Diagnosis of the Infertile Couple
In couples with infertility, approximately one-third have a female factor, one-third a male factor and another third of couples have both male- and female-based problems. Therefore, it is important to assess both partners when attempting to identify the source of infertility.
Semen Analysis – The semen analysis will address the volume of ejaculate, concentration (number) of sperm cells, and the level of normal sperm motility (movement) and morphology (shape). The information gathered during this analysis will supply important clues as to the degree and source of male infertility problems.
- Assessment of Ovulation – most women with regular cycles (26-35 days) will be ovulating. A simple way to determine if the cycles are ovulatory is to obtain a serum progesterone on day 22 of the cycle. Women with irregular or infrequent menstrual cycles are by definition not ovulating or not ovulating on a regular basis. Most such women respond to ovulation inducing medications.
- Hormonal Assessment – all women should be screened with a cycle day 3 FSH (Follicle Stimulating Hormone) and estrogen level. This simple test will indicate whether or not ovarian function may be diminished. In women with amenorrhea (no menses) a very high FSH may indicate premature menopause or premature ovarian failure. Women over 35 need further assessment of their ovarian reserve with a clomiphene citrate challenge test or an antral follicle count by ultrasound and a blood test for AMH (Anti-mullerian Hormone). In addition a simple test of the thyroid gland (TSH), as a screening of thyroid function and a serum prolactin should be obtained.It is recommended that women with excessive bodily hair growth have blood testing for male hormone levels, such as testosterone. All women normally produce these hormones, but excessive production may be associated with abnormal ovulation.
- Tubal Patency – a hysterosalpingogram (HSG), where radio-opaque dye is instilled into the uterus will detect whether the fallopian tubes are open or blocked and may suggest whether scar tissue is present around the tubes. This test is done on an outpatient basis in a radiology suite. In addition, information about the uterine cavity is obtained at the same time . Recently a new test called FemVue allows the patient to have her fallopian tubes evaluated by utilizing a non-allergenic saline and air mixture with ultrasound visualization, avoiding exposure to radiation. This test also allows assessment of the uterine cavity. This test is performed in the physician’s office. The physicians at Northern California Fertility Medical Center have already commenced evaluation of fallopian tube patency using this innovative technique.
- Uterine Cavity Evaluation – in addition to HSG and the new FemVue test described above, there are two other alternatives to evaluate the uterine cavity. Hysteroscopy – a small fiber-optic telescope is inserted into the uterus through the cervix to directly visualize the uterine cavity and look for any abnormalities. This is done in the office with mild oral sedation.Hysterosonogram (also known as saline infusion sonogram) – here the uterine cavity is examined by injecting a small amount of saline into the uterus and looking at the cavity under ultrasound guidance.
- Pelvic Factor Evaluation – Endometriosis/Adhesions- if either of these conditions is present on or around the ovaries, and/or fallopian tubes, distortion of the normal anatomy may be responsible for infertility in the female. Implants of endometriosis scattered throughout the pelvis may also cause inflammation that may diminish fertility, even if the ovaries and tubes are not affected.The above conditions are diagnosed via laparoscopy, which is minimal incision outpatient surgery performed at a surgery center. Under anesthesia, a fiberoptic telescope is inserted into the abdomen below the navel to allow visualization of the pelvis (uterus, ovaries, and tubes) to determine whether the conditions described above are present . Using an operative laparoscope, the above conditions can be treated at that time, using laser to vaporize the affected areas or cautery to ablate them.
- Other rare causes of infertility that may be present are evaluated on an individualized basis.