The basic infertility evaluation

The definition of infertility is the inability of a couple to conceive after 1 year of sexual intercourse without using any type of contraception, or after 6 months if the female partner is over the age of 35. In normal fertile couples the monthly conception rate is approximately 20%. Most infertility specialists evaluate patients who are hypofertile or sterile (premature menopause, tubal ligation, vasectomy).

One out of 6 couples is affected with infertility in the United States. Over two million couples in the U.S. are evaluated for infertility yearly.

Infertility increases with age:

Age % Infertile
20-29 years 8.0% (1 in 10 couples)
30-34 years 14.6%
35-39 years 21.9%
40-44 years 28.7% (1 in 4 couples)

Infertility-Sign-300x300Therefore it is advised not to delay your childbearing and seek help early.

It is important to realize that about 80% of couples under age 35 will conceive within 6 months. If you are under 35 years of age and have already tried for 6 months you should start charting your ovulation and go to your gynecologist for a routine checkup. About 90% of all couples trying to conceive will do so within a year. About 96% of all couples trying to conceive will do so within 2 years. 98% will conceive by 3 years (with not much further gain after 3 years).

There are many causes of infertility these include:

Cause of infertility %
1. Not ovulating 20%
2. A problem inside the abdomen
(adhesions, scar tissue, endometriosis)
20-40%
3. Abnormal sperm count 40%
4. Unknown 15%

Of infertile couples evaluated, a cause is found to be a female problem only 1/3 of the time, a male problem only 1/3 of the time and 1/3 of the time it is a combination of both a male and female problem.

Useful things to consider before seeing an infertility specialist

Baby-in-Womb-pic-300x225Do you have a history of:

  1. Abnormal menses
  2. Pelvic infections (Gonorrhea, chlamydia, PID, endometritis, IUD use)
  3. Pelvic pain
  4. Prior surgery
    1. Pelvic (ovarian cyst, endometriosis, c-section, tuboplasty, etc.)
    2. Endometriosis in yourself or a family member (1 first degree family member 7x higher risk, 2 first degree relatives with 10x higher risk that patient will have endometriosis.)
  5. A problem with your uterus
    1. Long and heavy periods
    2. History of D&C
    3. History of recurrent miscarriage
    4. History of IUD use
  6. History of an abnormal pap smear with subsequent cryosurgery/laser of the cervix

YES answer to any of the above questions increases your risk of infertility and you should see your fertility specialist within 6 months of trying.

There are many tests to evaluate the infertile couple. Below is a summary of some of the tests.

The first step is to evaluate ovarian function—The most reliable indicator is regular menstrual cycles. But these tests may be performed to assess the timing and quality of ovulation:

  1. BBT charts
  2. Ultrasound evaluations to see if eggs are growing
  3. Blood work to determine if you have ovulated
  4. Anti-mullerian hormone, FSH and estradiol blood tests
  5. An ultrasound to determine the antral follicle count
  6. More extensive hormonal evaluation may be necessary if it is found that the patient does not ovulate. Which test is needed will depend upon whether levels are high, low, or normal

The next step would be to evaluate the fallopian tubes and pelvis. Typically this is done with a Hysterosalpingogram (HSG) or saline infusion sonography however this can also be done at the time of laparoscopy (surgery).  Often at the same time the fallopian tubes are evaluated the uterus is evaluated. The HSG or saline infusion sonography will evaluate the shape of the uterus and determine if it is normal.

Common Abnormalities of the uterus found on HSG
uterine-anomalies

sample_01 Normal HSG

sample_02 An abnormal HSG with blocked and dilated tubes (The circles on the pictures show the dilated blocked tubes and no dye passing through the ends of the tube.

It is important not to forget the male part of the evaluation. One third of the time an abnormal semen analysis is found. The test to evaluate the quantity and quality of the sperm is called a 
semen analysis
.

A semen analysis is usually the first test that is done on the male partner and will help determine if the male partner will have problems fathering a child.  It is also used as a diagnostic tool to determine if a surgical procedure, such as vasectomy or vasectomy reversal, is successful.  The test is quick, non-invasive and relatively inexpensive.

The following parameters are included in a complete semen analysis:

Volume:  a measure, in milliliters (ml), of the amount of semen ejaculated.
Sperm Count or Concentration:  the number of sperm present in each ml of semen.
Sperm Motility:  a measure of the percentage of sperm that show movement.
Total Motile Count (TMC):  the total number of moving sperm in a sample.
Progressive Sperm Motility:  a measure of the quality of sperm motility.  Sperm must be able to “swim” to reach the egg.  If an analysis reveals a high percentage of sperm with little or no forward movement, fertility may be impaired.
Sperm Morphology:  a qualitative evaluation of the size and shape of the entire sperm.

Rocky Mountain Fertility Lab uses the following values as normal ranges:

Semen Volume 1.5-5.0 milliliters
Sperm Concentration ≥15 million sperm/milliliter of sample
Sperm Motility ≥40% motile sperm
Total Motile Count ≥16 million motile sperm
Progressive Sperm Motility >32% 3+ and 4+ motile sperm
Sperm Morphology (Krueger’s Strict) Normal > 4% normal forms WHO criteria 2010

Additional parameters such as viability, presence of white blood cells (WBC’s), and presence/absence of fructose may be evaluated depending upon the results of the initial semen analysis.

Results of a semen analysis are usually available within 48 hours. Normal ranges may vary from lab to lab.

About 15% of couples presenting for a workup will have all of the above tests performed with no obvious cause for their infertility. These patients will be given the diagnosis of unexplained infertility. Don’t despair if a diagnosis cannot be found, those with unexplained infertility have high rates of success with therapy.

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