Infertility Evaluation Definition
The textbook definition of infertility is when a couple has difficulty achieving pregnancy after trying for one year. However, the work-up can be started earlier even if a couple has attempted pregnancy for a shorter period, especially if the female partner is older than 35. Some women have a known condition that will not allow a chance of conception without help and should get help without delay. In the female partner some of these conditions include blocked fallopian tubes from infections or tubal ligations, ovulation defects, and/or moderate to severe endometriosis. Very low sperm counts or no sperm in the male partner can also warrant immediate intervention or treatment.
Important Personal Factors and Infertility
- Women older than 35 have a more difficult time maintaining and achieving pregnancy related to their poorer egg quality compared to their younger counter parts.
- A man’s semen parameters can also be affected by age but not till the 5th or 6th decade of life.
- History of the male partner is also taken. We must review medical problems such as diabetes and hypertension as well as history of surgeries in the past. Trauma to the testicles can disrupt semen parameters and cause infertility.
- History of pregnancies from other relationships can help elucidate the couple’s current cause of infertility.
- History of possibly distorted pelvic anatomy caused by endometriosis, pelvic infections, fibroid uterus, and/or pelvic adhesions is important to review.
- History of abnormal pregnancies such as miscarriages and/or ectopic pregnancies.
- The longer the duration of infertility, the worse the prognosis.
- Associated hormonal problems that could affect fertility and ovulation include polycystic ovary syndrome, thyroid problems, high prolactin levels, diminished ovarian reserve and/or adrenal problems.
- Coital problems.
While each couple is different and care is individualized, common components of the infertility evaluation include the following:
- The female partner should have had a well woman evaluation with a complete medical and gynecological exam. A pap smear and a mammogram should be obtained per national guidelines. Tests for immunity against the rubella virus and chicken pox should be tested. If a patient is non-immune then she should be vaccinated before she attempts pregnancy. One partner should be tested for a cystic fibrosis mutation carrier state especially if both individuals are white Americans as they have a higher chance carrying the mutation. African Americans should get tests for Sickle cell anemia. Ashkenazi Jews should be tested for Tay- Sachs disease, Canavan’s Disease, and Gaucher’s Disease at a minimum. Other preliminary genetic tests can also be considered depending upon individual characteristics of the couple or circumstances.
- A sonohysterogram or hysterosalpingogram should be performed on the female partner between cycle days 6-10 early in the course of evaluation. This test looks at the uterine cavity for the presence of fibroids, polyps or congenital malformations and attempts to confirm tubal patency.
- A semen analysis is an important test to confirm that the sperm count, volume of semen, motility, morphology and other parameters are adequate for conception.
- A woman should undergo a hormonal evaluation because many hormones can effect proper ovulation. Tests for ovarian reserve can be tested with a day 2-3 FSH and estradiol levels or a clomiphene citrate challenge test. The ovarian reserve testing is very important in women older than 35 and for women with long standing infertility without other identifiable causes. Thyroid dysfunction and hyperprolactinemia can effect ovulation and should be tested for in practically all infertility patients as it is so easily fixable. On occasion, other hormonal tests are needed to further confirm diagnosis of various conditions such as polycystic ovary syndrome or congenital adrenal hyperplasia.
- The above testing scheme is by no means complete. Individual historical factors or parameters could lead to an in depth study or evaluation requiring more radiologic assessment or blood tests, etc. The above testing may have to be reconsidered if enough time has elapsed from the original evaluation.
After the initial assessment has been completed, a consultation between the couple and physician is usually the next step before deciding on a treatment plan. Individual considerations such as insurance coverage, time, and age of the patient and underlying cause of infertility are than considered in order to decide on the best course of action.
In general, the following treatment scheme(s) are followed.
- If the uterine cavity is normal, at least one fallopian tube is open and the semen parameters are normal enough–Clomid with or without intrauterine insemination (IUI) is attempted over 3-4 cycles. Injectible fertility medications (Follistim, Gonal-F, Repronex, Menopur, Bravelle) can then be considered with or without IUI, if clomid fails. Ultimately, if both the initial treatments fail then one can proceed with IVF. In some couples, either or both of the initial treatments may be eliminated before proceeding to IVF.
- If both tubes are badly damaged or sterilized then one can consider reconstructive surgery or IVF.
- Hysteroscopic surgery is performed in case there are any intracavitary defects such as endometrial polyps, submucosal fibroids, intrauterine adhesions or uterine septums.
- Hyperprolactinemia and thyroid dysfunction are usually treated with hormonal treatment.
- Laparoscopy- is rarely required unless there is reason to believe that there are conditions that need to be treated surgically such as tubal disease, endometriosis, etc. that a patient may benefit from to enhance her fertility.
- Depending upon the exact circumstances a combination of the above treatments may be necessary.
**It is important to continually consult and be guided by a reproductive endocrinology and infertility specialist at our center through the entire process of achieving a pregnancy when a couple has difficulty doing so.
Wayne State University Physician Group
26400 West Twelve Mile Road, Suite 140
Southfield, MI 48034
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