Comments on Infertility

INTRODUCTION

In general, a couple is considered to have a problem with infertility if they have had one year of unprotected intercourse without conception. Approximately 10 to 15% of all couples have a problem with infertility.

Infertility management includes providing emotional support, doing infertility studies to identify specific causes, selecting appropriate therapy, and counseling the couple about the management plan. Infertility is caused by a malefactor in approximately one-third of all cases, a female factor in one third of all cases, and in the last third of cases, there is a combination of male and female factors. The major causes of infertility and their approximate incidence are following. Frequently, there can be multiple causes. 1)Male factor- 40%, 2) Cervical factor  10%, 3) Implantation factor -5%, 4) Uterine and tubal factor - 30%, 5) Ovulatory factor -20%, 6) Peritoneal factor - 20%. The basic infertility work-up is designed to evaluate each one of these factors in order to identify particular problems which may be causing infertility. The simpler, less invasive and less costly tests are usually done first.

INFERTILITY WORKUP

A. Semen Analysis: The semen sample is used to determine whether the male is fertile. This requires a masturbation specimen collected in a sterile container obtained from the laboratory. It usually is collected at home but has to be less than one (1) hour old and kept at 60 to 80°. If the semen sample is abnormal, the male is frequently asked to provide another sample at a later date.

B. Critical Morphology: This test is a detailed evaluation of sperm structure and is not done by most labs. In our lab it is the best predictor for sperm function. Even if a semen analysis has been done elsewhere, we may request a repeat in our lab.

C. Diagnostic Semen Wash: This laboratory procedure accomplishes an extraction of the sperm out of the semen with re-suspension of the sperm in another solution. This diagnostic test is necessary for all IVF and GIFT procedures as well as for other selected indications. It involves a 1 or 2 day advance scheduling with the lab, collection of the specimen into a sterile container and delivery of the specimen to the office within (1) hour of collection.

D. Endocrine Studies: When a male factor problem is not explained by the above studies, hormone evaluations are frequently done. This can include LH, FSH, testosterone, prolactin, and thyroid studies.

E. Post-Coital Test (PCT): Evaluates the sperm present in cervical mucous after intercourse for motility, quantity and survivability.

F. Antisperm Antibody Testing: If there is evidence of clumping of sperm on semen analysis or if no sperm are seen on PCT, the semen is evaluated for antisperm antibodies.

G. Testicular Biopsy: Patients with azoospermia may wish to consider testicular biopsy with cryopreservation of any obtained sperm. This is done in anticipation of IVF with ICSI. The procedure can be done in our facility.

II. Ovulatory Factor

A. Basal Body Temperature Chart (BBT): Daily recording of a woman’s basal body temperature is the simplest method for determining whether or not she is ovulating. Ovulation is suggested if the temperature record is biphasic, i.e., a low phase and high phase, with about a 0.6° F difference. The time of ovulation can not be predicted on a prospective day to day basis. However, in retrospect, when the entire month’s record is evaluated, one can frequently determine when ovulation occurred.

B. Follicular Study: Ultrasound is a diagnostic procedure which uses high frequency sound waves to picture structures inside the body. Use of the vaginal probe ultrasound allows the physician to monitor the ovulation process in the ovary during the patient’s menstrual cycle. It also provides more information than a traditional pelvic exam. In the study cycle, there are usually two morning visits scheduled for the ultrasounds (See Ill-A). The first ultrasound is scheduled prior to anticipated ovulation to confirm follicle (oocyte) development and is combined with the PCT. The 2nd ultrasound is scheduled after ovulation to ascertain that the follicle has ruptured and the egg released. Ultrasound may also detect ovarian endometriosis and fibroids.

C. Serum Progesterone Level: Occasionally the BBT does not give an accurate picture of whether ovulation is occurring. On occasion, a blood test to evaluate the serum progesterone level is used. The blood is drawn 6 to 7 days after anticipated ovulation. This is usually about the 21st or 22nd day of the cycle, which is the peak of corpus luteum function.

