An Initial Infertility Evaluation
/Infertility is a problem with many social, economic, and psychological ramifications for patients presenting to an OB-GYN’s office, so it’s important to be able to start this work up with confidence. We’re here today to help!
We know somewhere between 82-92% of couples will conceive within 12 months of regular, unprotected intercourse; of those that don’t conceive in the first year, an additional 5-15% of couples will achieve conception within 24 months. So the odds of success are high, but may take some time. The frequency of infertility does climb with age, though: 7.3-9.1% among 15-34 year olds; 25% of 35-39 year olds; and 30% of 40-44 year olds. Infertility is defined based on these incidences:
12 months of regular, unprotected intercourse without conception in women under age 35, or
6 months of regular, unprotected intercourse in women over age 35.
These time frames are also the indication for our workup. Ideally, the first infertility visit should involve both partners; up to 26% of all infertility is provably male-factor in origin, and 6% of infertility may be related to coital problems! A history & physical for both partners can suggest where the workup will be most beneficial:
Female:
PMH & PSH (ie. history of cancer, previous treatment? Ovarian surgery, uterine surgery?)
Menstrual history
History of any previous pregnancies
Social history: extensive smoking, drug use, etc.
Exam should focus on features of hyperandrogegism (i.e., PCOS), hyperinsulinism (i.e., uncontrolled DM or metabolic syndrome) or thyroid dysfunction, as well as assuring anatomy is present.
Male:
History of testicular trauma, cancer, exposure to cytotoxic drugs
History of previous children?
From couple:
Regularity & timing of intercourse.
Sometimes it’s as simple as… are they having intercourse when patient is ovulating? Is he ejaculating within the vagina?
When considering a laboratory & imaging workup, cost can be a challenging factor. Sometimes insurances require certain tests, or a certain sequence of tests, in order for coverage to be assured. Others don’t cover this testing at all, and thus it’s up to you to make the appropriate decisions to work out the reason for infertility in a couple. Testing ideally includes the following:
Semen analysis - for assessing male factor
Some assessment of ovarian reserve
Day three FSH and estradiol level
Anti-Mullerian hormone
Antral follicle count
Early cycle count of antral follicles; done on day 3 of cycle. What is normal is different at each institution, but can be 3-8 per ovary.
Assessment of uterine cavity with hysterosalpingogram or sonohysterogram
Can test tube patency as well, though with sonohyst, if there is spilling of fluid, that only confirms that at least 1 tube is patent.
TSH, A1c, PRL.
In deciding on your workup, keep in mind the most common causes of infertility: a semen analysis will almost always be indicated! These all add up to >100% because some couples will have multiple reasons.
Unexplained: 28%
Male factor (ie. hypogonadism, post-testicular defects, seminiferous tubule dysfunction) = 26%
Ovulatory dysfunction: 21%
Tubal damage: 14%
Endometriosis: 6%
Coital problems: 6%