Infertility

Infertility, the inability of a couple to become pregnant after one year of unprotected intercourse, is very common.

The ability of a couple to become pregnant depends on several factors. Among all cases of infertility, about 20 percent can be traced to male factors, 40 percent can be traced to female factors, and 30 percent can be traced to factors in both. In about 15 percent of couples, the cause for infertility cannot be traced to specific factors in either partner.

Today, many tests are available for evaluating infertility. It is important to gather information about these tests and to discuss options carefully with your doctor.

Associated Factors

Several factors are associated with infertility, although it is unknown if these factors actually cause infertility. Possible factors include male reproductive problems, ovulation problems, damage of the fallopian tubes, endometriosis, problems with intercourse, and an abnormal interaction of cervical mucus and sperm. However, in many cases, the cause of infertility cannot be determined.

Male Fertility

There are a variety of tests to evaluate male infertility. Doctors usually begin with a medical history, physical exam and semen analysis.

Medical history: Your health and medical history may provide clues about the cause of infertility. Your doctor will ask about your childhood development, sexual history, illnesses and infections, surgeries, medications, exposure to certain environmental agents, and previous fertility evaluations.

Physical exam: A physical exam usually includes a general medical examination with special attention to signs of hormone deficiency or other conditions. Your doctor may also perform a genital exam.

Standard semen analysis: A semen analysis can provide information about the volume and pH of semen; the concentration, motility (movement) and shape of sperm; the presence of immature sperm; and the presence of other substances and cells that affect fertility.

Your doctor will usually request that you abstain from sex for at least two days before providing the sample. If the result is abnormal, your doctor will request two additional samples several weeks apart to confirm whether there is a problem.

Blood tests: Blood tests can provide information about hormones that play a role in male fertility, including those produced by the hypothalamus, the pituitary gland and the testes. Hormone levels and patterns can determine if these structures are functioning normally. These tests are usually only performed if the semen analysis is abnormal.

Genetic tests: If your doctor suspects genetic or chromosomal abnormalities, she may order a test to check for missing or defective regions of genes and chromosomes.
 

Female Fertility

There are a variety of tests to evaluate female infertility. Doctors usually begin with a medical history, physical exam and other preliminary tests.

Medical history: Your past health and medical history may provide clues about the cause of infertility. Your doctor will ask about your childhood development, sexual history, illnesses and infections, surgeries, medications, exposure to environmental agents, and previous fertility evaluations.

Physical exam: A physical exam usually includes a general medical examination with special attention to any signs of hormone deficiency or other conditions. Your doctor will also perform a pelvic exam, which can identify structural abnormalities of the reproductive tract and signs of low hormone levels.

Blood tests: Blood tests can provide information about hormones that play a role in female fertility, including those produced by the hypothalamus, the pituitary gland and the ovaries. These hormones include follicle-stimulating hormone (FSH), luteinizing hormone (LH) and prolactin.

Ovulation tests: Ovulation (the release of an egg from an ovary) is essential for fertility. Abnormalities of ovulation can often be determined with a woman's menstrual history, her basal body temperature and hormone levels.

Menstrual history: Amenorrhea (absent menstrual periods) usually signals an absence of ovulation, which is a known cause of infertility. Oligomenorrhea (irregular menstrual cycles) can signal erratic ovulation; although oligomenorrhea does not make pregnancy impossible, it reduces its likelihood.

Basal body temperature: Monitoring of basal body temperature (measured early in the morning when body temperature is at its lowest point) can help determine if ovulation is occurring. This temperature usually rises by 0.5 to 1.0 degrees after ovulation. However, basal body temperature patterns can sometimes be difficult to interpret.

Hysterosalpingography: This procedure can help identify structural abnormalities of the uterus and fallopian tubes that can contribute to infertility. During hysterosalpingography, a liquid dye is placed in the uterus and fallopian tubes to outline these structures on X-rays; hysterosalpingography is usually performed after the completion of a menstrual period but before ovulation.

Hysteroscopy: During hysteroscopy, a thin, lighted tube is advanced into the uterus and fallopian tubes to directly examine these structures. A hysteroscopy is usually performed in women who are thought to have an abnormal uterine cavity; several structural abnormalities can be surgically treated during hysteroscopy.

Uterine abnormalities: Uterine abnormalities include congenital structural abnormalities, such as a uterine septum (a band of tissue that makes the uterine cavity small); abnormalities linked to exposure to diethylstilbestrol (DES), which can cause a T-shaped uterus; fibroids; polyps; and structural abnormalities from gynecologic procedures.

Fallopian tube abnormalities: Scarring and obstruction of the fallopian tubes is most often due to pelvic inflammatory disease. Other conditions that affect the fallopian tubes include endometriosis and pelvic adhesions (scar tissue) from abdominal infection or surgery.

Pelvic ultrasound: Pelvic ultrasound can detect structural abnormalities of the uterus, ovaries and other pelvic tissues and organs.

Laparoscopy: During laparoscopy, a thin, lighted tube is advanced through a small abdominal incision to examine the pelvic structures directly. This test can detect damage and obstruction of the fallopian tubes, endometriosis and other abnormalities of the pelvic structures. Laparoscopy is the best test for diagnosing endometriosis or pelvic adhesions (scarring). Furthermore, endometriosis tissue can be removed during laparoscopy, and this removal has been shown to improve pregnancy rates in infertile women. Your doctor will likely recommend laparoscopy if you have had endometriosis, appendicitis, pelvic surgery, pelvic inflammatory disease, or other conditions known to affect the fallopian tubes or uterus. Laparoscopy is also helpful when other tests fail to reveal a cause of infertility.

Genetic tests: If your doctor suspects genetic or chromosomal abnormalities, he or she may order a test to check for missing or defective regions of genes and chromosomes.
 

Test Limitations

In many cases, infertility tests can identify the most likely cause of infertility and help guide the treatment of this condition. However, studies have shown that these tests also have limitations. For many of these tests, the definition and the significance of a "normal" result are still uncertain. In general, test results are more likely to be abnormal in infertile couples than in fertile couples; however, many couples with abnormal test results are able to conceive. Your doctor can provide helpful information about the interpretation of infertility test results.
 

Learn More

Your doctor is the best resource for information related to your particular case. Not all patients with infertility are alike, and it is important that your situation is evaluated by someone who knows you as a whole person.