Infertility: Diagnosis

Manisha Patel, MD January 23, 2006

Pt is a 25 year old p0000 married female who presents to clinic with a complaint of infertility. She reports that she and her husband have been having unprotected intercourse for 3 months with no resultant pregnancy. She is inquiring about evaluation/treatment for infertility.

When should a formal evaluation for infertility begin? Infertility is generally defined as one year of unprotected intercourse without conception. However, immediate evaluation should be offered to woman older than 35, women with irregular or infrequent menses, woman with a history of pelvic infection or endometriosis, and in men with known or suspected poor semen quality.

What is the likelihood of conception within 1 year of unprotected intercourse? 85 – 90%

What is the probability of pregnancy with a single cycle (cycle fecundability)? 20 –25%

In the evaluation of the infertile couple, what in the history and physical is pertinent to include?

History:
-HPI: Symptoms of thyroid disease, pelvic or abdominal pain, galactorrhea, hirsutism,
-OB Gyn Hx:

1. o Gravity, parity, pregnancy outcomes, associated complications, duration of infertility
2. o Cycle length and characteristics, onset and severity of dysmenorrhea, Rx for abn paps

o Coital frequency and any sexual dysfunction/dyspareunia
-Past surgical history, past or current medical illnesses, PID history, STD exposure
-Current medications and allergy, use of tobacco, alcohol, and other drugs, occupation
-Family history of birth defects, mental retardation, or reproductive failure
Physical: Weight and BMI
-Thyroid enlargement, nodule, or tenderness
-Breast secretion and their character
-Signs of androgen excess
-Pelvic or abdominal tenderness, organ enlargement, or mass
-Vaginal or cervical abnormalities, secretions, or discharge
-Any mass, tenderness, or nodularity in the adnexa or cul-de-sac

What initial screening tests should be performed in a patient with infertility?

-Pap smear, STD screening: Role for chlamydia antibody test is not yet defined.
-Blood type, Rh factor, antibody screening if not already known

Screening for CF: especially in high risk couples
-Rubella immunity and vaccination if seronegative
-Varicella immunity who have no or uncertain history of past infection

What are the causes of infertility and how common are each cause?

-Male Factor: 35%
-Ovulatory Dysfunction: 15%
-Tubal and pelvic pathology: 35%
-Cervical Factor: 3%
-Uterine Factor: generally uncommon
-Unexplained: 10%

How do you evaluate for male factor infertility? Semen analysis: include at least two properly performed semen analyses obtained at least four weeks apart. Pt should remain abstinent for 2-3 days.

Specimen should be collected either by masturbation directly into a clean container or via intercourse using a specially manufactured silastic condom that does not contain spermicide and examined within an hour after collection.

What are the normal parameters of a semen analysis? WHO normal reference values:

Semen Volume: 1.5 – 5.0 ml

Ph: > 7.2

Sperm concentration: > 20 million/ml

Total sperm number: > 40 million/ejaculate

Percent motility: > 50%

Normal morphology: > 14%

How can you evaluate for ovulatory dysfunction? -Menstrual history: If menses are regular, predictable, consistent in volume and duration, accompanied by moliminal symptoms Æ most likely ovulatory -Basal Body Temperature: Measured each morning, on awakening but before rising using a thermometer with markings in 1/10^th of 1 degree. BBT should rise after ovulation due to the thermogenic effect of progesterone. Biphasic pattern suggests ovulatory cycle with menses occurring 12 days or more after the rise in temperature. Not practical if menstrual hx already suggest anovulation. -Serum progesterone: any level greater than 3 ng/ml on CD 21 or 1 wk prior to menses provides reliable objective evidence that ovulation has occurred. Again, not practical if menses irregular. -Urinary LH secretion: Detect the midcycle LH surge in urine during a 48 hr window prior to ovulation. To reliably detect the LH surge, test daily beginning 2 or 3 days before the surge is expected -Endometrial biopsy: predictable postovulatory progesterone-induced secretory endometrium maturation allow experienced pathologists to “date” the endometrium but rarely used. The diagnosis of luteal phase deficiency is made when dates and histology are out of phase more than 2 days. -Serial transvaginal ultrasound to follow growth and rupture of follicles

How do you diagnose cervical factor infertility?

Post Coital Test: (Controversial and inconsistently used) Couple to engage in unprotected intercourse within 4 hrs of appointment for evaluation of cervical mucus specimen with a gross and microscopic examination to grade mucus characteristics (volume, pH, clarity, cellularity, viscosity (Spinnbarkeit), salinity (Ferning)), and to assess the number and motility of sperm)

What are the 3 basic methods for evaluation of the uterine cavity?

Hysterosalpingography (HSG), Transvaginal ultrasound with or without saline contrast, Hysteroscopy: definitive method for both diagnosis and treatment of intrauterine pathology

When should tubal factor infertility be suspected and how is it diagnosed?

History of PID, septic abortion, ruptured appendix, prior abd or tubal surgery or ectopic pregnancy

2 classic methods of evaluation:

HSG: done 2-5 days following end of menses

Laparoscopy: gives detailed information about pelvic anatomy, adhesions,

endometriosis, ovarian pathology

When is unexplained infertility diagnosed? Diagnosed when all the standard elements of the infertility evaluation yield normal results: normal semen analysis, uterine cavity, tubal patency, and ovulation.

Speroff, L, Fritz M. Female Infertility. In Clinical Gynecologic Endocrinology and Infertility, Lippincott Williams and Wilkins, Philadelphia, 2005, 1013 – 1064.