The Fertility Evaluation

 

Investigations

Many of the investigations involved in finding out why a woman is not conceiving can be done by a Gynaecologist, but you may need referral to an Infertility Specialist for the full range of infertility investigations and a discussion of the relevance of test results to your infertility problem. A referral may be made to an Infertility Specialist directly from the General Practitioner, or from a Gynaecologist. An Infertility Specialist is a doctor who has specialised in Reproductive Medicine.

Investigations of the male and female will usually take place at the same time. A referral to an Andrologist, a specialist in male reproductive disorders, may be made if certain male problems are found.

The fertility evaluation consists of a range of common tests. The sequence of tests may vary according to the individual situation, but the general rule is to proceed from the simple and risk-free tests to those which are more invasive, and to evaluate both partners simultaneously. Infertility is a shared concern, wherever the problem may reside. Therefore, limiting the evaluation to one member of a couple is inappropriate.

1.   History and physical evaluation.

The evaluation begins with information regarding:

o        Past medical and surgical events

o        Current health status, including diet and lifestyle

o        Occupational risks

o        History of sexual development and relations, including birth control, pregnancies, current relationship and practices.

Examination of the woman consists of a general physical and a more detailed examination of the pelvic area often using an ultrasound. The internal (pelvic) examination is helpful in providing information about the size, shape and position of the reproductive organs.

The male evaluation consists of a general physical, and more detailed examination of the penis, scrotum and testes.

2.   Laboratory studies.

At the time of the initial visit some laboratory studies may be done. If a papsmear is due to be performed, this may be done at this time. Many consultants do a routine Pap test on the woman during her internal examination to rule out cervical cancer. Women with irregular or absent menstrual cycles may have blood tested for pituitary, thyroid and ovarian hormone levels to check for pituitary dysfunction, ovarian failure or polycystic ovary syndrome. Other tests, including hormonal profiles may be ordered on each partner, as indicated by the history or physical examination. All women should be immune to rubella (German measles) and this is easily checked by a blood test. If a woman is non-immune (ie susceptible to rubella infection), vaccination would usually be advised. Folic acid administration is usually advised.

3.   Semen analysis

The semen analysis is the most important test in the evaluation of the male. The test gives an accurate measurement of the number of sperm (stated in millions per ml), the motility of the sperm cells, the size and shape of the sperm cells, the volume and consistency of the ejaculate. The examination should be performed on a fresh specimen within two hours of collection in a sterile container. It is obtained by masturbation and the entire ejaculate should be collected.

Standards vary from laboratory to laboratory, and as it is important for IVF purposes to have the percentage of normal morphology (shape) accurately assessed, your consultant may order the test to be repeated at the Royal Women's Hospital or the Melbourne IVF laboratory, where more extensive testing of semen for sperm antibodies or for penetration defects may also be performed.

Where abnormalities are found on semen analysis, repeat tests are often required to assess the type and degree of the problem found.

Diagnosis of causes of male factor infertility may require blood tests for the hormones FSH, and testosterone, which play a role in the development and maturation of sperm. A karytype (chromosome analysis) and other tests may be ordered if the sperm count is very low or zero.

4.   Diagnostic laparoscopy and hysteroscopy.

This test is an important part of the evaluation of many couples. It is generally reserved for the end of the evaluation process.

Laparoscopy is done under general anaesthesia with small incisions made at the umbilicus and the pubic hairline. A laparoscope (a fibreoptic telescope) is passed through the umbilical incision and the ovaries, fallopian tubes, uterus and pelvic cavity can be viewed for abnormalities. Tubal patency can be checked by injecting dye through the uterus and observing it spill through the fimbriated ends of the fallopian tubes. Hysteroscopy may also be performed, using another fibreoptic device called a hysteroscope. It provides direct visualisation of the uterine cavity for growths, adhesions and abnormal anatomy. Increasingly, laparoscopy is omitted in couples where the need for IVF is obvious from the history or analysis of test results.

5.   Sonohystogram

This is a noninvasive test, which gives some valuable information about the anatomy of the uterine cavity and the patency of the tubes. This involves an ultrsound with the concurrent speculum examination, and insertion of a tiny tube into the cervix to pass dye through the uterine cavity and tubes. It is often performed instead of a laporoscopy and hysteroscopy.