A year of unprotected intercourse in women under 35 years of age and after six months in women 35 or older that does not result in natural conception can be an indicator of Infertility.
The workup for infertility begins with the clinical history and examination.
The ability of a couple to become pregnant depends on normal fertility in both the male and female partners and so both must be evaluated.
This is highly important factor to consider because our society has a certain tendency to blame the women for infertility and men never get rightly investigated for the causes.
EVALUATION OF INFERTILITY IN WOMEN
Although a variety of tests are available for evaluating female infertility, it may not be necessary to have all of these tests. Doctors usually begin with a medical history, a thorough physical examination and some preliminary tests.
Medical History –
A woman’s past health and medical history may provide some clues about the cause of infertility.
Following questions are usually asked during the medical history evaluation –
- Age at which periods began for a woman
- The duration of menstrual cycle and if its regular or not
- Any pain during periods or pain during intercourse
- Frequency of sexual intercourse
- Any history of illness or surgeries in the past
- Any medications which the patient might be taking
- Children from previous relationships (if any)
Physical Examination –
A physical examination usually includes a general examination, with special attention to any signs of hormone deficiency or signs of other conditions that might impair fertility.
The points that are noticed include-
- Excessive facial hair
- Breast development
- Pelvic examination
After a detailed clinical history and examination , doctor may need some basic investigations to find out the cause for infertility. These tests are explained below –
1. Blood test for hormones – FSH, LH, estradiol, prolactin & AMH are done on day 1-3 of the menstrual cycle.
FSH– Follicle stimulating hormone is one of the most important hormones in the normal menstrual cycle. It helps in producing mature eggs by stimulating the ovaries. If the ovaries are not working and the eggs are not developing, the body response is to increases FSH production.
LH– Luteinizing hormone, again an important hormone that helps an egg to grow and be released once mature.
The time phase during the menstrual cycle when the egg is released from the ovary it is called ovulation. Ovulation can be tracked by urine testing strips which detect a rise in LH at the time of ovulation.
Estradiol – It is tested to check the quantity and quality of egg production.
Prolactin – This hormone is normally responsible to produce milk for breast feeding. Prolactin hormone naturally prevents conception by inhibiting ovulation in breast feeding mothers. If abnormally high without a woman breast feeding it may lead to irregular menstrual cycles and lack of ovulation.
AMH – AMH or Anti-Mullerian hormone, a recent test introduced to check ovarian reserve. This hormone is produced by granulosa cells in ovarian follicles. It is first made in primary follicles that advance from the primordial follicle stage. If low means the woman is approaching menopause and chances to conceive are low.
2. Blood test for Thyroid function – Thyroid gland is situated in the neck and produces thyroid hormone which helps regulating numerous body functions including reproduction. An increase or decrease in the thyroid hormone both may lead to infertility and disturbance of menstrual cycle. Tests done to check thyroid function are TSH, T3& T4.
3. Day 21 Progesterone – Progesterone hormone is normally secreted in the second half of the menstrual cycle after ovulation. It helps to maintain the uterine lining, but if fertilization does not occur, the levels drop and the uterine lining is shed in menstrual bleeding.
A day 21 progesterone level >30ng/ml indicates that ovulation has occurred.
4. Transvaginal Ultrasound – is done to check the uterus and the ovaries.
Any uterine abnormalities like fibroids or a uterine septum can be detected. Ovaries are checked for growing follicles . Multiple small follicles in both ovaries may be due to polycystic ovarian disease (PCOS – in which the eggs fail to mature and lead to irregular cycles and infertility) A follicle size 18-24 mm (1.8 cm -2.4 cm) on day 14 (in an average 28 day cycle) is considered good.
5. Hysterosalpingography (HSG) – (Commonly called as Tube test) This is done to help identify structural abnormalities of the uterus and fallopian tubes. It involves inserting a small catheter through the vagina, cervix and into the uterus. A liquid that helps in seeing the internal situation in an X-ray is injected through the catheter, which fills the uterus and fallopian tubes. An x-ray is taken after the liquid is injected, which shows the outline of the uterus and tubes. An abnormally shaped uterus or blocked fallopian tube would be visible on the x-ray.
The test is done while the woman is awake and lying on an x-ray table. Most women experience moderate to severe pelvic cramps when the liquid is injected, but this usually improves after 5 to 10 minutes. The pain can be reduced by taking an over the counter analgesic like ibuprofen 200 mg 1 hour before the procedure. The test is usually performed on menstrual cycle days of 5-10.
