Work-up of the Infertile Couple

Question 1

Is infertility common?

Answer 1

YES. 1 in 7 of every couple will have fertility challenges.

Question 2

What is infertility?

Answer 2

• after trying for 12 months for a woman less than age 35.

- after trying for 6 months for a woman over age 35.

Question 3

What are the causes of infertility?

Answer 3

• female= 40%
• male= 40%
• 10%= combined
• 10%= unexplained

Question 4

What does an infertility evaluation involve?

Answer 4

• detailed pt history
• semen analysis
• HSG
• ovarian function testing

Question 5

What are some things to rule out in women for infertility?

Answer 5

• length of trying to conceive.
• menstrual hx
• hyperthyroidism
• smoking, alcohol, drugs
• gyn problems
• surgical hx (adhesions..)
• family hx of birth defects

Question 6

What are some things to rule out in men for infertility?

Answer 6

• fathered child previously
• urological problems
• varicocele
• difficulty with erections or ejaculation.
• stress
• frequency of ejaculation
• smoking, alcohol, drugs
• recent fever or illness
• DM or CAD
• antacids, antibiotics…
• sauna, hot tub or jacuzzi

Question 7

After taking a history, what do we do next in evaluating the female?

Answer 7

Screening of ovarian reserve:

• age
• day 3 of menstrual cycle blood work for FSH (goal less than 10 IU/L) and anti-mullerian hormone (AMH; goal greater than 1).
• antral follicle count via ultrasound.

Question 8

** So what do FSH and AMH really tell us, respectively?

Answer 8

• FSH= better test for egg QUALITY.

- AMH= better test for egg QUANTITY.

Question 9

How do we assess anatomy for infertility?

Answer 9

• transvaginal pelvic ultrasound= size and shape of ovaries, fibroids (leiomyomas), endometriomas, and size of uterus.
• HSG= fluoroscopic procedure that looks to see if tubes are open.
• sonohysterogram (saline sonogram)- if indicated.
• laparoscopy- if indicated.
• hysteroscopy- if indicated.

Question 10

Why can fibroids (leiomyomas) or endometrial polyps cause problems?

Answer 10

• blocks sperm transport

- can cause improper implantation

Question 11

When do we do a laparoscopy?

Answer 11

only if pathology is suspected, such as endometriosis (which can be ablated) or adhesions that are affecting transport.

Question 12

What is a hysteroscopy?

Answer 12

• procedure that utilizes a thin, lighted tube with a magnifying glass that is inserted into the cervix and inside of the uterus

Question 13

What follows the history for the male?

Answer 13

• semen analysis

Question 14

What is evaluated in a semen analysis?

Answer 14

• volume
• sperm concentration (normal= 15 million per mL).
• motility (normal= 50%)
• morphology

Question 15

What percent of sperm are considered abnormal in a single ejaculate?

Answer 15

95%
*this has nothing to do with birth defects, sexuality or health. It only means optimal efficiency of penetration and fertilization!

Question 16

Where is the nucleus of the sperm?

Answer 16

in the head

Question 17

Where is the mitochondria within the sperm?

Answer 17

• in the mid-piece

Question 18

If a semen analysis is poor, what do we do?

Answer 18

• repeat another one in 3 months because sperm can be affected for 3 months from drinking, smoking, or drugs. So have the guy chill on his boozing for 3 months.

Question 19

What pre-pregnancy screening labs do we do for the woman?

Answer 19

• CBC (MCV)
• TSH
• prolactin
• vit D
• evidence of rubella and varicella immunity.
• infectious disease blood work.
• genetic screening
• targeted blood work based on hx (androgens..)

Question 20

What treatment options are available?

Answer 20

• medical management (thyroid, clomiphene…).
• surgical management (fibroids, polyps, adhesions…).
• intrauterine insemination (partner or donor sperm).
• in-vitro fertilization (IVF)= own eggs or donor eggs.