Infertility is defined as a person that is not pregnant after one year of trying to conceive. About 40% of infertility is due to a problem with the woman, 40% from a problem with the man, and 20% either a combination or a problem that is never identified. 85% of couples that are trying to get pregnant will be pregnant within one year of trying. Of those 15% that are not pregnant after one year, about half of them will become pregnant without medical intervention.
Primary infertility is infertility in someone who has never been pregnant in the past. Secondary infertility is infertility in someone who has been pregnant at least once before. There is a lot of overlap in the causes of primary and secondary infertility. The big difference is that in secondary infertility we know that the women were born with the necessary apparatus to become pregnant.
When one considers infertility logically the causes are not too complex. Either there are no sperm produced, there is no egg produced, the sperm or egg are produced but do not function properly, the sperm and the egg are not able to interact, or the fertilized embryo cannot implant. The evaluation of the infertile couple involves systematically testing for these problems and identifying the cause for the individual couple.
The most common cause of female infertility is anovulation, not making any eggs. The most common cause of anovulation is polycystic ovarian syndrome but there are other problems that can interfere with egg production. Some examples are thyroid problems, problems with a hormone called prolactin, and some environmental situations. The second most likely problem is blockage of the fallopian tubes. Less common causes are problems with the uterine cavity or the cervix.
The evaluation of the infertile couple begins with a detailed history. The doctor will ask about past pregnancies, past problems with infections or trauma, past surgeries, menstrual patterns, what previous birth control has been used, sexual frequency and patterns, medical problems, medications, past medical interventions for infertility, and so on. The answer to these questions help the doctor to pinpoint the cause of infertility in your unique situation. If you have other medical problems like diabetes or hypertension, your treatments for these conditions will need to be optimized prior to trying to conceive. Sometimes medications will need to be changed that may be safer for pregnancy.
There will be a physical exam looking for potential medical problems that could be effecting fertility. a pelvic exam will be done to make sure the anatomic structures of the reproductive tract are normal. Things like cervical scarring, fibroids, or ovarian masses will be looked for.
Your partner will be asked to get a semen analysis. This involves ejaculating into a cup. that ejaculate is then tested for sperm numbers and function. 40% of infertile couples have a sperm issue. This test should be done early in the work up. If the man is not producing sperm, or they do not function properly, this needs to be known prior to doing a lot of invasive studies and procedures to the women.
The initial laboratory tests will in part depend on the history and physical exam. A CBC (blood count) and a test for rubella antibodies are usually ordered. These do not look for causes of infertility but look for issues that may need to be addressed before becoming pregnant. One of the things the CBC looks for is anemia, if this is present, iron may be prescribed. The rubella antibody is to check that your childhood immunizations are still protecting you. If not, a vaccine booster shot may be recommended.
Additional blood tests that are typically ordered are a TSH, a prolactin level. The TSH looks for problems with the thyroid. Both hypothyroidism (not enough thyroid hormone) and hyperthyroidism (too much thyroid hormone) can interfere with the ovaries ability to make eggs and cause anovulation. The treatment is usually very simple and effective if there is a thyroid problem, either a thyroid replacement medication or a medication to decrease the thyroids output. Prolactin is a hormone that is made by the brain during breastfeeding. Its primary function is to produce breast milk but it also inhibits ovulation. This makes sense; the body figures if you are breastfeeding a baby you probably don’t need another one right now. If the prolactin is elevated, there is a medication that will help return it to normal and allow you to become pregnant.
There are two tests that are often ordered that need to be on a certain day of the menstrual cycle. They are FSH and progesterone levels. Cycle days are calculated by using the first day of menstrual bleeding as day one and then simply counting forward. The FSH is checked on cycle day 3. It evaluates for early menopause and checks that the ovaries are capable of functioning. The progesterone levels are drawn on cycle day 21. This evaluates if you ovulated with that cycle. If your periods are irregular, a period may be stimulated by taking a medication called provera once a day for 10 days. The menses will start sometime during the week after the last pill.
An HSG (hysterosalpingogram) may be ordered. This is a test that is done in the radiology suite. It evaluates for anatomic problems with the uterus and fallopian tubes. A speculum is placed in the vagina like with a pap smear. Dye is then injected into the uterus using a small plastic tube placed through the cervix. X-rays are then taken to watch the flow of the dye up the uterus, through the tubes, and into the abdominal cavity. This will tell us if there are structural problems with the inside of the uterus or with the fallopian tubes. It will also diagnose blockage of the tubes. The HSG can be therapeutic as well as diagnostic, meaning it can sometimes fix problems. If the tubes are blocked because of mucus plugging, the HSG can unblock the tubes and return fertility. This test can cause a lot of cramping. I recommend taking ibuprofen before the procedure. Antibiotics are often given to decrease the risk of infection from the study.
Once the cause of infertility is discovered, treatment can be started to overcome the cause. The treatment will depend on the unique problem. Sometimes no specific problem can be identified. This is called unexplained infertility. Even in these cases there are treatments that can be used that are often successful.