Evaluation of the Infertile Couple
The goal of the initial evaluation of the couple is to determine the likely cause of the infertility, and to determine the most logical approach to treatment. The primary care physician or general gynecologist can play a critical role by taking a detailed history and ordering the initial testing so that the first appointment with an infertility specialist can be spent on planning appropriate additional testing and discussing therapeutic options.
History
| Duration of infertility |
Duration of infertility |
| Fertility in other relationships |
Prior pregnancies, fertility in other relationships |
| Medical, surgical history |
Gynecologic history (PID; endometriosis; fibroids; cervical dysplasia; IUD use; DES exposure; previous pelvic or abdominal surgery) |
| Medications |
Medications, including prior contraceptive use (oral contraceptives, IUDs) |
| Alcohol, marijuana use, cigarette smoking |
Menstrual history (age at menarche, cycle length and regularity); presence of hot flashes |
| Environmental exposure (heat [e.g., saunas, hot tubs], chemical, radiation exposures) |
Diethylstilbesterol exposure, cigarette smoking |
| Sexual dysfunction/frequency of intercourse |
Frequency of intercourse |
| Previous infertility testing and/or therapies |
Previous infertility testing and/or therapies |
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Tests to order prior to the initial visit with the infertility specialist
Male Partner
- Semen analysis: The male partner should provide a semen sample for semen analysis. In general, most laboratories have a private facility where the male partner can produce the sample. He should abstain from ejaculation for 48 hours but no more than six days prior to providing the sample. Alternatively, he may bring in the specimen from home in a sterile plastic container, but the sample cannot be more than 1.5 hours old, should not have been exposed to soaps, lubricants, or condoms, and must be kept warm (held against the body) until delivery.
Results are expressed in volume (ml), concentration of sperm per ml, percent motile, and percent normal forms. To obtain the total number of motile sperm, multiply volume (ml) x concentration (sperm/ml) x percent motile sperm x percent normal forms. Greater than 10 million total motile sperm is considered adequate.
Female Partner
- Document ovulation: May be done with over the counter ovulation kits. In a 28 day cycle, ovulation usually occurs at day 14. May be later in women with longer cycles (usually 14 days from the end of the cycle). Alternatively, serum progesterone level can be measured in the second half of the cycle (day 20-22 in a 28 day cycle). If a progesterone level is greater than 3 ng/mL, ovulation has occurred.
- Day three FSH level: Levels greater than 10 mIU/mL are associated with an extremely low pregnancy rate. The majority of fertile women have day three FSH levels that are less than 10mIU/mL.
- TSH level to test for occult thyroid disorder.
Additional testing that may be ordered by the fertility specialist
- Clomiphene citrate challenge test (CCCT): This is a more sensitive test for ovarian reserve than day three FSH alone. Clomiphene citrate (100 mg po days five to nine of the cycle) is given. Day three and day 10 FSH levels are measured. An abnormal test is an elevated level of FSH (> 15) on either day three or day 10. This test should be done on all couples with unexplained infertility, and all women over age 35. The likelihood of having an abnormal CCCT increases with advancing maternal age.
- Hysterosalpingogram (HSG, or tubogram): This test is done in the first half of the cycle, immediately after menses have ended, but before ovulation. Antibiotic prophylaxis with doxycycline 100 mg po bid for three days is routinely given starting the day before the test. The test involves injection of dye into the cervix followed by radiography to assess tubal patency (“fill and spill”) as well as shape of the intrauterine cavity. The test may be uncomfortable for the patient, and premedication with ibuprofen or Tylenol® is advisable. Occasionally, the flushing of the tubes is enough to remove debris and allow a pregnancy to occur in that cycle. Sonohysterogram, an alternative that is sometimes used, gives an adequate picture of the uterine cavity, but no information about tubal anatomy; fluid collecting intraperitoneally is presumptive evidence that at least one Fallopian tube is open.
- Laparoscopy: May be indicated if endometriosis or adhesions are suspected.
- Hysteroscopy: May be done if intra-uterine lesions (adhesions, polyps) are suspected, or if intrauterine abnormalities are noted on the HSG.
- Pelvic ultrasound: May be ordered if enlarged uterine size or ovarian masses are noted on exam.
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