Evaluation of Infertility

The evaluation of infertility occurs in a systematic manner. There are five areas evaluated in the female, then the male separately, and finally the couple as a unit. Details are outlined below.

Ovulation

The most common abnormality leading to infertility is a disorder of ovulation. This could be total lack of ovulation or ovulation with insufficient hormone production. Multiple problems can lead to ovulation abnormalities including thyroid disease, excess stress (most commonly excessive exercise or dietary restrictions), excess production of male hormones, insulin resistance, or classic polycystic ovaries. For the majority of women, the cause is not clear.

The most common test for ovulation is a progesterone level timed about 7 days before the expected next period. Normal values are over 10 pg/ml. Most labs will report levels as low as 2.5 as being normal. This low level does indicate ovulation but it is not sufficient to support a pregnancy.

Cervix

The cervix produces mucous of different types during different parts of the menstrual cycle. During most of the month, the mucous is thick. This is to prevent bacteria from gaining access to the tubes and abdomen. For a few days around the time of ovulation, the mucous becomes very stretchy like egg whites. This mucous is structurally very different and guides sperm up into the uterus. If this mucous does not develop the sperm will not be able to swim through to the egg. A post-coital test is done to evaluate the interaction of the mucous and sperm. At the time of ovulation, the couple has intercourse and then the woman comes in to have mucous removed and examined. The mucous is evaluated for stretch, number of sperm, and quality of movement of the sperm. In the past, the test was done a couple of hours after intercourse. Most Reproductive Endocrinologists now wait overnight before removing the mucous. Since sperm should live in the mucous for several days, there should be good movement 10 hours or more after intercourse. Some problems, such as sperm antibodies or inherent weakness of the sperm, may take several hours to become apparent.

Uterus

There are two components of the uterus, the structure that holds the pregnancy and the lining that accepts the embryo. The best known abnormality of the uterus is fibroid tumors. These are benign (not cancer) muscle growths. Fibroids disrupt the real estate of the uterus and just like real estate, location location location, is what maters. It is easy to see how large fibroids can cause a problem. However, even a small fibroid can cause infertility or recurrent poor pregnancy outcome if it disrupts the interior of the uterus. Large fibroids, growing on the outside of the uterus, may cause no problem.

Birth defects of the uterus occur in 3% of women. Most of these cause no problem. When a problem does occur, it is more likely to be related to a loss of pregnancy (recurrent miscarriage) than infertility. The most common of these abnormalities is a uterine septum. The uterus and upper vagina are formed from two tubes. These fuse and the wall in between dissolves. When the wall does not dissolve, it leads to a septum in the uterus and rarely duplication of the vagina.

The lining of the uterus goes through a precise series of changes to prepare it to accept the embryo. The glues that attach to embryo to the lining have now been identified (not everyone agrees) and tests are available. The traditional way of evaluating the lining is with a timed endometrial biopsy. The timing varies with the endpoint of the test. Abnormalities of the lining can be caused by infection, endometriosis, tubal damage, hormonal problems, or deficient blood flow to the lining.

Tubes

At ovulation the ovum is picked up by the tube. The tube moves towards the site of ovulation. It also appears to produce a mucous that helps it cover the ovary and capture the egg. Once the egg has been brought into the tube it meets with the sperm and is fertilized in the tube. It then remains in the tube for approximately five more days before entering the uterus. For proper function, the tube has to be open sufficiently to "catch" the egg, must be free of external adhesions to allow some movement towards the ovary, and have fimbria (fingers) to move the egg as well as to provide a proper environment for initial development of the fertilized egg. The tubes are usually first evaluated with an HSG (hysterosalpingogram). Laparoscopy will add more information but is rarely done solely to evaluate the tube.

Peritoneal

The lining of the abdomen and pelvis is called the peritoneum. This is where endometriosis grows. This is also were most adhesions develop. Endometriosis is a condition were the tissue that normally lines the uterus grows elsewhere. Adhesions are abnormal connections between organs. Adhesions can be caused by infection, endometriosis, or prior surgery. The peritoneum is evaluated by laparoscopy. Treatment of the abnormalities is done at the same surgery.

Male

In 40 % of infertile couples, the male is at least part of the problem. It is recommended to have 2 to 4 days abstinence before obtaining a semen sample for count. More than this will produce samples with more abnormal appearing sperm. Shorter intervals will falsely lower sperm counts and make volume smaller. Most commercial and hospital labs do a horrible job of semen analysis. Counts are usually correct but not much else. Sperm antibodies can be done on the same sample.

Couple

There has been a tremendous amount of misinformation about the best way to time intercourse to increase the chance of conception. Most of this misinformation has come from physicians who have confused obtaining a standard semen analysis with promoting conception. It has been clearly shown, both with normal sperm counts and low sperm counts, that daily intercourse during the fertile period produces the highest pregnancy rates. You cannot "save it up" and you cannot have intercourse too often. The fertile period starts 6 days before ovulation and ends the day after ovulation. Ovulation occurs about 14 days before the period.

No special positions are required to increase the chance of conception. You should avoid lubricants during the fertile period since all lubricants can interfere with sperm function.