The Infertility Evaluation

Evaluation

Waukesha infertility evaluation and treatment options Infertility is defined as one year of regular, unprotected intercourse without a resulting pregnancy. Over 6 million couples currently have fertility problems. Earlier evaluation and treatment is required for patients over the age of 35, those with a history of absent or long interval menstrual periods, known uterine/tubal disease or a partner who is known to be sub-fertile.

Infertility is an emotionally stressful, financially draining and psychologically painful subject. It is all the more difficult because it is rarely, if ever, expected. In each ovulation cycle, normal couples have only about a 25% chance of becoming pregnant.

The following "Guttmacher" classic table has served as the standard of statistical information since 1956 and gives us a good idea of the normal expectations of pregnancy.

Time Required for Conception in Young Couples Who Will Attain Pregnancy:

Time of Exposure

% Pregnant

3 months

57%

6 months

72%

1 year

85%

2 years

93%

 

 

 

 

Infertility is usually classified as primary – occurring with no previous history of pregnancy, or secondary – occurring after one or more successful pregnancies. The causes of either type of infertility may be the same. Each pregnancy is unique and can predict nothing about future fertility, although a couple who has conceived before stand a better statistical chance of conceiving again. Fertility can never be presumed. A couple does not know they are fertile until they achieve a pregnancy.

DIAGNOSIS:

There are three main areas included in any evaluation of infertility.  Each accounts for approximately one third of the identified causes of infertility.

Male Factor

Semen Analysis

Because of the relative low cost of this test, it is normally one of the first to be done.  This is pivotal in determining which way to go with both male and female reproductive therapy. The specimen is ideally produced after two days of abstinence from any sexual activity and should be brought to the laboratory (at body temperature) for analysis no later than 45 minutes after it is produced. Several factors are evaluated in a semen analysis:

Volume:

2-3 ml

Count:

greater than 20 M/mL

Motility:

greater than 50%

Morphology:

less than 30% abnormal forms

Liquefaction:

usually 5-30 minutes (fresh sample)

If the semen analysis is abnormal, you may be referred to a urologist for further evaluation concerning corrective medications, corrective surgery, or sperm acquisition.

Ovulation and Hormonal Disorders

Ovulation Cycle

  • Recruitment failure – anovulation (failure to ovulate)
  • Maturation failure – anovulation, immature egg
  • Ovulation failure – "trapped" egg, luteinized follicle
  • Luteinization failure – poor ovarian progesterone

Ovulation Chart

  • Pituitary gland interferences - FSH/LH (day 2-4 of cycle), TSH (thyroid), Prolactin
  • Male hormone interference - 17-hydroxyprogesterone, free testosterone (usually indicated in patients presenting with symptoms of elevated testosterone or polycystic ovarian syndrome “PCOS”)

Other laboratory testing that may be included at the same time as the above, based on history:

  • Insulin Resistance Panel – includes 2hr glucose tolerance test (GTT) and insulin levels. Done in patients with obesity, previous gestational diabetes or "borderline" diabetes screen, or those suspected of or identified as having PCOS (polycystic ovarian syndrome)
  • Lupus Panel/Anticardiolipins/Factor V Leiden (may be identified by different names at different facilities) - basic antibody/autoimmune screening for patients with known history of multiple miscarriages.  There is a great deal of controversy regarding screening for additional antibodies, and subsequent treatment if they are found.
  • Clomiphene Challenge - bioassay of FSH response as a test of ovarian reserve.  Especially helpful in predicting the potential for pregnancy in patients who are at the older end of the ovarian aging spectrum.

Tubal, Uterine, Pelvic Cavity Problems

  • Tubal - an xray procedure called a hysterosalpingogram is done to evaluate the uterus and fallopian tubes. This will also allow your doctor to see if your tubes are blocked.
  • Uterine – an HSG or sonohystogram can be done to evaluate for scarring from infection, deformity from inherited conditions, polyps, or fibroids
  • Pelvic Cavity – laparoscopy can be performed to evaluate for scarring from old infection, previous surgery or endometriosis.

“Unexplained" Infertility:  In more than 10% of cases, there may be no identified cause found for infertility, but there are still methods to treat.

Pregnancy Rate per Cycle per Method in Unexplained Infertility

No Treatment

1.3-4.1%

IUI

3.8%

Clomiphene

5.6%

Clomiphene & IUI

8.3%

Gonadotropins

7.7%

Gonadotropins & IUI

17.1%

IVF

20.7%

GENERAL PRINCIPLES IN EVALUATION AND TREATMENT

Evaluations are individualized based upon the patient history and laboratory findings.  Because it is relatively inexpensive, easy to administer, and side effects are usually not too significant, clomiphene is frequently the first treatment choice in disorders of ovulation.  However, a good rule of thumb is the "4-Cycle Rule", whereby, if there is no pregnancy in 4 apparently good ovulatory cycles with well timed intercourse or inseminations, a re-evaluation of the plan is warranted.

Contact Women's Healthcare Waukesha for infertility evaluation and treatment options CALL 262.549.2229