The armamentarium of diagnostic tests available for the evaluation of an infertile couple is large. Therefore, a clinician should be judicious in his/her use of tests. The history and physical exam shape the endocrinologic and radiologic testing algorithm specific to each patient. Other factors to consider include patient age, risks associated with the test, invasiveness, expense, and probabilities of significant findings (Table 53–1). The patient(s) should be included in the decision-making process.
The initial aspect of the interview includes discussion of the factors (ie, ovulation, sperm concentration, ovarian reserve, etc.) that affect fertility so that the patient(s) is aware of the potential etiologies. In this light, the physician can present an algorithm for the diagnostic evaluation that the patient will understand. This will help the patient grasp the peculiarities of the specific tests, such as timing the hysterosalpingogram to the day of the menstrual cycle, and provide an opportunity for the patient(s) to ask fertility-related questions and to address any information learned from friends, family, or the Internet.
The initial clinical assessment should begin with a thorough history of both partners. Factors to consider while obtaining the medical history are outlined in Table 53–2 for the female and in Table 53–3 for the male. The history should guide the physical examination beyond the general evaluation; for example, a rectovaginal exam to detect uterosacral ligament nodularity associated with endometriosis is indicated if a woman presents with a history of severe dysmenorrhea. However, a thorough physical exam may divulge key information such as acanthosis nigricans and its association with insulin resistance.
Table 53–2. Medical History for Female Factor Infertility. ||Download (.pdf)
Table 53–2. Medical History for Female Factor Infertility.
|In utero diethylstilbestrol (DES) exposure|
|History of pubertal development|
|Present menstrual cycle characteristics (length, duration, molimina)|
|Prior pregnancies, outcomes|
|Previous surgeries, especially pelvic|
|History of abnormal Papanicolaou (Pap) smear, treatment|
|Drugs and medications|
|General health (diet, weight stability, exercise patterns, review of systems)|
Table 53–3. Medical History for Male Factor Infertility. ||Download (.pdf)
Table 53–3. Medical History for Male Factor Infertility.
|Frequency of intercourse|
|Exposure to toxins|
|Previous infections, treatment|
|Drugs and medications|
|General health (diet, exercise, review of systems)|
|Decreased frequency of shaving|
The laboratory and radiologic tests assess 4 key aspects for fertility in a couple: the sperm (male factor), the oocyte (ovulatory factor and ovarian reserve), transport (pelvic factor including fallopian tubes), and implantation of ova (uterus). In many cases, the couple will be attempting to absorb significant amounts of information, some of which may be highly technical, at a time of heightened emotion. It is therefore helpful to offer literature or a written summary of the discussion. Frequently, the initial history will indicate a probable diagnosis or a contributing cause of infertility, but it is important to complete a basic evaluation of all of the major factors so a secondary diagnosis is not ignored.
Evaluation of Male Partner
Male factor is diagnosed in 25–40% of infertile couples. The majority of the diagnoses involve testicular pathology such as varicocele. Although validation is incomplete, there is a trend toward increasing use of molecular techniques to quantify the fertility potential of semen as our knowledge of fundamental molecular genetics expands. Experience and investigation have relegated several tests previously used to assess fertilization to historical interest. Beyond the history and physical exam, the initial evaluation of male factor is through semen analysis. If abnormal, the semen analysis should be repeated in 4 weeks or more to confirm findings. Normal semen analysis excludes any important male factor, whereas abnormal semen analysis suggests the need for further evaluation (endocrine, urological, or genetic).
The male partner should abstain from coitus for 2–5 days before collecting the sample, and the specimen should be received in the lab within 1 hour of collection. Table 53–4 lists normal sperm values. If fundamental parameters of count and motility are normal, the assessment of the morphology of the sperm becomes more critical. Specialized expertise in determining sperm morphology and strict application of criteria should be used before declaring the semen normal.
