Definition of Infertility
It can be frustrating when a couple is unable to conceive when they want a baby. Sometimes, a couple wants evaluation for the ability to get pregnant, especially if there is a concern about fertility.
Infertility is a couple’s problem. In general, infertility is the failure to get pregnant within 12 months of intercourse without contraception. It is estimated that 15% of couples may experience infertility. Of course, since there are two people involved, there can be problems with either the female (“female factor” in about 50% of cases) or the male (“male factor” in about 30% of cases) that contribute to the difficulty getting pregnant. The remaining 20% of infertility involves problems with both the female and male.
Fertility evaluation is appropriate for women under the age of 35 years who have tried to conceive for 12 months without pregnancy. Women older than 35 years may seek this evaluation after 6 months without pregnancy. For women older than 40 years, it is reasonable to seek the assistance of subspecialists as reproductive endocrinologists.
In most cases of infertility, no single cause can be identified. Over 40% will have a combination of factors contributing to the infertility. When both partners are evaluated, approximately one third of all cases can be resolved with appropriate treatment.
Infertility Evaluation: Female
1. History
A medical history provides important information to evaluate causes of infertility. The electronic medical record is an amazing tool. However, the computer record is not necessarily comprehensive. Some of these questions touch upon intimate details of your life. You want to be honest and specific so that you can get the help that you have requested. You might need to talk with family to get more details of their health history, especially if they have experienced infertility.
Should you need further evaluation for female infertility, please be aware that some of these questions, tests, or procedures may not apply to your situation. Be sure to check with your insurance company and the provider’s office for information concerning evaluation costs and consider your out-of-pocket costs. It is important to have a qualified physician that you trust to guide you during this season of life.
Here are some general categories of information that could be helpful:
- Symptoms – Do you experience unusual bleeding with your menstrual cycle? Do you have pelvic pain or pain with intercourse? Are your menstrual cycles predictable each month? The most common reason for female infertility is a problem with ovulation.
- Recent pursuit of pregnancy – How long have you tried to conceive? Have there been previous evaluations and/or surgery in the pursuit of pregnancy? Have you been trying with the same partner? How often do you have intercourse? Do you have any problems with intercourse?
- Medical history – Any medical diagnosis is good to share with your provider. All medical conditions including past or current gynecologic problems such as uterine fibroids, pelvic infections, polycystic ovarian syndrome, endometriosis, thyroid disease, and diabetes should be reported. Possibly, you may have had gynecologic imaging or diagnostic procedures. If so, the reports, documentation or images can be very helpful.
- Surgery history – Provide a list of any surgery that you have had, especially related to the abdomen and pelvis. Your provider may ask for operative notes, pathology reports, or surgical photos if they are available. Any previous medical care or intervention provided by others may be important to share.
- Medications and over-the-counter supplements- Any prescriptions and supplements are vital to include with your history.
- Family history – Is there a history of infertility, female problems as endometriosis or premature menopause? Are there any genetic problems or birth defects?
- Social history – Do you use tobacco or vape? Do you drink alcohol? Do you use marijuana or other substances? How much of any of these substances do you use and with what frequency?
- Occupational history – Do you work outside of the home? If so, what is your job? Do you have any potential exposures to radiation or toxic materials (e.g. pesticides, etc.)?
- Pregnancy history – Have you been pregnant before? Were the pregnancies with the same partner? What were the outcomes of each pregnancy?
2. Physical exam
After a woman’s history is obtained in the detail noted above, a physical exam is needed. Much can be gained from an examination. In the case of an infertility evaluation, the woman’s exam is often completely normal. But a normal exam does not mean that there is no female cause (female factor) of infertility. A physical exam attempts to identify any anatomic or functional cause of infertility. Though problems with ovulation can interfere with conception, there are other anatomic concerns.
The physical exam should include:
- vital signs (e.g. blood pressure)
- weight and height
- thyroid gland exam (for enlargement as a goiter or tenderness as with thyroiditis)
- breast exam (including to rule out nipple discharge or milk production unrelated to nursing)
- abdominal exam (to document that there is no tenderness)
- pelvic exam (evaluate the lower genital tract for a normal appearance; the pelvic exam will hopefully document a nontender and normal size and shape of the pelvic organs, etc.)
