Infertily can be a frustrating and nerve wracking experience for couples. Most couple will conceive within one year of attempting pregnancy. Approximately 70% of couples conceive within the first 6 months and 85-90% by 12 months. However, 10-15% of couples have not conceived after one year of unprotected intercourse. A couple may choose to pursue evaluation at any point in their attempts at conception. Most physicians recommend evaluation after one year of trying; however, a couple may want to present for earlier evaluation depending on their age.
The three main causes of infertility include ovulation dysfunction or anovulation(no ovulation occurring), fallopian tube scarring or disease, and sperm abnormalities. An evaluation by a physician for infertility will focus on a careful history and physical examination. A physician will want to know if a patient is having regular menstrual cycles which indicate regular ovulation. For a patient with irregular menstrual cycles, it is possibile that a low frequency of ovulation is occurring which would contribute to infertility. A physician will also want to know if a patient has a history of sexually transmitted diseases such as chlamydia. A history of chlamydia can cause fallopian tube scarring which makes it difficult or impossible for the egg to enter the uterine cavity. A physician will also want to know if a couple has had a previous pregnancy together or if the partner has fathered any other pregnancies. It is also important to know if a patient has had any previous surgeries on her cervix or in her uterus that could be affecting the sperm's ability to enter the uterus or a fertilized egg's ability to implant in the uterus.
Initial diagnostic testing for infertility include male partner semen analysis. Sperm abnormalities account for 35 % of infertility cases. A semen anlaysis is simple to perform. A man provides an ejaculate sample to the lab within 30 minutes of ejaculation. A man should refrain from intercourse or ejaculation for 48 hours prior to the test. The semen analysis will evaluate for total sperm count, sperm motility (number of sperm moving), sperm morphology (number of sperm shaped normally), and progressive motility (sperm moving in the forward direction). Abnormalities in these areas can contribute to infertility. If abnormalities are found, a second semen analysis is usually performed to verify the test. If the abnormalities persist, a man is usually referred to a urologist for evaluation of the cause of sperm abnormalities.
Other diagnostic testing for infertility include testing for ovulatory function. This can be done by evaluating a patient's menstrual calendar, testing a woman's basal body temperature and tracking it throughout her cycle, testing progesterone levels in the blood, or testing a woman't urine for luteinizing hormone(the hormone which signals the ovary to release an egg). For women who are menstruating at regular intervals, having cycles in similar length and experiencing premenstrual and menstrual symptoms usually confirms ovulation. A woman whose basal body temperature rises consistently is also likely ovulating. A blood progesterone level can be checked usually one week after ovulation, and if elevated, indicates ovulation has occurred. The "ovulation indicator kit" will generally become positive one day before ovulation occurs. This kit is testing a woman's urine for luteinizing hormone. A woman should use this kit daily approximately 2-3 days prior to the expected day of ovulation. Ovulation dysfunction affects approximately 15 % of couples experiencing infertility.
Fallopian tube abnormalities are a common cause of infertility and occur in 30-35% of infertile couples. Abnormalities may be due to previous infection, ectopic pregnancies, or surgeries on the fallopian tube. Endometriosis can also cause fallopian tube scarring. To evaluate for fallopian tube abnormalities a physician may choose a radiologic test called a hysterosalpingram. This test involves injecting fluorescent dye into the uterine cavity and evaluating the dye as it moves through the fallopian tubes. The test is usually performed 2-5 days after the last day of menses. Another testing option would be laparoscopy (minimally invasive surgery) to directly evaluate the fallopian tubes as dye is injected into the uterus. This allows a thorough evaluation of the pelvic organs.
Further resources regarding infertility evaluation include:
http://www.uptodate.com/contents/patient-information-evaluation-of-the-infertile-couple?source=see_link
http://www.acog.org/~/media/For%20Patients/faq136.ashx
http://www.reproductivefacts.org/
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