Table 53–4. Normal Semen Parameters. ||Download (.pdf)
Table 53–4. Normal Semen Parameters.
|Count||20 million/mL or more|
|Volume||2 mL or more|
|WHO criteria||>30% normal|
|Kruger Strict Criteria||>14% normal|
|White blood cell count||<1 million/mL|
The semen parameters in normal fertile males may vary significantly over time, and the first response to any abnormal result should be to wait an interval of several weeks and repeat the test. A normal semen analysis will usually exclude significant male factor. Although low counts, decreased motility, and increased numbers of abnormal forms are most frequently associated with infertility, unfavorable semen parameters may still be found in 20% of males undergoing vasectomy after having completed their families. If the semen analysis reveals abnormal or borderline parameters, the history should be reviewed for any proximate cause of an abnormality, keeping in mind that the cycle of spermatogenesis takes approximately 74 days. A male with <5 million sperm per milliliter warrants an endocrinologic evaluation including follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone, or a karyotype in selected cases. The patient should be referred to a urologist with a special interest and expertise in infertility as indicated.
Several tests, including sperm chromatin structure assay (SCSA), comet, and terminal deoxyuridine triphosphate (dUTP) nick-end labeling (TUNEL), have been developed to quantify the damage to DNA or chromatin (packaged DNA). There is some evidence associating increased DNA damage as determined by these tests with poor fertility outcome. The SCSA determines the percent of chromatin that is fragmented by exposing sperm DNA to acid denaturation (fragmented DNA is more vulnerable). Clinical experience has not matched initial expectations, although the test may be useful for couples with unexplained infertility with repeated in vitro fertilization (IVF) failures. The comet assay consists of placing the sperm DNA on gel electrophoresis; DNA with increased strand breaks will be smaller and therefore travel further on the slide. The TUNEL assay identifies DNA strand breaks by their incorporation of labeled dUTP. The comet and TUNEL assay are not in wide clinical use.
More detailed assessment of sperm function may include postcoital test, antibody studies, a sperm penetration assay (hamster egg penetration assay). Such assessments are designed to investigate more subtle problems or abnormalities of function not revealed by the assessment of sperm number and motility. Although helpful in some cases, the sensitivity of these assays in detecting fertility is still uncertain and varies with the particular laboratory where the test is performed. Because no universal methodology has yet been accepted, the interpretation of these tests requires close communication with the laboratory selected.
Cervical mucus is a heterogeneous secretion containing more than 90% water. It has intrinsic properties including consistency, spinnbarkeit (stretchability), and ferning. When mucus is obtained from the cervical canal in the preovulatory phase, it normally exhibits a response to the high estrogen environment. The mucus is thin, watery, and acellular; it dries in a crystalline pattern (ferning), and acts as a facilitative reservoir for the sperm.
The functional sperm must interact normally with the egg and surrounding cells in the uterine tube. The normal migration of sperm is affected by attrition and filtering, and it is estimated that fewer than 1000 sperm will be found in the environment of the oocyte. The initial interaction of sperm and female genital tract can be determined by postcoital examination of the cervical mucus (Sims-Huhner test).
The purpose of the postcoital test is to determine the number of active spermatozoa in the cervical mucus and the length of sperm survival (in hours) after coitus. The test should be performed as close to ovulation as possible, but not after. The test involves aspirating cervical mucus with a syringe 6–8 hours after coitus and checking under a microscope for the number and the motility of the sperm; fewer than 10 motile sperm per high-power field is considered abnormal. The postcoital test is controversial and has limited use in the infertility workup. Its value in assessing cervical hostility to sperm has never been proven.
Tests developed to predict the fertilizing ability of sperm include the zona-free hamster egg penetration test (the sperm penetration assay) and the hemizona test. These assays compare the ability of sperm to penetrate the zona-free hamster egg (a hamster egg in which the zona pellucida has been enzymatically digested) or to bind to human zona with sperm from a known fertile donor. The value of these tests remains controversial, and they are not in general clinical use.
