Infertility Evaluation and Diagnosis
A common, textbook definition of infertility is the "failure to conceive following one year of unprotected sexual intercourse." A more precise definition of infertility takes into account the age of the woman trying to conceive, as this is a crucial factor in this process:
Infertility is the inability to conceive following one year of unprotected intercourse if under 35 years of age or six months if over 35.
In addition to the age of the woman, there are a number of factors that can contribute to an individual or couple’s inability to conceive, and it is important to consider all of these when first evaluating the situation.
While we often associate infertility with women, this distressing condition is just as likely to be caused by issues in the male partner. A third of the time, fertility problems are found in men, a third of the time in women and a third of the time in both partners. A thorough fertility evaluation will take into account the physical health and medical history of both the female and male partner, as well as the age of the female partner, which is always considered a crucial factor.
An individualized evaluation conducted by a fertility specialist can help ease frustration and worry by providing information, answers and direction as to further diagnosis and treatment. Evaluation is the first step to taking full advantage of reproductive potential and timeline. A fertility evaluation will take into account:
Physical health. Illness, birth defects, or acquired anatomical disorders can interfere with conception and healthy pregnancy. We are fortunate that even the most challenging conditions, such as blocked fallopian tubes, absence of a uterus or egg follicles or absence of sperm, can be treated by fertility therapy.
Female age. This is a key consideration in evaluating fertility. Conception and healthy fetal development depend primarily on the quality of a woman’s eggs, and egg production and quality in turn is largely dependent on a woman’s age. One of the most frustrating aspects of older parenthood is the simple fact that egg quantity and quality declines with age. While a woman is born with about 2 million eggs, this number declines to about 300,000 at puberty. A woman will ovulate her healthiest eggs during her 20s and early 30s. By the mid 30s the remaining eggs are of lower quality, and by the early 40s only eggs with very low fertility potential are available for ovulation. As eggs age, they are more likely to have abnormal numbers of chromosomes, leading to failure of a fertilized egg to develop to the point of implanting in the uterus and to a higher likelihood of miscarriage. Age also may affect the production of the hormones estrogen and progesterone, which are essential to establishing and maintaining pregnancy.
PFC suggests following these guidelines to know when to begin a fertility evaluation:
- Women trying to get pregnant after age 30 but under the age of 35 who have not conceived after a year of well-timed intercourse
- Women between the age of 35-39 who have not conceived after six months of well-timed intercourse
- Women trying to get pregnant after age 40 who have not conceived after three months of well-timed intercourse.
- Men with low sperm counts
- Men or women with known fertility risk factors
- Single women or lesbian couples who may need fertility services
What to expect from a fertility evaluation. The process of evaluating and diagnosing infertility consists of a complete medical examination and a series of tests that assess the primary fertility factors in both men and women. A thorough infertility evaluation enables the patient’s doctor to more specifically focus in on a diagnosis, and from there, a treatment that will hopefully enable them to conceive.
A new patient evaluation will assess:
- Male fertility health
- Ovarian function and egg quality
- Uterine and fallopian tube anatomy
Male fertility health. Evaluation will assess the status of male sperm as well as the male reproductive history and lifestyle. An evaluation for habits such as hot tub use, medications being taken or exposures to organic chemicals are examples of the information we gather in the male fertility evaluation.
Evaluating male sperm. A sperm analysis can provide a lot of answers to a couple experiencing fertility struggles. This test measures four properties of a sperm sample, each of which is important to egg fertilization and conception:
- Semen Volume. The amount of the ejaculate produced. A lower than normal sperm count can indicate blockage of the seminal vesicles, where seminal fluid is produced. Low semen volume could also be due to retrograde ejaculation, where the ejaculated sperm is entering the bladder rather than exiting the urethra.
- Motility. This is the percentage of sperm in the sample that is alive and exhibiting healthy, forward movement. This quality is vital to enabling the sperm to unite with the egg in the fallopian tube.
- Morphology. This refers to the percentage of normally shaped sperm – an aspect that can indicate whether the sperm has developed or ‘matured’ properly in the testicle. Poorly developed sperm may be unable to fertilize the female egg.
Urologic Examination. If necessary, the male partner may be advised to receive a urological exam, as well as more specific sperm testing and evaluation of hormone levels. If a male partner is thought to have a sperm abnormality, we will recommend that he receive an exam from a urologist – a physician who focuses on the male urinary tract and reproductive organs. A urologist who specializes in andrology will have further expertise with the male reproductive system. A urology exam will include:
- Assessment of kidney and bladder function to rule out infection or other problems
- Examination of testicles. Small size may be associated low hormone levels, which impact sperm development.
- Examination for a varicocele. A varicocele or dilated vein in the scrotum can overheat the testes, negatively impacting sperm production and quality.