3. Laboratory studies
Some lab studies are to catch up on routine care. A Pap smear is useful to prove that the cervix is healthy. Mammograms are initiated after the age of 40 years unless family history or personal experience leads up to earlier assessment. Other information is helpful to establish normal function:
- Thyroid hormones (low function can result in menstrual abnormalities and lack of ovulation)
- Complete blood count (to assess possibility of anemia, infection, etc.)
- Progesterone (an indication of ovulation if performed about one week before the menstrual cycle)
- Ovarian reserve (known as anti-Müllerian hormone level)
- Estradiol
- Follicle stimulating hormone (FSH) and Luteinizing hormone (LH)
- Androgen levels (as testosterone and DHEAS)
- Prolactin (produced by the pituitary gland)
- Antisperm antibodies
4. Imaging tests
Imaging for infertility evaluation in women is necessary. This kind of evaluation is a non-invasive assessment of anatomy. Non-invasive evaluations do not involve the risks of surgical procedures which may include anesthesia and incisions. Non-invasive imaging should be performed by experienced physicians or skilled technicians. These tests are informative about the appearance of the pelvic anatomy, but it is not a direct picture of the organ. Actual tissue samples are not acquired, so some diagnoses cannot be made.
Examples of such tests include:
- Pelvic ultrasound – The cervix, uterus and ovaries can be evaluated through an ultrasound probe placed on the lower abdomen or in the vagina (transvaginal ultrasound). Some abnormalities resulting in infertility problems may be identified such as polycystic ovaries and hydrosalpinx. Other anatomic concerns may be identified as cervical or uterine polyps, uterine fibroids, and abnormal ovarian cysts.
- Sonohysterography – This ultrasound procedure involves placing sterile fluid through a small plastic catheter through the cervix and into the uterus. Problems of the inner part of the uterus (endometrial cavity) may be identified as polyps or adhesions.
- Hysterosalpingography - This x-ray procedure involves temporarily filling the uterus with liquid radiologic contrast material. The radiologist can see if the shape of the inner part of the uterus is normal. Uterine abnormalities may be identified as uterine fibroids or endometrial cavity adhesions. Also, an important part of the exam is to determine if the fallopian tubes are open by demonstration of the contrast draining out of the ends of the tubes. If the tube does not drain or there is an abnormal shape, a tubal cause of infertility may be found.
5. Surgical procedures
Some surgical procedures may be recommended based upon the compiled information that has been accumulated from the extensive medical history, physical examination, laboratory studies and imaging. There are two different outpatient, minimally invasive surgical procedures that may be suggested:
- Hysteroscopy - This procedure uses a camera to visualize the inside of the uterus and cervical canal. The goal is to document a normal uterine cavity with no evidence of obstruction to the openings of the Fallopian tubes. This procedure is performed under anesthesia and is usually brief. Sometimes, a sample of tissue is obtained. Intrauterine abnormalities may be treated or removed as endometrial polyps, uterine fibroids (within the uterine cavity), endometrial adhesions, and resection of an endometrial septum. The tissue is always sent to the laboratory for a microscopic exam. Cancer is rarely the concern in the case of infertility evaluation.
- Laparoscopy – This procedure uses small surgical incisions on the abdomen to visualize the lower abdomen and pelvis. Laparoscopy is done under general anesthesia. Infertility may be the main reason for the procedure, but the woman may experience other symptoms which could be evaluated and possibly, treated at the time of surgery. Endometriosis or pelvic adhesions are examples of problems that can be diagnosed only by laparoscopy.
The surgeon will look at the appearance and condition of the pelvic organs. The status of the uterus, ovaries, Fallopian tubes, and surrounding peritoneal surfaces are important. At the end of the procedure, the evaluation may include the assessment to determine if the Fallopian tubes are open. This exam is performed by filling the uterus with blue-colored solution so that the blue fluid hopefully flows from the ends of each normal Fallopian tube.
Summary
No couple wants to experience unplanned infertility when their dream is to grow their family with the precious life of a newborn. If infertility is a concern, the couple should be prepared for the appropriate evaluation with the appropriate professionals and pursue the next steps to achieve their dream.
