Infertility

What is infertility?

Infertility is the inability of a couple to achieve or carry a pregnancy to term. This designation is given after one year of unprotected intercourse.

How common is infertility?

Infertility is currently a problem for one out of five couples trying to have children.

When should we begin investigating whether or not we're infertile?

If after a year of trying to conceive you are not successful, a basic infertility evaluation may be started. If the female partner is older than 30, however, or has a significant past medical history of irregular periods or previous pelvic infections, the infertility evaluation and tests can be started earlier.

What is the procedure for determining if we're infertile?

The infertility work-up itself follows a fairly specific sequence. A complete work-up or evaluation of the woman usually takes three or four cycles to complete. This is because certain tests have to be done at specific times in the menstrual cycle. The nature of the infertility work-up necessitates that it become a priority in your daily life. Suddenly, there are specific days that you must have intercourse. In certain tests you even have to report to the doctor's office a specific number of hours after intercourse. As a result, spontaneous lovemaking becomes difficult. Vacations and business trips become low priority. Schedules have to be made to fit the demands of the testing cycle. Many women find it hard to take time off from work, especially if they don't want it known that they are undergoing an infertility evaluation. It can be a stressful time. Both husband and wife are being tested and scored. There can be a feeling of "pass or fail" and a real sense of despair if a test comes back showing questionable or negative results. Women often feel frightened and violated by the infertility tests. Men often feel helpless. For the husband, testing is over if the semen analysis is normal. In contrast, he may see his wife having to go through various tests which can be painful and frightening. This understandably can upset both parties. Added to this worry and uncertainty is the lingering fear over what the doctor will discover. What if he finds an answer, but a discouraging one? For these many reasons, deciding to start an infertility work-up is a big decision.

The following is an overview of the tests involved. You may use it to understand what tests may be required, or to double-check that you have had all the tests.

Initial appointment

The couple is usually seen together for the first appointment. This provides an opportunity to establish good communication. It also is an opportunity to evaluate what, if anything, has been done and what will be needed in the future. A list of tests and a time frame for completing the evaluation will be given at this time.

A detailed medical history of the couple will be taken. The physician will also want to know about the medical history of the immediate family. Attention will be paid to previous surgery, infections, chronic illnesses and hospitalizations. Background information on smoking, alcohol intake, medications and exposure to environmental or occupational toxins will be requested. A detailed reproductive history from both partners will be needed. This includes information on when menstrual cycles started, how long they last every month, quantity and quality of flow, and a description of menstrual cramps. Details about the types of birth control practiced will be obtained. Any history of previous pregnancies will be discussed. Information about previous venereal disease is crucial in the evaluation. A fairly detailed report concerning their sexual history as a couple will be needed. Questions about lubricants and frequency of intercourse will be asked as well.

Physical examination

A physical examination of both partners should be done on the first or second visit. For the woman this means a general physical with attention paid to the development of secondary sex characteristics, such as breast development and the amount and location of body hair. A pelvic exam will determine the general size, shape, position and condition of pelvic organs. A Pap smear is routinely taken (to rule out cervical cancer), as well as a gonorrhea culture. The physician will order routine tests on blood and urine to check for general health problems.

For the man there will be an examination of the genital organs, with the doctor noting size, position and condition of the penis and testes. A rectal exam is done to determine the size and consistency of the prostate gland and seminal vesicles. The development of secondary sex characteristics will also be noted. Routine blood and urine tests will be done.

Ovulation detection

You may be given instructions about using the basal body thermometer (BBT) to monitor the shifts in body temperature. Two to three months of BBT charts are often requested. This will give a sense of the general times the woman is ovulating. The physician will use these charts to determine when some of the tests have to be scheduled, as many can only be done at special times in the cycle.

Medical evaluation of the male

Semen analysis

This is the first and most informative test done on the male. An analysis can be done any time because a man is not as cyclic as a woman. Abstinence from intercourse for 24 to 48 hours before the analysis is suggested. Abstinence for a longer period than two days is not necessary. For the semen analysis, the man will be asked to masturbate a specimen into a clean jar. This can be done at home and kept at body temperature and delivered to the lab for evaluation. Then the laboratory will examine the specimen under a microscope to look for the number of sperm present, how fast the sperm are swimming (motility) and the shape of the sperm (morphology). The total volume of the specimen and its viscosity (thickness) will also be checked.

A fertile semen specimen should have at least 20 million sperm, with at least 50 percent of the sperm motile, and 50 to 60 percent with good morphology. Normal volume is 2-5 cc. A semen analysis should be repeated at least once, because all levels fluctuate. It is also a good idea to repeat semen analysis periodically if the infertility investigation of the couple is lengthy, as these levels can change over a long period of time.

If the semen analysis indicates there may be an infertility problem, other tests on the semen will be done. The semen will be checked for the presence of fructose, which is a special kind of sugar produced in the epididymis. If it is absent this may mean there is a blockage in the ductal system, although sperm production may be normal. In addition, the semen may be checked for unusual clumping or agglutination that could indicate an immunologic response -- a "sperm antibody" condition. Some physicians also order a new test called the "zona free hamster egg test" to check that the sperm are able to penetrate the outer layer of a hamster egg, which is very similar in structure to a human egg.

Several additional tests may be done on the male if the semen analysis is not normal:

  • Evaluation for a varicocele is done by palpating the scrotum while the man is bearing down or coughing. The link between the presence of a varicocele and infertility is not clearly understood. The most common theory is that the presence of a varicocele causes poor circulation which ultimately inhibits normal sperm production.
  • In the event of a subfertile semen analysis, a small biopsy of both testicles may be done. This procedure is done in a hospital under local or general anesthesia. The testicular tissue is examined in the laboratory. This test can tell the doctor if there is an absolute infertile state with no sperm-producing tissue present, or if there is blockage in the vas deferens (indicated by the presence of normal testicular tissue, yet little or no sperm in the ejaculate).
  • If a blockage in the vas deferens is suspected during a testicular biopsy, a vasography can be done to pinpoint the area of the blockage. This is an X-ray study in which dye is injected into the vas deferens and a series of X-rays are taken.