How common is infertility?
Infertility is currently a problem for one out of five couples trying to have children.
Top Back
When should we begin investigating whether or not we're infertile?
If after a year of trying to conceive you are not successful, a basic infertility evaluation may be started. If the female partner is older than 30, however, or has a significant past medical history of irregular periods or previous pelvic infections, the infertility evaluation and tests can be started earlier.
Top Back
What is the procedure for determining if we're infertile?
The infertility work-up itself follows a fairly specific sequence. A complete work-up or evaluation of the woman usually takes three or four cycles to complete. This is because certain tests have to be done at specific times in the menstrual cycle. The nature of the infertility work-up necessitates that it become a priority in your daily life. Suddenly, there are specific days that you must have intercourse. In certain tests you even have to report to the doctor's office a specific number of hours after intercourse. As a result, spontaneous lovemaking becomes difficult. Vacations and business trips become low priority. Schedules have to be made to fit the demands of the testing cycle. Many women find it hard to take time off from work, especially if they don't want it known that they are undergoing an infertility evaluation. It can be a stressful time. Both husband and wife are being tested and scored. There can be a feeling of "pass or fail" and a real sense of despair if a test comes back showing questionable or negative results. Women often feel frightened and violated by the infertility tests. Men often feel helpless. For the husband, testing is over if the semen analysis is normal. In contrast, he may see his wife having to go through various tests which can be painful and frightening. This understandably can upset both parties. Added to this worry and uncertainty is the lingering fear over what the doctor will discover. What if he finds an answer, but a discouraging one? For these many reasons, deciding to start an infertility work-up is a big decision.
The following is an overview of the tests involved. You may use it to understand what tests may be required, or to double-check that you have had all the tests.
Initial appointment
The couple is usually seen together for the first appointment. This provides an opportunity to establish good communication. It also is an opportunity to evaluate what, if anything, has been done and what will be needed in the future. A list of tests and a time frame for completing the evaluation will be given at this time.
A detailed medical history of the couple will be taken. The physician will also want to know about the medical history of the immediate family. Attention will be paid to previous surgery, infections, chronic illnesses and hospitalizations. Background information on smoking, alcohol intake, medications and exposure to environmental or occupational toxins will be requested. A detailed reproductive history from both partners will be needed. This includes information on when menstrual cycles started, how long they last every month, quantity and quality of flow, and a description of menstrual cramps. Details about the types of birth control practiced will be obtained. Any history of previous pregnancies will be discussed. Information about previous venereal disease is crucial in the evaluation. A fairly detailed report concerning their sexual history as a couple will be needed. Questions about lubricants and frequency of intercourse will be asked as well.
Physical examination
A physical examination of both partners should be done on the first or second visit. For the woman this means a general physical with attention paid to the development of secondary sex characteristics, such as breast development and the amount and location of body hair. A pelvic exam will determine the general size, shape, position and condition of pelvic organs. A Pap smear is routinely taken (to rule out cervical cancer), as well as a gonorrhea culture. The physician will order routine tests on blood and urine to check for general health problems.
For the man there will be an examination of the genital organs, with the doctor noting size, position and condition of the penis and testes. A rectal exam is done to determine the size and consistency of the prostate gland and seminal vesicles. The development of secondary sex characteristics will also be noted. Routine blood and urine tests will be done.
Ovulation detection
You may be given instructions about using the basal body thermometer (BBT) to monitor the shifts in body temperature. Two to three months of BBT charts are often requested. This will give a sense of the general times the woman is ovulating. The physician will use these charts to determine when some of the tests have to be scheduled, as many can only be done at special times in the cycle.
Medical evaluation of the male
Semen analysis
This is the first and most informative test done on the male. An analysis can be done any time because a man is not as cyclic as a woman. Abstinence from intercourse for 24 to 48 hours before the analysis is suggested. Abstinence for a longer period than two days is not necessary. For the semen analysis, the man will be asked to masturbate a specimen into a clean jar. This can be done at home and kept at body temperature and delivered to the lab for evaluation. Then the laboratory will examine the specimen under a microscope to look for the number of sperm present, how fast the sperm are swimming (motility) and the shape of the sperm (morphology). The total volume of the specimen and its viscosity (thickness) will also be checked.
A fertile semen specimen should have at least 20 million sperm, with at least 50 percent of the sperm motile, and 50 to 60 percent with good morphology. Normal volume is 2-5 cc. A semen analysis should be repeated at least once, because all levels fluctuate. It is also a good idea to repeat semen analysis periodically if the infertility investigation of the couple is lengthy, as these levels can change over a long period of time.
If the semen analysis indicates there may be an infertility problem, other tests on the semen will be done. The semen will be checked for the presence of fructose, which is a special kind of sugar produced in the epididymis. If it is absent this may mean there is a blockage in the ductal system, although sperm production may be normal. In addition, the semen may be checked for unusual clumping or agglutination that could indicate an immunologic response -- a "sperm antibody" condition. Some physicians also order a new test called the "zona free hamster egg test" to check that the sperm are able to penetrate the outer layer of a hamster egg, which is very similar in structure to a human egg.
Several additional tests may be done on the male if the semen analysis is not normal:
- Evaluation for a varicocele is done by palpating the scrotum while the man is bearing down or coughing. The link between the presence of a varicocele and infertility is not clearly understood. The most common theory is that the presence of a varicocele causes poor circulation which ultimately inhibits normal sperm production.
