Infertility

The causes of infertility are complex, and finding the cause of one couple's problems requires a thorough evaluation of both partners.

The first step is a visit to the doctor for a thorough physical examination and medical history, for which the doctor will ask about both partners' personal health backgrounds and sexual histories--how often they have intercourse, for example, and whether either has been pregnant or caused a pregnancy before. For example, if the woman has had children with a previous partner but the man has never caused a pregnancy, even though he's had opportunities, that is a hint that the infertility might be due to a problem with the man.

Women often undergo blood tests for reproductive hormones and an ovarian ultrasound as the first step. There is no way to count the number of eggs a woman has left, but these tests can give an idea of the health of her ovaries, or her ovarian reserve--the chance that her ovaries are going to be able to produce a healthy egg. Depending upon the history and examination, a laparoscopy, hysteroscopy, or hysterosalpingogram (HSG) may be performed to further evaluate the reproductive anatomy. For men, a semen analysis is a standard first step, and a testicular biopsy can give more information about a poor sperm count. Patients may want to try tracking their ovulation at home.

Even an exhaustive and thorough evaluation by skilled professionals may not identify a reason for the failure to conceive or carry a successful pregnancy. Unexplained infertility is one of the most frustrating diagnoses for both patients and physicians.

This section contains more on:

Semen analysis

Testicular biopsy

Home test for ovulation

FSH tests

Ovarian ultrasound

Endometrial biopsy

Hysterosalpingography

Laparoscopy

Other tests

Semen analysis is the most basic test for men. For the test, men produce a sample of semen that goes to a lab for analysis. Men should refrain from sexual intercourse or masturbation for three days before the test.

In a semen analysis, the lab determines sperm count (the number of sperm per milliliter of semen), sperm motility (how well the sperm moves), and sperm morphology (whether the sperm looks normal). Low sperm count doesn't necessarily mean a man is infertile. Although men with lower sperm counts tend to be more likely to be infertile, there are plenty of fertile men with low sperm counts, too. The sperm count may also show that the man isn't producing any sperm at all. Sperm that don't move well are less likely to make it to the egg; the female's reproductive tract filters out sluggish sperm. Sperm that are oddly shaped are less likely to be able to fertilize the egg. (Abnormal sperm do not cause abnormal pregnancies; they don't cause any pregnancies at all.) Even in a normal sample from a fertile man, the majority of the sperm can be abnormal, but a very high percentage of abnormal-looking sperm may indicate a problem.

If a man has no sperm in his semen, he could have one of two problems: he might not be producing sperm, or he might be producing sperm but have a blockage somewhere between the testicle and the urethra, for example in the vas deferens. To check whether a man is producing sperm, a doctor can do a testicular biopsy.

In a testicular biopsy, a doctor will clean the area and inject local anesthesia, then use a needle to draw out a sample of tissue that will be examined under a microscope. Usually sperm is visible in this sample--it is more common for a man to have a blockage than to not produce sperm. Sperm from the testicle can be used to perform intracytoplasmic sperm injection (ICSI) as part of in vitro fertilization--in essence, the man can act as his own sperm donor.

If no sperm is found in the biopsy, the man is infertile, and the couple may wish to consider other options, including using a sperm donor.

Some women are able to track when they are ovulating at home. This may be useful for couples who are attempting to time intercourse around the woman's fertile time. Ovulation occurs about 14 days before the first day of menstruation.

One method for doing this is to track the basal body temperature. With this method, the woman attempts to pinpoint the time she ovulates by taking her temperature first thing every morning, before she gets out of bed. After ovulation, body temperature goes up by a degree or so. Some women have a very regular pattern where the temperature is low for two weeks, then high for two weeks. Since the temperature doesn't go up until after ovulation, it is too late to tell you when to have intercourse, but some women will be able to identify a regular pattern that will help them predict ovulation.

Women can also test their cervical mucus. Usually mucus turns thick, like a raw egg white, around the time of ovulation, but many women don't notice a difference.

Home testing kits are also available to check for ovulation. These kits work by testing for luteinizing hormone or LH, the hormone that causes ovulation, in urine. To use the kit, you start testing your urine a day or two before expected ovulation and test it every day until it detects the LH surge. That means you are going to ovulate in the next 24 to 36 hours. These tests work well for many people. Others may find the test difficult to read or may find that the test doesn't work for them. In studies, these tests have been found to be about 80 to 85 percent accurate.

High levels of follicle-stimulating hormone (FSH) can be a sign that the ovaries are not working as well as they should be. FSH is produced by the pituitary, a gland at the base of the brain. As the name suggests, FSH stimulates the follicles, which enclose the eggs, to develop. FSH works in a feedback loop with estrogen: As the follicle develops, it makes estrogen, which then travels back to the pituitary, which lowers FSH production in response. This loop repeats every month and helps regulate the menstrual cycle.