Sperm possess antigens and semen may contain antibodies including sperm-agglutinating, sperm-immobilizing, or cytotoxic antibodies. The antibodies can be measured in semen or in serum. The immunobead test is the antibody assay used in most labs and is considered positive when only 20% or more of motile spermatozoa have immunobead binding. However, the test is considered to be clinically significant when 50% of sperm are coated with immunobeads.
Evaluation of Female Partner
An ovulatory dysfunction is responsible for approximately 20–25% of infertility cases (~40% of female factor infertility). The problem should be investigated first by review of historical factors, including the onset of menarche, present cycle length (intermenstrual interval), and presence or absence of premenstrual symptoms (molimina), such as breast tenderness, bloating, or dysmenorrhea. Signs and symptoms of systemic disease, particularly of hyperthyroidism or hypothyroidism, and physical signs of endocrine disease (ie, hirsutism, galactorrhea, and obesity) should be noted. The degree and intensity of exercise, a history of weight loss, and complaints of hot flushes all are clinical clues to possible endocrine or ovulatory dysfunction.
Early in gestation, the germ cells undergo mitosis to produce oogonia. The oogonia undergo meiosis in their transformation to oocytes but arrest at prophase of meiosis I until the time of ovulation. A layer of granulosa cells encircles the oocytes, creating the follicle. A female will have the highest number of germ cells, approximately 6 million, in her ovaries at 20 weeks' gestational age. Henceforth, atresia depletes the follicular pool at a brisk pace, with only 1–2 million oocytes remaining at the time of birth. The ovaries contain approximately 500,000 oocytes at the time of first ovulation. Menopause signals the complete depletion of germ cells, with a woman having ovulated approximately 500 oocytes during her reproductive years.
An inverse relationship exists between fecundity and the age of the woman. The decline in fecundity is a result of progressive follicular atresia through apoptosis, which accelerates in the early thirties and progresses rapidly in the late thirties and early forties. Concomitantly, there is a decrease in follicular quality as a result of an increase in oocytes with chromosomal anomalies and progressive deletions in mitochondrial DNA. The concept of ovarian reserve represents the remaining follicular pool of the ovaries. As ovarian reserve decreases, the ovaries' responsiveness to gonadotropins decreases, necessitating higher amounts of FSH to achieve follicular growth and maturation.
Ovarian reserve should be evaluated in women older than 35 years of age who are seeking fertility. Evaluation of the level of FSH and estradiol in the early follicular phase (cycle days 2–4) may provide helpful guidance in terms of the likelihood of achieving success, as mild elevations in either FSH or estradiol may precede overt ovulatory dysfunction but still indicate a poor prognosis for successful pregnancy. Use of the clomiphene challenge test has gone out of favor, whereas newer tests such as inhibin-B and anti-müllerian hormone (AMH) remain to be validated in large studies. The specific cause of oligo-ovulation or anovulation is determined by the history, the physical examination, and appropriate laboratory studies.
Confirmation of Ovulation
If the patient reports a history of mittelschmerz and/or regular menses with molimina (headaches, bloating, cramping, and emotional lability) and mild dysmenorrhea occurring at intervals of 28–32 days, the likelihood of the patient having regular ovulatory cycles is very high. Otherwise, ovulation can be confirmed with a serum progesterone assay performed in the mid-luteal phase or the third week of the cycle. Progesterone levels of 3 ng/mL or greater are consistent with ovulation.
Pelvic ultrasonography can provide evidence for ovulation. In the follicular phase, the developing follicle can be monitored to maturation and subsequent rupture. The disappearance of, or change in, the follicle and free fluid in the cul-de-sac can document ovulation.
To detect the LH surge, the patient can use commercially available urinary LH kits or serum LH assay. Ovulation occurs 24–36 hours after the onset of the LH surge and 10–12 hours after the peak of the LH surge. The kits can be used to time intercourse or intrauterine insemination.
