When conception does not occur, a medical evaluation of both the male and female is recommended, in order to determine the cause of infertility.
Despite all investigations, about 15 percent of couples have unexplained infertility, for which a cause cannot be identified at the present time.
An efficient evaluation begins with a review of the couple’s medical history and continues with physical examination and specific investigations:
A complete physical examination (including a Pap smear and testing for infection) is necessary.
Evaluation of ovulation
The basal body temperature graph (BBT) detects ovulation by showing a rise in the body temperature.
Ovulation Predictor Kits (OPK) detect the LH hormone surge in the urine. Once a positive result is obtained,
ovulation will occur within 24 hours.
The serum progesterone level is measured 7-9 days after ovulation.
Other hormones routinely checked as part of the ovulation evaluation are TSH (thyroid) and Prolactin.
Ovarian reserve testing
Cycle Day 3 FSH and Estradiol levels may provide prognostic information on ovarian reserve.
AMH is a hormone produced in ovarian follicles witch is thought to be an accurate test for ovarian reserve.
Ultrasound can show the presence of follicles (the sacs containing developing eggs) and the thickness of the uterine lining. Ultrasound can also show abnormal conditions such as ovarian cysts or fibroids (benign tumors in the uterus).
A hysterosalpingogram (HSG) uses a radio-opaque dye injected into the cervical opening to visualize the inside of the uterus and determine if the fallopian tubes are open.The HSG is performed in the 2nd week of the menstrual cycle (i.e. after menstrual bleeding has stopped but before ovulation).
A speculum is placed in the vagina. The vagina and cervix (opening to the uterus) is swabbed with an antiseptic solution, and a catheter is placed in the cervix. The dye is injected into the uterus and tubes and it shows up on the X-ray. An HSG takes 5-10 minutes to perform.
If the tubes are not blocked by scar tissue or adhesions, the dye will flow into the abdominal cavity. This is a good sign but it does not guarantee that the tubes will function normally.
A hysterosalpingogram may also indicate endometrial polyps, submucus fibroids, intrauterine adhesions (synechia), uterine and vaginal septa or other uterine cavity abnormalities.
Sometimes, hysterosalpingogram has a therapeutic effect, dislodging material which blocks the tubes. A number of women have become pregnant following a hysterosalpingogram without further treatment.
Sonohysterography is a technique in which a fluid is injected through the cervix into the uterus, and ultrasound is used to make images of the uterine cavity. The fluid shows more detail of the inside of the uterus than when ultrasound is used alone. Sonohysterography can find the underlying cause of many problems, including abnormal uterine bleeding, infertility, and repeated miscarriage.
This procedure can detect the following conditions:
Abnormal growths inside the uterus, such as fibroids or polyps
Endometrial adhesions (or scarring)
If a uterine abnormality is suspected after the HSG, a hysteroscopy is indicated, to visualize the interior of the uterine cavity. The procedure is performed with a thin telescope mounted with a fiber optic light, called a hysteroscope. The hysteroscope is inserted through the cervix into the uterus and enables the doctor to see any uterine abnormalities or growths.
Laparoscopy is a surgical procedure that allows a physician to examine the uterus, ovaries and fallopian tubes and to discern endometriosis or pelvic adhesions.
The procedure is done under general anesthesia and is usually performed in a hospital or surgery center. If the physician determines the cause of infertility during the procedure, it may often be treated on the spot. In cases of severe tubal disease or scar tissue, in vitro fertilization may be the best option for conceiving a child.
Scissors may be used to cut out scar tissue, and lasers or electrocautery may be used to treat endometriosis. The injection of dye through the tubes, similar to HSG, may also be performed at this time to detect blockage in the fallopian tubes.
The postcoital test (PCT) evaluates the interaction between the sperm and the cervical mucus at a time near ovulation to determine if an incompatibility exists. Abnormal mucus may occur because of infections or surgery. If it is done too early before ovulation or too late after, the results may be falsely abnormal.
A collection of a semen sample obtained by masturbation is analyzed in the laboratory for the sperm count, sperm motility, and sperm shape.
If the semen analysis is persistently abnormal, a urological exam, more specific sperm testing and hormonal testing are recommended.
The urological examination will check for the presence of anatomical abnormalities (varicocele, congenital absence of the vas deferens).
Ultrasound is sometimes used to confirm an uncertain diagnosis, but there is doubt whether subclinical varicoceles are associated with infertility. A varicocele is an enlarged vein along the upper part of the scrotum. The blood carried in these veins may elevate the scrotal temperature, and possibly carry toxic materials into the testicle, affecting sperm production.
Hormonal testing includes measurement of Prolactin, FSH, LH and Testosterone.
Prostate fluid culture
Urinalysis may be needed to investigate retrograde ejaculation or infection.
Antisperm antibody test may also be ordered to evaluate potential immune system disorders.
Sperm Chromatin Structural Assay (SCSA) or DFI (DNA Fragmentation Index) – New studies suggest that sperm with certain levels of DNA fragmentation serve as a strong predictor of reduced male fertility. Gynera Fertility Center is now offering SCSA, a test to measure the level of DNA fragmentation in the sperm, to enhance the diagnosis of and treatment for male infertility. Patients with a high DNA fragmentation level are likely to have significantly-reduced fertility potential as well as a greater risk of miscarriage.
Testicular biopsy is performed in men with azoospermia, which is the absence of sperm in the ejaculate.
Men with testicular failure (and very low sperm counts) should be tested for Y-chromosome microdeletions and abnormal karyotypes, or chromosomal count. Microdeletions may be transmitted to offspring, resulting in fertility problems for boys born after treatment.
Infertility screening checklist
Female screening checklist:
A. Cycle Day 3 Blood work
1. FSH (Follicle Stimulating Hormone)
B. Infectious disease panel
1. Rubella Immunity
2. Toxoplasma Immunity
3. Blood Group/type (ABO/Rh)
4. HIV – Antibody
5. Hepatitis B- HBs Ag, HBc Ab
6. Hepatitis C-Antibody
C. Mid-cycle (around cycle day 12) ultrasound
D. PAP smear
E. Cervical cultures
Male screening checklist:
A. Semen Analysis
B. Infectious diseases panel
1. HIV -Antibody
2. Hepatitis B- HBs Ag, HBc Ab
3. Hepatitis C-Antibody