In a single cycle, the likelihood of conception (achieving pregnancy) for a healthy young couple is approximately 20 percent. Over twelve months, the combined likelihood of achieving pregnancy is about 85 percent. It is important to know that these numbers willstart to decrease beginning in a woman's early thirties, and decline fasterafter age 35.
Multiple factors can affect a couple's ability to conceive. Generally, the causes can be divided into male and female categories.
- Male Factor (40 percent)
- Female Factor (40 percent)
- Male & Female Factors (10 percent)
- Unexplained (10 percent)
Therefore, a thorough evaluation of the infertile couple begins with investigation for both male and female causes of infertility.
We also evaluate couples suffering from recurrent pregnancy loss.
Evaluation of the male
Thorough patient history
- Avoid ejaculation for 2-5 days before the appointment
- Lab collection preferable, but can obtained at home if kept warm and brought to the lab within a half-hour of collection.
- Sperm Concentration
- Total number of sperm per volume of semen, counted in millions/milliliter.
- ³ 20 million/ml is normal
- Motility (Movement)
- Percentage of forward-swimming sperm in the sample.
- ³ 50% is normal
- Morphology (Shape)
- Percentage of normally-shaped sperm in the specimen.
- > 14% is normal using strict criteria
- The presence of many white blood cells may indicate that infection is present.Infections can usually betreated with a course of antibiotics.
When an abnormality is noted, the patient will typically obtain a repeat specimen. If it remains abnormal, a referral to an urologist is sometimes recommended for a physical examination and further work-up.
Evaluation of the female
This evaluation starts with a detailed patient history and physical examination, with attention to past illnesses and surgeries, menstrual cycle characteristics, previous pregnancies, and contraception (birth control).
Ovulation (monthly release of an egg)
- Ovulation Predictor Kit
- Using a home urine testing kit, we can measure luteinizing hormone (LH), a hormone that causes ovulation.
- A positive test predicts ovulation within 24-40 hours.
- Progesterone Level
- One week after ovulation, the patient has blood drawn to test for elevation of this hormone (produced by the ovaries).
- Basal Body Temperature
- After ovulation, a small increase in body temperature occurs, which lasts throughout the second half of the cycle.
- Taketemperature by mouth every morningbefore getting out of bedx 2-3 menstrual cycles
- Vaginal Ultrasound
- Collapse of a mature follicleconfirms ovulation
Polycystic Ovary Syndrome (PCOS)
- Criteria for the diagnosis of PCOS include 2 out of 3:
- Infrequent ovulation- usually with less frequent menstrual bleeding but sometimes menstrual cycles can be regular
- Clinical and or biochemical signs of increased testosterone or similar hormones
- Evidence of polycystic ovaries by ultrasound.
- Diagnosis also involves exclusion of various other disorders such as congenital adrenal hyperplasia, Cushing's syndrome, androgen secreting tumors, as well as thyroid or prolactin disorders which have a similar presentation.
- May need further screening tests for pre-diabetic conditions and cholesterol abnormalities, as well as uterine lining evaluation with ultrasound or office biopsy.
- Ability of the eggs remaining in a woman's ovaries at a given age, to produce a viable pregnancy.
- Decreases with age.
- Testing recommended on all women who are ³ 35 years, as well as women with a history of poor response to fertility drugs.
- Basal FSH, Estradiol
- Single blood test that is performed between days 2 and 4 of the menstrual cycle; we routinely use this test.
- Clomiphene Citrate Challenge Test (CCCT)
- Administration of clomiphene citrate, with 2 blood test measurements on day 3 and day 10 of the menstrual cycle; we use this test less commonly.
- Basal Antral Follicle (BAF) count
- Transvaginal ultrasound to count the number of small follicles (cyst with egg inside) at the beginning of cycle; low number indicates poor reserve
Tubal Factor, Uterine Factor, and Pelvic Factor
If the above tests demonstrate that a woman is ovulating, further tests and procedures may be performed to look for other causes of female infertility. These include
- Hysterosalpingogram (HSG)
- Performed right after the menstrual period is completed
- X-ray taken while dye is placed in the uterus through a thin tube inserted through the cervix
- Dye fills the inside of the uterus and then shows whether the fallopian tubes are open
- Outpatient surgical procedure that requires general anesthesia
- Small telescope attached to video camera is placed through a small incision made in the navel to evaluate the pelvis
- If endometriosis or adhesions (scar tissue) are found, they are usually treated at the same time
- Dye can also be injected through the cervix to determine if the fallopian tubes are open
- Small telescope attached to a video camera, placed through the cervix, and into the uterus which is filled with fluid
- Abnormalities in the uterus can be correctedusing this technique
- Can be performed in the office, or in the operating room in conjunction with a laparoscopy
- Saline Infusion Sonography (SIS)
- Simple ultrasound procedure to determine whether or not the uterine cavity is normal, and can be performed in the office
- A small tube inserted through cervixis used toinject a small amount of saline to view the uterine cavity during the ultrasound
- Can also be used to assess whether at least 1 of the fallopian tubes is open.
Recurrent Pregnancy Loss
Evaluation typically begins after 2 miscarriages that have occurred prior to 13 weeks of pregnancy.
- Lifestyle factors like smoking
- Medical problems like diabetes and obesity
- Chromosome abnormalities in the parents
- Uterine Cavity abnormalities
- Saline sonogram, hysterosalpingogram, or hysteroscopy
- Blood testing
- Parental chromosome testing