D. Urinary LH Surge Home Kits: These kits are available to check the urine for the LH hormone surge that occurs approximately 24 hours prior to ovulation. This test is usually done first thing in the morning. Knowing if and when the LH surge occurs can be very helpful in timing other diagnostic and therapeutic procedures. We discourage its routine use for intercourse.

E. Endocrine Studies: If a woman is not ovulating or has ovulatory dysfunction, it is very helpful to determining why this is occurring. Such endocrine studies usually include prolactin, TSH, and DHEA-.S. FSH/LH, estradiol and thyroxin tests may be done in some circumstances.

III. Cervical Factor

A. Post-Coital Test (PCT): The cervical mucous is evaluated after intercourse prior to ovulation to see if the mucous has the appropriate physical characteristics, and to determine if it supports viable, active sperm for a long period of time. The test is done one to three days before expected ovulation (11th to 14th day of a regular 28 day cycle). The couple should have intercourse the evening prior to the appointment. The PCT is usually done as part of the follicular study cycle (See II-B).

B. Antisperm Antibody Testing: If the woman has abnormal post-coital tests, the couple may be evaluated for antisperm antibodies. Specific details for this procedure will be discussed with them if this test is indicated.

IV. Implantation Factor

• A properly recorded basal body temperature chart during the cycle  in which the biopsy is taken.

• Knowledge of when the woman’s next period starts after the biopsy is done.

V. Uterine and Tubal Factor

A. Chlamydia Antibody Test: Chlamydia causes 80% of tubal disease but usually does not cause symptoms. This blood test screens for past exposure to an infection caused by the Chlamydia organism. Prior exposure to this organism may contribute to impairment of tubal function in the woman. Since this is a sexually transmitted disease, both partners are tested. If results indicate, proper antibiotic therapy is initiated for one or both partners.

B. Hysterosalpingogram (HSG): A radiopaque dye is injected into the uterus and x-rays are taken to view the shape and the size of the uterine cavity and fallopian tubes. The HSG also detects whether the tubes are open. The test is done in Spectrum Health East X-ray Department between day 6 and 12 of the woman’s cycle after her flow ends. Medication may be taken two hours prior to the procedure to help relieve cramps that may occur. The woman should call the office the first day of her period to schedule the procedure for the appropriate time.

C. Diagnostic Hysteroscopy (Dx Hyst): This diagnostic procedure uses a flexible scope which permits the physician to look inside the uterine cavity to see whether there are any deformities or tumors distorting the cavity. It is also possible to visualize the corners of the uterus to see if the openings into the tubes are normal. This procedure is usually done in the office. Medication maybe taken two hours prior to the procedure for cramping that may occur with the procedure.

VI. Peritoneal Factor

A. Diagnostic Laparoscopy (Dx Lap): This out-patient surgical procedure, done at Spectrum Health East under general anesthesia, permits the physician to look inside the abdomen to inspect the various abdominal and pelvic organs, including the female organs. This diagnostic procedure is primarily done to see whether there is evidence of endometriosis or pelvic adhesions that could interfere with the transport of the egg from the ovary to the tube and on into the uterus. If endometrial implants and pelvic adhesions are identified, additional therapeutic procedures such as cautery or laser treatment may be done to destroy the implants and release the adhesions. An ovulation induction cycle may be done in conjunction with this surgical procedure. During the laparoscopy, eggs would be retrieved from the ovary, combined with washed sperm, and both placed in the ends of the tubes at the conclusion of the surgery. This provides an opportunity to achieve a pregnancy during the laparoscopy cycle. This option known as GIFT (Gamete Intra-Fallopian Transfer), would be discussed with the couple if appropriate.

Douglas C. Daly, M.D.
Board-Certified Reproductive Endocrinology/ Infertility Board-Certified Obstetrics/ Gynecology