How is Infertility Diagnosed?
Infertility evaluation is typically suggested after one year of trying to conceive, but in older patients over 35, most physicians initiate diagnostic evaluation after if a couples has been unable to conceive after six months.
The American Society for Reproductive Medicine guidelines for a standard infertility evaluation include:
- Semen analysis, assessment of ovulation
- Hysterosalpingogram (HSG), an X-ray test that evaluates the fallopian tubes and the uterine cavity
- Tests for ovarian reserve (see below)
When the results of a standard infertility evaluation are normal, physicians assign a diagnosis of unexplained infertility.
Assessment of Male Infertility
Male factor infertility is the only cause of infertility in approximately 30 percent of couples and a contributing factor in another 20 to 30 percent. Evaluation of the male partner includes a physical examination to assess testicular abnormalities such as a varicocele, which is an enlargement of the veins within the scrotum and a common cause of low sperm production or absence of the vas deferens. The assessment also includes a semen analysis, history of prior paternity and anatomical problems, such as cryptorchidism, which is the absence of one or both testes from the scrotum, medical and surgical history, sexual dysfunction, and any use of medications, tobacco, alcohol, or illicit drugs. Read more about male infertility…
Assessment of Female Infertility
Ovulation defects are present in 40 percent of infertile women and in approximately 15 percent of couples with infertility. Symptoms of ovulatory function include menstrual disturbances and can be identified by history in the majority of women. A patient with menstrual abnormalities should be investigated for underlying causes such as polycystic ovarian syndrome, thyroid disease, and other causes.
In addition to menstrual history, other ovulation evaluation methods include tests that assess levels of hormones that trigger successful ovulation and uterine preparation for pregnancy, such as:
- Mid luteal serum progesterone. Progesterone, a hormone produced by the ovaries during ovulation, causes the endometrial lining of the uterus to get thicker, making it receptive for a fertilized egg. If a fertilized egg implants, progesterone then helps the uterine lining (endometrium) to maintain pregnancy. Progesterone levels rise following ovulation, peaking 5 to 9 days after ovulation (the luteal phase.) After the mid luteal period, serum progesterone levels will begin to fall if the egg is not fertilized.
- Urinary luteinizing hormone (LH,) a hormone produced in the pituitary gland that triggers ovulation and development of the corpus luteum, the visible collection of blood left after the rupture of the follicle during the luteal phase of the menstrual cycle. The luteinizing hormone (LH) surge urine stick or ovulation predictor helps to identify the time of ovulation. A woman will urinate on an LH surge stick once or twice a day, starting a few days before suspected ovulation. Often the stick will show two lines indicating that ovulation is 24–36 hours away.
- Saliva testing is an ovulation predictor that reveals when salt crystals are forming that shows an increase in estrogen that is related to ovulation.
- Wrist watches that measure subtle body chemical changes on the surface of the skin to help to identify time of ovulation.
- Basal body temperature thermometers are used by women to chart their basal body temperature to predict their fertile period or ovulation. The basal thermometer is used in connection with a chart, which typically shows low temperatures before ovulation in the follicular phase, and higher ones after ovulation in the luteal phase.
- Endometrial biopsy is used to determine if the lining of the uterus is adequately prepared to sustain a pregnancy. This test is usually done a day or two before the next menstrual cycle is expected. A small sample of the endometrial lining is removed and then evaluated to see if it’s typical of a certain cycle day. The technician dates the sample, and if there’s a discrepancy of more than two days between that date and the menstrual cycle, the lining is considered “out of phase.”
Test results show:
- If the endometrial biopsy was “in phase” but progesterone level is low, progesterone supplements may be prescribed to increase the level of this hormone. Progesterone may be taken orally, by vaginal suppository or vaginal gel, or by injection.
- If the progesterone level was normal but the endometrial biopsy was “out of phase,” medication such as Clomid is prescribed to stimulate the ovaries. This medicine is taken orally and stimulates the growth of the follicle to increase chances of producing a higher quality egg.
Assessment of Ovarian Reserve
Women over 35 or a history of prior ovarian surgery may be at risk for diminished ovarian function or reserve (fewer healthy eggs due to natural aging). Ovarian reserve testing may include:
- Follicle-stimulating hormone (FSH), which helps control a woman’s menstrual cycle and the production of eggs. A FSH test is done on the third day of the menstrual cycle and is used to evaluate egg supply.
- Estradiol, an important form of estrogen, is tested to measure a woman’s ovarian function and tevaluate the quality of the eggs. Like FSH, it is done on the third day of a woman’s menstrual cycle.
- Clomiphene citrate challenge test, (CCCT) provides an additional assessment of ovarian reserve. It is performed by measuring the day 3 FSH and estradiol levels. Then the patient takes Clomid on days 5-9, and her FSH is measured again on day 10. The test is abnormal if either the day 3 or day 10 FSH values are elevated or if the day 3 estradiol is greater than 80 pg/ml. A poor CCCT test, regardless of patient age, indicates that there will be a decreased response to injectable FSH in assisted reproductive technology cycles. Pregnancy success rates are very low in these women and there is an increased chance of miscarriage.
The results of these tests are not absolute indicators of infertility but abnormal levels correlate with decreased response to ovulation induction medications and lowered IVF success.
Assessment of Uterus and Fallopian Tubes
Assessment of the uterine contour and tubal health is an integral part of the basic infertility evaluation.3 This may include an hysterosalpingography (HSG), an X-ray image of the uterine cavity and fallopian tubes following injection of a dye. Ultrasound may be used to identify uterine fibroids, polyps, congenital anomalies, information on ovarian volume and follicle counts.
When Is A Laparoscopy Used for Infertility Evaluation?
Laparoscopy is a minimally invasive surgical procedure that uses a small camera that allows direct visual examination of the pelvic reproductive anatomy, such as the outside of the uterus, ovaries and fallopian tubes. It is performed in women with unexplained infertility or signs of reversible tubal disease.