserve in this age group.
These hormone levels are drawn on the second or third day of full menstrual flow. The purpose is to evaluate ovarian reserve. Diminished ovarian reserve may be suspected by elevation in either the FSH or the estradiol. An antral (early) follicle count can be used to further clarify the patient's ovarian reserve. The ovarian reserve essentially tells us whether it is worthwhile to offer treatment to the patient using her own eggs.
The FSH levels will vary somewhat by the endocrine lab and the assay used. Unfortunately the prognosis is based on the highest, but not necessarily the most recent, FSH level. It is advisable to obtain an opinion and possible further testing from an infertility specialist for those patients with abnormal levels, especially those under age 38.
The hysterosalpingogram (HSG) is still the best, and least invasive method of evaluating the inside of uterine cavity and patency of the fallopian tubes. In addition, a sonohysterogram (ultrasound after saline is placed in the uterus through a catheter) is a relatively non-invasive way of evaluating the uterine cavity alone if intrauterine pathology is suspected, but does not give you any information about tubal patency. Both tests can uncover uterine abnormalities such as intracavitary adhesions, fibroids or polyps. But, only the HSG can evaluate tubal abnormalities such as occlustions or hydrosalpinges. Abnormalities on an HSG or sonohysterogram may warrant further evaluation with laparoscopy and or hysteroscopy.
The proper development of the follicle, which contains the egg, and the timing of its release is critical to the evaluation of infertility. Ultrasound is a safe, painless and non-invasive way of evaluating this factor and timing subsequent tests.
Once the timing of ovulation is determined accurately, the next step is to asscess if the sperm can penetrate the cervical mucus. When ultrasound and the urine LH kit pinpoint the timing, the couple is instructed to have intercourse and come in the next morning, at which time a microscopic examination of the cervical mucus will show if there is adequate penetration of the sperm.
Menstrual cycle regularity and premenstrual symptoms are reliable medical history indicating the probability of ovulation. However, some women ovulate but fail to produce adequate quantities of progesterone (luteal phase deficiency) following ovulation. The clinical tests for ovulation (e.g. temperature chart, positive ovulation predictor kit) are not sufficient to diagnose luteal phase deficiency. We recommend obtaining a progesterone level approximately 8 days after detection of the LH surge.
It is important to perform this test early in the infertility evaluation since in at least 40% of couples experiencing infertility the sperm quality will be a factor. The test will identify a potential male factor by checking the semen volume, sperm concentration, motility and morphology (appearance) in a semen sample.
With this streamlined work up, which can be completed within one menstrual cycle, a couple can be efficiently evaluated, specific major causes of infertility identified, and treatment options considered. As with all medical testing, an infertility evaluation must be tailored to each patient's situation.