The basal body temperature (BBT) is the temperature obtained in the resting state and should be taken shortly after awakening in the morning after at least 6 hours of sleep and before ambulating. Progesterone has a central thermogenic effect; it elevates the BBT by an average of 0.8 °F during the luteal phase. The luteal phase is thus characterized by a temperature elevation lasting about 10 days. When a biphasic monthly temperature pattern is recorded, it is confirmatory evidence of luteinization, but the absence of a biphasic pattern may be seen in ovulatory cycles.
The finding of secretory endometrium confirms ovulation. The use of an endometrial biopsy (EMB) near the end of the luteal phase can provide reassurance of an adequate maturational effect on the endometrial lining. Within 48 hours of ovulation, the cervical mucus changes under the influence of progesterone to become thick, tacky, and cellular, with loss of the crystalline fernlike pattern on drying.
The only absolute documentation of release of an oocyte is pregnancy. In the case of oligomenorrhea, amenorrhea, short or very irregular menstrual cycles, or when ovulation is not confirmed, evaluation of the hypothalamic–pituitary–ovarian axis is warranted. A usual initial assessment includes the serum concentrations of FSH, estradiol, prolactin, and thyroid-stimulating hormone.
The subject of the inadequate luteal phase remains an area of controversy. There is disagreement on how to make the diagnosis, when the diagnosis is significant, and how best to treat the problem if diagnosed. Luteal phase defect is a histologic diagnosis made when the endometrium lags 3 days or more behind the expected pattern at the time of EMB. EMB to assess luteal phase defect is rarely performed nowadays due to high levels of variability in histologic diagnosis.
The pelvic factor includes abnormalities of the uterus, fallopian tubes, ovaries, and adjacent pelvic structures. Factors in the history that are suggestive of a pelvic factor include any history of pelvic infection, such as pelvic inflammatory disease or appendicitis, use of intrauterine devices, endometritis, and septic abortion. Endometriosis is included as a pelvic factor in infertility and may be suggested by worsening dysmenorrhea, dyspareunia, or previous surgical reports. Any history of ectopic pregnancy, adnexal surgery, leiomyomas, or exposure to diethylstilbestrol (DES) in utero should be noted as possibly contributory to the diagnosis of a pelvic factor. A pelvic examination can be informative, yielding information such as a fixed uterus suggestive of adhesions, leiomyomas, or adnexal masses.
A transvaginal ultrasound examination can be an efficient means of supplementing information gained from the standard bimanual examination. Hydrosalpinges, leiomyoma, and ovarian cysts, including endometriomas, can often be observed, and the appropriate focused evaluations initiated.
A hysterosalpingogram (HSG) is a fluoroscopic study performed by instilling radiopaque dye into the uterine cavity through a catheter to determine the contour of the endometrial cavity and patency of the fallopian tubes. Sensitivity and specificity of an HSG are approximately 65% and 85%, respectively. Abnormal findings include congenital malformations of the uterus, submucous leiomyomas, intrauterine synechiae (Asherman's syndrome), intrauterine polyps, salpingitis isthmica nodosa, and proximal or distal tubal occlusion. The hysterosalpingogram can be obtained in an outpatient setting with minimal analgesia consisting of premedication with a nonsteroidal anti-inflammatory drug. The test is usually scheduled for the interval after menstrual bleeding and before ovulation. Either water- or oil-based dye may be selected; Table 53–5 summarizes the advantages and disadvantages of each. There is evidence for a fertility-enhancing effect of HSG using the oil-based dye.
Table 53–5. Comparison of Oil-Based versus Water-Based Dye Used in the Hysterosalpingogram. ||Download (.pdf)
Table 53–5. Comparison of Oil-Based versus Water-Based Dye Used in the Hysterosalpingogram.
|Fertility enhancement||Oil: higher pregnancy rates|
|Patient discomfort||Water: less cramping|
Water: rugae seen
Oil: better image
|Embolization||Minimal risk with either dye|
|Granuloma||Greater risk for retained oil|
Peritonitis is a risk of the procedure observed in up to 1–3% of patients; many clinicians use a short-course doxycycline during the immediate period before and after the procedure to minimize risk. An HSG is contraindicated in the presence of an adnexal mass or an allergy to iodine or radiocontrast dye.
