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Since the majority of women become pregnant within one year of having unprotected intercourse, most couples are advised to try to conceive this long 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. The remainder of this page describes the basic infertility evaluation protocols and what men and women should expect from their initial work-ups.
Basic Infertility Evaluation for Women
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 typically starts with a careful 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 disease, 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, or drug usage) which could contribute to the infertility.
Next a 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. 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.
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Basic Infertility Evaluation for Men
Approximately 45% of couples will have associated male infertility. It is for this reason that evaluation and treatment of the male is critical to a thorough comprehensive 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 hazardous 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 will indicate the presence of an infection. The semen evaluation will assess 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 to determine the overall balance of the hormonal system and specific state of sperm production. Serum LH 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 therapeutic route is chosen, which may involve medical or endocrinologic treatment, surgical correction, or a decision to manipulate or process the sperm which already exists to achieve a pregnancy.
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