Infertility Evaluation

Since the majority of women become pregnant within one year of having unprotected intercourse, most couples are advised to try to conceive on their own for a year before beginning fertility testing. For women over 35, those with known medical problems that might affect fertility (such as polycystic ovarian disease or pituitary tumors), or women who are attempting to get pregnant through artificial insemination, earlier testing may be appropriate. It is important that both partners be tested initially to carefully assess the extent of the fertility problems.

Female Infertility Evaluation

The basic infertility evaluation for women includes a history and a physical examination. Additional testing to further refine the diagnosis is often completed as well.

The evaluation starts with a careful review of the history of each woman's symptoms and previous experiences. This can include:

  • A review of the pattern of menstrual cycle bleeding to help determine if ovulation is occurring and if other problems such as diminished reserve (aging) of the ovary or uterine defects (fibroids or polyps) are present.
  • Collection of information which might suggest an anatomic problem with the tubes, such as questions about past history of sexually transmitted infections, painful periods or intercourse, and/or a previous abdominal surgery.
  • Questions about prior surgery to the cervix or freezing for abnormal pap smears.
  • A general review of systems to ascertain symptoms suggestive of other endocrine abnormalities which might be contributing to infertility.
  • A careful social history to evaluate for any environmental exposures or social habits (such as smoking, drinking alcohol, drug usage or extreme exercise) which could contribute to the infertility.

The physical examination is performed to evaluate the pelvic organs and assess potential hormonal problems. Finally, additional hormonal testing or ultrasounds may be required to evaluate ovulation and ovarian age. An x-ray of the uterus and tubes (hysterosalpingogram or HSG test) may be completed to assess uterine or tubal status, and surgical procedures such as a laparoscopy or hysteroscopy may be indicated to evaluate the structure of the uterus or fallopian tubes in more detail.

Male Infertility Evaluation

Approximately 45% of couples will have associated male infertility. It is for this reason evaluation and treatment of the male is critical to develop a comprehensive treatment program for the infertile couple. A combined approach is essential to ensure successful evaluation and management.

An initial male fertility work-up includes a history, physical examination, general hormone tests and one or more semen analyses, which measure semen volume as well as sperm number, motility and quality of motion. The initial evaluation typically begins with a series of questions that may include:

  • A review of past medical history, prior surgeries and medications used.
  • A discussion of family history of infertility or birth defects.
  • A careful review of social history and occupational hazards to evaluate potential exposure to substances that could impact fertility.

Next a thorough physical examination is performed to evaluate the pelvic organs - the penis, testes, prostate, and scrotum. Laboratory tests, such as a urinalysis, semen evaluation, and hormonal assessment are also conducted. The urinalysis indicates if an infection is present. The semen evaluation assesses sperm motility or movement, the shape and maturity of the sperm, the volume of the ejaculate, the actual sperm count, and the liquidity of the ejaculate. Hormonal tests evaluate levels of testosterone and FSH (follicle stimulating hormone) to determine the overall balance of the hormonal system and specific state of sperm production. Serum LH (luteinizing hormone) and prolactin are other hormonal tests that may be done if initial testing indicates the need for them. When a diagnosis is not obvious after the initial evaluation, further testing may be required. One or more of the following tests may be recommended:

  • Seminal Fructose Test to identify if fructose is being added properly to the semen by the seminal vesicles.
  • Post-ejaculate Urinalysis to determine if obstruction or retrograde ejaculation exists.
  • Semen Leukocyte Analysis to identity if there are white blood cells in the semen.
  • Kruger and WHO Morphology to examine sperm shape and features more closely.
  • Anti-sperm Antibodies Test to identify the presence of antibodies that may contribute to infertility.
  • Sperm Penetration Assay (SPA) to confirm the sperm's ability to fertilize.
  • Ultrasound to detect varicoceles (varicose veins) or duct obstructions in the prostate, scrotum, seminal vesicles and ejaculatory ducts.
  • Testicular Biopsy to determine if sperm production is impaired or a blockage exists.
  • Vasography to check the structure of the duct system and identify any obstructions.
  • Genetic Testing to rule out underlying mutations in one or more gene regions of the Y chromosome or to test for cystic fibrosis in men missing the vas deferens.

After the diagnostic evaluation is completed, a decision is made as to which therapies to choose; they may include medical or endocrinologic treatment, surgical correction, or a decision to manipulate or process the sperm which already exists to achieve a pregnancy.