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Monday, March 19, 2007

Infertility -- The Basic Infertility Evaluation

Once a couple presents an infertility problem, an organized cost considerate rapid evaluation that makes no major assumptions about cause should be recommended.

Assumptions are common, but should be discouraged. When the couple first identifies an infertility problem there often is a tendency to guess at the cause for the problem. I often hear: "(s)he is the problem," "it must be me since my spouse has had children in another marriage," or "I know I'm normal since I've never been sick a day in my life." Assumptions are usually counterproductive.

The basic infertility evaluation should always include an evaluation of

  • Female:
    • Ovulation
    • The pelvic factor. Pelvic factor infertility as discussed here will include

  1. vaginal abnormalities
  2. cervical mucus abnormalities
  3. defects in the uterine cavity
  4. proximal fallopian tube occlusion
  5. distal blockage of the fallopian tube
  6. endometriosis
  7. barriers to implantation
  • Male:
    • Movement of the testes into the scrotum
    • The testicular cells and their functions
    • Puberty and the full maturation of sperm
    • The course of movement for sperm upon ejaculation
    • Ejaculation
    • Necessary postejaculatory changes in sperm

In addition, it is usually adviseable to confirm that there are no other major barriers to fertility. This might include looking at the periovulatory cervical mucus for the presence of progressively motile sperm several hours following intercourse (postcoital test). This might also include examining the pelvis for the presence of abnormalities, such as endometriosis or adhesions (laparoscopy and possibly hysteroscopy).

If the couple has experienced multiple consecutive miscarriages, the evaluation that I recommend includes

  1. Demonstration of a normally shaped uterine cavity,
  2. Evaluation for a hormonal deficiency in progesterone production,
  3. Analysis of both the maternal (wife's) and paternal (husband's) chromosomes,
  4. Laboratory testing for immunologic causes of pregnancy loss, and
  5. Taking a history for maternal disease states or environmental toxin exposure

The components of the basic infetility evaluation are discussed in detail. The components of the basic recurrent pregnancy loss evaluation will be the subject of another project (currently in progress).


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