Evaluation of Couples with Fertility Problems

Achieving pregnancy is a team effort. The causes of infertility are just as likely to be caused by male and female factors, and the treatment always involves both members of a couple. With this in mind, both the woman and her partner should come to appointments whenever possible.

History and Physical

First, a thorough history is obtained to determine if either member of the couple has a past or current medical problem which might decrease the chances of pregnancy. Important topics to discuss include:

General health
Medications
Previous surgeries
Gynecologic problems
Sexual activity
Menstrual cycles
Past pregnancies

Next, a general physical exam will focus on medical problems that might cause infertility, such as signs of PCOS. Some fertility issues, such as endometriosis or infection, can be suggested by tenderness on pelvic examination. However, most common causes of infertility will not be obvious on examination.

Testing

Semen Analysis – A semen analysis is a lab test using a sample of ejaculate from the male partner. This test is used to find out the amount of sperm and quality of sperm. Sperm that are diminished in number or function are less likely to reach and successfully fertilize the egg. A semen analysis is done for almost all couples.

The three most important aspects of a semen analysis are:

Concentration (commonly called “count”)
Percent that are motile
Percent that appear to be normally formed (called “morphology”)

Men that have decreased values often require additional testing to look for reversible causes.

Imaging

Transvaginal ultrasonography is a common part of the initial evaluation. It provides excellent images of the pelvic structures, including the cervix, uterus, and ovaries. Careful evaluation of the pelvic organs will often detect abnormalities such as uterine fibroids, fluid-filled fallopian tubes (termed hydrosalpinx) and abnormal ovarian cysts. When saline is injected into the uterus during ultrasound (termed sonohysterogram), endometrial polyps and fibroids can also be detected.

Hysterosalpingography (HSG) is an X-ray test that is an important part of the basic infertility evaluation. This test is performed in the radiology department by placing a device through the cervix to inject dye into the uterus and tubes. The test causes menstrual-like cramping, so it is recommended that the women take a pain medicine (e.g., ibuprofen) prior to the procedure.

Tests for Ovarian Reserve

Ovarian reserve is an imprecise term that refers to the quanity and quality of eggs of remaining in a woman’s ovaries. Most women have normal ovarian reserve, as reflected by the tests discussed below, from the teenage years to the mid thirties. Decreased ovarian reserve becomes increasingly common after 35 years of age and is believed to be why fertility decreases with age. In some infertile women, decreased ovarian reserve will be found at a younger age. Decreased ovarian reserve is used by some specialists as an indication to proceed to more advanced treatment options at an expedited rate.

Day 3 FSH – FSH, or follicle stimulating hormone, is a hormone central to egg development. It is lowest early in the menstrual cycle and peaks the day before ovulation. As a woman ages, decreased ovarian reserve results in an increased FSH level on Day 3 of the menstrual cycle. There is some variation of Day 3 FSH levels between cycles.

Antral Follicle Count – Antral follicles are small fluid-filled areas within the ovary from which eggs can be released during subsequent cycles. Decreased ovarian reserve is reflected by a decreased number of antral follicles early in the cycle as determined by transvaginal ultrasonography.

Anti-Mullerian Hormone (AMH) – This is a hormone made by granulosa cells in the ovaries and remain the same among cycles and throughout the cycle. Lower levels may indicate decreased ovarian reserve.

Clomiphene Challenge Test – Measuring FSH after stimulating the ovaries with the medication clomiphene citrate will detect a small number of women with decreased ovarian reserve who have a normal Day 3 FSH. Because of the increased expense of this diagnostic test, it is only performed if it guides diagnostic decisions.

Tests for Ovulation

Several tests can be used to determine if a woman is ovulating. If infertility is longstanding or appears to be related to ovulation problems, many specialists will induce ovulation with oral or injectable medications and monitor treatment effectiveness with ultrasound and hormone measurements.

Basal Body Temperature – A time-tested method that has been used for years is the measurement of a woman’s basal body temperature with an oral thermometer before getting out of bed in the morning. The day after ovulation, a woman’s basal body temperature increases by about 10 Fahrenheit. The patient can record her temperature every morning. Unfortunately, this test documents ovulation only after the fertile time is past, so it is not as commonly used today.

Urine Ovulation Predictors – Women can use over-the-counter kits to predict ovulation. These kits detect the increase in urinary luteinizing hormone (LH) that occurs approximately 24 hours before ovulation. During natural cycles, these kits can be used to time intercourse or IUI, which are routinely recommended the day after detecting the LH surge in order to coincide with ovulation.

Luteal Phase Evaluation – The luteal phase is the time between ovulation and menstruation, and is normally 12 to 14 days in length. The ovary must produce enough progesterone for long enough to allow the fertilized egg to implant approximately one week after ovulation. Subtle defects in the luteal phase are thought to cause infertility and recurrent miscarriages in some women. If the luteal phase is short, some women are offered progesterone to use in the second half of their cycle.

Mid-Luteal Progesterone – Ovarian production of progesterone reaches a peak approximately 7 days after ovulation, or around Day 21 of a 28-day menstrual cycle. A blood test taken at this time can determine if a woman has ovulated.

Endometrial biopsy – In the past, a biopsy of the uterine lining was taken late in the luteal phase. A pathologist would attempt to determine if the endometrium was responding appropriately to progesterone. Because this test is uncomfortable, expensive and inaccurate for detecting fertility problems, it is not commonly used today for this purpose.

Other Infertility Testing

Some of the tests for these subtle abnormalities are less frequently performed today because the commonly-used therapies will often treat these conditions. Tests such as the post-coital test and endometrial biopsy are no longer part of the standard infertility evaluation, but they may be performed in special cases.

The post-coital test (PCT) was extensively used in the past to evaluate cervical mucus after intercourse. However, cervical mucus problems are effectively treated with intrauterine insemination (IUI), which is one of the most commonly-used fertility enhancement techniques. Since this is an early treatment method for infertility of any cause, PCTs are rarely done today. Likewise, subtle endometrium and ovulation problems are effectively treated by ovulation induction with oral or injectable medications or with IVF. For this reason, many specialists will spend less time and money on relatively inaccurate diagnostic tests and more time and money on effective treatment methods.

Surgical Tests

Diagnostic Laparoscopy is an outpatient surgical procedure that requires general anesthesia, and is thus performed in the operating room. A lens connected to a camera is inserted through a small abdominal incision to examine the pelvis. Problems that decrease fertility, such as endometriosis and pelvic adhesions, can be accurately diagnosed and treated with this technique.

In the past, laparoscopy was a standard and early component of most infertility evaluations. With the increased success rate associated with IVF, this step is often omitted, since treatment of subtle cases of endometriosis or pelvic adhesions has little effect on subsequent IVF success.

Diagnostic Hysteroscopy is another outpatient surgical procedure where a small lens connected to a camera is inserted through the cervix to examine the uterine cavity. Since this procedure can be performed with minimal anesthesia, it is sometimes performed in the office. Alternatively, sonohysterography (see above) can be used to evaluate the endometrial cavity and has the advantage of causing less discomfort for the patient.

Sources:

American Society for Reproductive Medicine. Infertility: an overview, United States. 2003. Birmingham, Ala: American Society for Reproductive Medicine.
Falcone T, Hurd WW, eds. Clinical Reproductive Medicine and Surgery, New York: Elsevier, 2007.

Prepared in partnership with Melina Dendrinos, MD, Class of 2008

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