6. Saline Infusion Sonography (SIS) – Infusion of sterile saline into the uterine cavity via a small catheter placed through the cervical opening makes the visualization of the inside of the uterus better during transvaginal ultrasound and can detect uterine polyps (Small growths of tissue).
7. Hysteroscopy – In a hysteroscopy, a small tube containing a light source is inserted through the cervix and into the uterus to directly visualize the lining of the uterus and the sites where the fallopian tubes enter the uterus. Air or fluid is injected to expand the uterus and to allow the physician to see inside the uterus.
A hysteroscopy is usually performed in women who are thought to have an abnormal uterus, based upon history, hysterosalpingogram, or ultrasound. Diagnostic hysteroscopy can be performed in the physician’s office without anesthesia or sedation. If hysteroscopic surgery is necessary, this is usually performed in a day surgery operating room with a regional anesthesia (local, epidural, or spinal) or general anesthesia.
8. Laparoscopy – During laparoscopy, a thin, lighted tube is inserted through a small incision in the abdomen, allowing the physician to view the uterus, ovaries, and fallopian tubes. Laparoscopy is performed as a day surgery procedure and requires that the patient receive general anesthesia.
Laparoscopy can detect damage and obstruction of the fallopian tubes, endometriosis, and other abnormalities of the pelvic structures. It is the best test for diagnosis of endometriosis or pelvic adhesions (scarring). Furthermore, endometriosis can be treated during laparoscopy, which can help to improve pregnancy rates in women with infertility who have endometriosis. However, laparoscopy is not routinely done during an evaluation of infertility.
9. Genetic test – Genetic testing may be recommended if there is a suspicion that genetic or chromosomal abnormalities are contributing to infertility or f there is a history of repeated miscarriages. These tests usually require a small blood sample, which is sent to a laboratory for evaluation.
EVALUATION OF INFERTILITY IN MEN
In men , evaluation begins with clinical history and examination.
Clinical History – A man’s past health and medical history are important in the process of evaluation. A healthcare provider will ask about childhood growth and development; sexual development during puberty; sexual history; illnesses and infections; surgeries; medications; exposure to certain environmental agents (alcohol, radiation, steroids, chemotherapy, and toxic chemicals); and any previous fertility testing.
Physical Examination – A physical examination usually includes measurement of height and weight, assessment of body fat and muscle distribution, inspection of the skin and hair pattern, and visual examination of the genitals.
Special attention is given to features of testosterone deficiency, which may include loss of facial and body hair and decrease in the size of the testis.
Other conditions that might affect fertility include –
● Varicocele, a varicose vein of the testicle
● Absent vas deferens or thickening of the epididymis
1. Semen Analysis – Volume, pH level, concentration, motility, morphology, WBC (White Blood Cell) count are checked in a semen sample. This analysis provides information about the amount of semen and the number, motility, and shape of sperm.
Procedure – A man should avoid ejaculation (sex and masturbation) for two to seven days before providing the semen sample. Ideally, a sample should be collected in a clinician’s office after masturbation; if this is not possible, the man may collect a sample at home in a sterile laboratory container or chemical-free condom. The sample should be delivered to the lab within one hour of collection.
If the initial semen analysis is abnormal, the clinician will often request an additional sample; this is best done one to two weeks later.
2. Blood Hormones – Blood tests provide information about hormones that play a role in male fertility. If sperm concentration is low or if the doctor suspects a hormonal problem, he may order blood tests to measure total testosterone, Luteinizing Hormone (LH), follicle-stimulating hormone (FSH), and prolactin (a pituitary hormone).
3. Genetic tests – If genetic or chromosomal abnormalities are suspected, specialized blood tests may be needed to check for it.
4. Other tests — If a blockage in the reproductive tract (epididymis or vas deferens) is suspected, a transrectal ultrasound test may be done.
If retrograde ejaculation (movement of semen into the bladder) is suspected, a post-ejaculation urine sample is needed.
A testicular biopsy (collection of a small tissue sample) may be recommended in men with no sperm on the semen analysis. The biopsy can be done by surgically opening the testis or by fine-needle aspiration (inserting a small needle into the testis and withdrawing a sample of tissue).
An open biopsy is usually done in an operating room with general anesthesia, while a fine-needle aspiration may be done with local anesthesia in an office setting. The biopsy allows the physician to examine the microscopic structure of the testes and determine if sperm are present.
The presence of sperm production in the testes when there are none in the ejaculate suggests blockage in the reproductive tract.