The evaluation of infertility involves an investigation into both male and female disorders that can result in infertility. Approximately 60% of infertility is due to female disorders and 40% is due to male disorders. Approximately 20% of all infertile couples have more than one disorder causing infertility which emphasizes the importance of completing the infertility evaluation.
Common female causes of infertility include:
- ovulation disorders
- cervical abnormalities
- uterine fibroids
- uterine scarring
- fallopian tube abnormalities
- pelvic adhesions
- decreased ovarian reserve (decreased number of eggs on the ovaries)
Common male causes of infertility include:
- low sperm counts
- decreased sperm motility
- abnormal sperm morphology
Overview of the Infertility Evaluation
The evaluation typically starts with a thorough history and physical examination. The history can give the physician clues to possible causes of infertility such as an ovulation, fallopian tube disease, endometriosis, male factor infertility and other medical disorders.
The physical exam is performed to evaluate the patient’s overall health and in addition, focuses on the causes of infertility. This examination typically includes an ultrasound examination of the uterus and ovaries looking for any abnormalities such as fibroids, uterine polyps, uterine malformations, endometrial development, endometriomas (endometriosis on the ovaries) and the measurement of ovarian size (an indicator of ovarian function).
Normal fallopian tubes cannot be visualized during this ultrasound exam however abnormal fallopian tubes, often referred to as a hydrosalpinx, can be visualized.
The uterine cavity is also commonly evaluated with either a hysterosalpingogram (x-ray of the uterus), an ultrasound of the uterus after the injection of saline (sonohysterography), or hysteroscopy (telescopic examination of the uterus). All three are equally effective in evaluating the uterine cavity for polyps and uterine malformations. The only technique that allows the evaluation of the patency of fallopian tubes is a hysterosalpingogram (HSG).
An HSG is a non-invasive procedure which can be performed at Coastal Fertility Specialists. HSGs are used to detect blockages of the fallopian tubes and disorders or structural problems within the uterus. A small catheter is placed at the cervix and dye is slowly injected while images are taken with an x-ray machine. The flow of dye through the uterus and out of the tubes is studied and recorded on x-ray film. In most circumstances the HSG is scheduled after a menstrual period but before ovulation (six to fourteen days after the start of menstrual flow). This test is usually scheduled by calling our office after your period begins.
Many patients have heard from others that this is a painful test. In the past this was certainly true. Currently we use different instruments to inject the dye, which is less painful. A new form of dye, which does not contain iodine, causes less distension and discomfort. We are aware of the possibility for discomfort and make every effort to be gentle in carrying out the procedure.
Estimate of Ovarian Reserve
Ovarian reserve is a term used to refer to the number of eggs remaining in the ovaries. This is estimated by performing an ultrasound and counting the number of antral follicles (resting eggs) and performing blood work. The blood work includes measuring the brain hormones, FSH, LH and estradiol concentrations, at the beginning of the menstrual cycle in addition to anti-mullerian hormone which is a good marker for egg quantity. These results give indirect measurements of the ovarian reserve and correlate directly with pregnancy rates in spontaneous cycles, ovulation induction and intrauterine insemination cycles and in-vitro fertilization.
A semen analysis is also performed as a standard infertility evaluation. A semen analysis involves counting the number of sperm present, evaluating the sperm motility and sperm morphology. A normal semen analysis result reads greater than 20 million sperm per milliliter, 50% motility and greater than 4% normal morphology. Additional tests can be performed to determine the capacity of the sperm to fertilize which some patients can be at risk for even if they have a normal semen analysis. It is important that the semen analysis is performed at a center that specializes in infertility.
Approximately 50% of all cases of infertility are unexplained after the evaluation is complete, which simply means there are enough eggs, sperm and the fallopian tubes are open and working. With surgery and other testing, the cause of the “unexplained infertility” can be found, however, this extended analysis does not change our approach to treatment or increase pregnancy rates. It only adds costs and therefore we rarely recommend further testing unless your history has areas of increased concern.
Make an Appointment with us
Here at Coastal Fertility Specialists we have the ability to diagnose and treat many causes of infertility. We will do everything we can to investigate the causes of your fertility problems and help you bring home a baby. Call us at 843-883-5800 for any questions or to schedule an appointment.