A sonohysterogram, a transvaginal ultrasound of the uterus with instillation of saline into the uterine cavity, is a sensitive and specific test for the detection of intrauterine lesions, specifically space-occupying lesions. Hysterosalpingo contrast sonography, transcervical injection of sonopaque material during ultrasonography, is used to determine tubal patency as well as detect intrauterine defects; more commonly used in Europe, the procedure's sensitivity is comparable to that of HSG.
Laparoscopy with chromotubation (dye instillation) is the gold standard for the evaluation of tubal factor, and when performed in conjunction with hysteroscopy, information on uterine contour can be obtained simultaneously. Tubal abnormalities such as agglutinated fimbria or adhesions (which restrict motion of the tubes) or peritubal cysts may suggest tubal disease that would not necessarily be detected on hysterosalpingogram. The diagnosis of endometriosis is usually based on laparoscopic findings.
The necessity of laparoscopy in an infertility workup is controversial. There is significant evidence that pelvic pathology may exist in almost one-third of patients with normal HSG and ultrasound; consequently, some believe that with laparoscopy one can treat the pathology (such as adhesions) found at the time of procedure or can spare a patient needless cycles of ovulation induction that are unlikely to succeed by providing knowledge of severe pelvic disease. Others believe that although pelvic disease may be present, a stepwise empiric approach is more cost-effective.
A cervical factor may be indicated by a history of abnormal Papanicolaou (Pap) smears, postcoital bleeding, cryotherapy, conization, or DES exposure in utero. The major evaluation of the cervical factor is by speculum examination, which may reveal evidence of cervicitis that may require further evaluation and treatment, or cervical stenosis, especially in a patient with prior history of cervical conization. If none of these findings are present, it is unlikely that cervical mucous presents a major obstacle. The postcoital test has been part of the assessment of cervical factor for many years in the past; however, the current consensus is that it is no longer required due to high variability in its methodology and interpretation. Moreover, treatment for otherwise unexplained infertility generally is a combination of ovarian stimulation and intrauterine insemination (IUI), which therefore bypasses the cervical factor. Therefore, postcoital test may only be reserved for patients in whom results will actually influence the treatment strategy.
Combined Factors & Unexplained Infertility
After the completion of the diagnostic workup, the findings should be reviewed with the patients and a treatment plan finalized based on guidance from the physician and input from the patient(s). In approximately 20% of couples, a combination of factors found may be suboptimal, and multiple therapies may need to be instigated, either sequentially or simultaneously.
Diagnosis of unexplained infertility, on the other hand, generally implies normal uterine cavity, bilateral patent tubes, normal semen analysis, and evidence of ovulation. Postcoital tests and endometrial biopsy are no longer necessary in order to diagnose unexplained infertility. For the couple with unexplained infertility, an empiric stepwise approach is an excellent option. However, depending on the history, workup, and individual situation, additional test(s) including surgery to rule out endometriosis should be discussed.
Coutifaris C, Myers ER, Guzick DS, et al. NICHD National Cooperative Reproductive Medicine Network. Histological dating of timed endometrial biopsy tissue is not related to fertility status. Fertil Steril
Domingues TS, Rocha AM, Serafini PC. Tests for ovarian reserve: reliability and utility. Curr Opin Obstet Gynecol
Jacobson TZ, Duffy JM, Barlow D, Farquhar C, Koninckx PR, Olive D. Laparoscopic surgery for subfertility associated with endometriosis. Cochrance Database Syst Rev
Practice Committee of the American Society for Reproductive Medicine. Definitions of infertility and recurrent pregnancy loss. Fertil Steril
The Practice Committee of American Society of Reproductive Medicine. Optimal evaluation of infertile female. Birmingham, AL: American Society of Reproductive Medicine; 2006.