In the event of a subfertile semen analysis, a small biopsy of both testicles may be done. This procedure is done in a hospital under local or general anesthesia. The testicular tissue is examined in the laboratory. This test can tell the doctor if there is an absolute infertile state with no sperm-producing tissue present, or if there is blockage in the vas deferens (indicated by the presence of normal testicular tissue, yet little or no sperm in the ejaculate).
If a blockage in the vas deferens is suspected during a testicular biopsy, a vasography can be done to pinpoint the area of the blockage. This is an X-ray study in which dye is injected into the vas deferens and a series of X-rays are taken.
Medical Evaluation of the Female
Hormonal evaluation
This is done through a series of blood tests. FSH (follicle stimulating hormone) and LH (leutinizing hormone) levels are checked. Both these hormones are produced in the pituitary gland. Low levels of FSH may indicate that the pituitary gland is not releasing enough of this vital hormone which is necessary to stimulate the egg to ripen in the ovary. Low levels of LH may indicate the egg is being stimulated to develop but because LH levels are low, the egg is never released. Blood tests to check thyroid levels and prolactin levels also may be needed. Elevated prolactin can cause irregular ovulation in some women. Testosterone and androgen levels (male hormones) will be checked if a woman's cycle is irregular. Overproduction of either of these hormones in the adrenal gland or ovary can cause irregular ovulation.
Evaluation of ovulation
Doctors like to use the BBT charts and do an endometrial biopsy and/or a plasma progesterone level to document ovulation. The plasma progesterone level is a blood test taken midway between ovulation and menstruation. Progesterone, the hormone produced by the ovary after ovulation, is responsible for triggering the build-up of the endometrial tissue (the lining of the uterus), which is essential if the fertilized egg is to implant and grow. The endometrial biopsy is a test used to evaluate this uterine tissue's build-up and thickening after ovulation. It is usually done after day 21 of the cycle. This is an office procedure and involves slightly dilating the cervix and putting a small instrument into the uterus that removes a tiny sample of tissue. The tissue is then examined under the microscope. If the tissue is lush and building up as it should, the doctor can infer that progesterone is present in sufficient quantity and that the woman has a good quality ovulation. The endometrial biopsy can be uncomfortable because the dilation of the cervix causes moderate to strong cramping. Deep breathing using abdominal muscles can sometimes relieve this sensation. Sometimes pain medicine will also be used. There can be slight vaginal bleeding after this test but it is usually minimal.
Evaluation of the fallopian tubes
The hysterosalpinogram is an X-ray used to determine if the fallopian tubes are open. A radiopaque dye is inserted up through the dilated cervix into the uterus. X-ray films are taken as the dye flows up and out of the tubes. The procedure usually lasts 20 to 30 minutes. Follow-up X-rays are often required. This X-ray is done in the first part of the cycle to ensure that there is no chance of exposing a possible pregnancy to X-ray. This test is uncomfortable. Because the cervix is dilated, there is cramping and an intense feeling of fullness as the dye flows into the uterine cavity. Some women also experience shoulder pain after the hysterosalpinogram. Sometimes medication for pain, a local cervical block and/or a medication to help relaxation will be ordered. It is a good idea to have someone come with you, as you may not feel like driving home. You won't necessarily be in pain, but women usually feel tired and weak after the stress of having such a test.
A variety of tests called "endoscopy" allows the doctor to inspect the internal pelvic organs. There are several types of endoscopy exams. Culdoscopy is a procedure in which a slim telescope is introduced into the abdominal cavity via a small incision made in the vaginal wall. The woman is in the knee-chest position throughout the procedure. Local anesthesia is usually given. Laparoscopy is a newer and more popular technique used to evaluate the outside of the uterus, the tubes and the ovaries. It is the most important test used to check for the presence of endometriosis. In this test, the woman is in the hospital under general anesthesia. The laparoscope is inserted through a small incision near the bellybutton. The abdomen is inflated with carbon dioxide gas to allow for the best possible access to the pelvic organs. If needed, small adhesions or scar tissue can be removed during this test. Dye can also be injected up through the cervical canal and the doctor can observe spilling out the ends of the tubes if the tubes are open and clear. A new endoscopic procedure called hysteroscopy is now being used when a doctor wants to see the internal cavity of the uterus. This involves introducing a small telescope-like device through the cervix into the uterus. General or local anesthesia is used. Any abnormal structures, such as septums, polyps, or scar tissue, inside the uterus can be examined using this procedure.
Male-female interaction evaluation
The main test used to check the survival of the sperm in the cervical mucus is the Huhner or post-coital test. It is done to ascertain the quality of the woman's mucus as well as the way in which the woman's mucus and the man's sperm interact. This test is done at the time of ovulation when the mucus is most fertile. The couple is instructed to have intercourse, without using lubricant, a specified number of hours before they come in for evaluation. A swab of mucus is taken and examined under a microscope to look for the presence and activity of sperm, as well as the quality and viscosity of the mucus. Poor results are indicated if the mucus is thick, if the sperm are not moving well or if none are present in the cervical mucus. When poor results are discovered, the test should be repeated. (It is important to note that the post-coital test should not serve as a substitute for a full semen analysis, as both yield somewhat different information.) Poor post-coitals may also be a clue to the presence of infections, such as Chlamydia and T-Mycoplasma. Certain microorganisms are now thought to be a possible cause of infertility. Many infertility specialists will check couples for T-Mycoplasma. This organism is a cross between a virus and a bacteria and can be cultured in the lab by taking a sample of the cervical mucus from the female or a sample of mucus from the penis. This test -- as well as others to check for organisms like Chlamydia -- are expensive but should not be overlooked, especially if a couple falls into the "normal infertile" grouping where no specific organic reason has been found for the ongoing infertility.
Top Back
What's
New