As the ovaries become depleted of eggs, the pituitary must produce a higher level of FSH before it gets a response. While this is normal in a woman approaching menopause, some women may have ovaries that act older than they should. For example, if a 35-year-old woman has FSH levels like those of a 45-year-old, her chances for conception may be like those of an older women. Women with low ovarian reserve (indicated by high levels of FSH) usually do not respond well to fertility medications.

Because FSH goes up and down over the course of a month, it has to be measured at a set time in the cycle. Typically FSH levels are measured with a blood test between days two and four of the menstrual cycle (day one is the first day of menstrual bleeding). FSH can vary from month to month; your doctor will use the highest measurement. You don't need to fast before an FSH blood test. The higher the FSH value, the lower the likelihood of pregnancy, because it suggests your ovaries aren't as responsive as they should be.

Another test of FSH is the so-called clomid challenge, named after a brand of fertility drug. For this test, a woman takes clomiphene citrate, a drug that stimulates the ovaries, from days five to nine of her menstrual cycle. On day 10, she has blood taken for a second FSH test. As with the day three FSH test, a higher level indicates the ovaries may not be functioning well. Some women with a normal day three FSH test have high FSH with the clomid challenge test.

Ovarian ultrasound is performed to get a look at the ovaries and to count antral follicles, those that have the potential to develop that month. Follicles are the sacs that contain eggs in the ovary. The person doing the ultrasound will look at the size of the ovaries.

A patient who has normal-sized ovaries and many follicles usually has ovaries that work well. Ovaries shrink as women age. By looking at the size of the ovaries and counting the follicles, the doctor may be able to estimate how much fertility medication a woman might need. A patient who has very small ovaries and few follicles probably won't respond well to fertility medications.

Ovaries lie very close to the vagina, so ovarian ultrasound is done transvaginally, meaning it uses a special ultrasound wand that is inserted into the vagina.

A doctor may want to take a sample of the endometrium (the lining of the uterus) to see if it seems to be in sync with ovulation. This is not a common test. The endometrium cycles each month--menstruation is how the body sheds extra tissue when pregnancy doesn't occur. This cycle must line up with ovulation so the endometrium is at the correct point in the cycle for an embryo to implant after an egg is ovulated and fertilized. In this procedure, the woman lies down and a speculum is inserted to hold the vagina open. A thin catheter is inserted through the cervix into the uterus, and a tiny sample of the endometrium is sucked out. This can be done with or without anesthesia. The sample will be examined to see if the endometrium seems to be prepared for pregnancy.

A hysterosalpingography is an X-ray of the uterus and fallopian tubes. For this test, a thin catheter is inserted through the vagina and cervix, into the uterus. Dye is injected through the catheter. As the patient lies on a table, an X-ray machine above the table takes pictures of the dye moving out of the catheter, filling the uterus, and going out through the fallopian tubes. If the tubes are open, the doctor can see the dye coming out through the tubes. This test also shows the inside shape of the uterus.

Some women have little or no discomfort with this test. Some women feel cramping as the dye is injected. The dye distends the uterus, and in women who have tubes that are closed, the tubes will expand, which can be uncomfortable. The pain goes away as soon as the procedure is over. It's a good idea to take ibuprofen before this test.

Laparoscopy uses a telescope and tiny incisions to look inside the abdomen. This test is used to look for signs of endometriosis or scarring.

Laparoscopy is done in an operating room with general anesthesia. Patients are intubated (a breathing tube is inserted) for the procedure. Laparoscopy is performed on a table that tilts the patient's body head-downward at a 45 degree angle. This position lets the intestines fall away from the reproductive organs, opening more space for the doctor to see the organs, but would be very uncomfortable if you were awake. Usually the scope goes in the belly button and another instrument goes in just above the pubic bone. The incision at each location is usually less than a quarter of an inch. The doctor puts gas into the abdominal cavity to distend it and make it easier to look at the organs. The doctor may also inject dye into the uterus to see if the fallopian tubes are open--if they are open, the dye will come out the other end of the tubes.

Patients usually go home the same day.

Additional testing is tailored to the couple's or individual's specific situation. The evaluation of a couple with recurrent miscarriages may be different from that of a woman with an ovulation disorder and irregular menstrual cycles. Specialized tests such as chromosome testing, hormone tests, or genetic tests may be ordered. Sometimes patients have abnormal hormone levels because of a tumor in the pituitary gland, so occasionally fertility testing may even lead to a CT or MRI of the head. Referrals to other physicians, including those specializing in maternal-fetal medicine, urology, medical endocrinology, or hematology may be required if a potential or underlying disorder is identified. Genetic counseling is another common component of fertility testing and evaluation.