Infertility Workup

Infertility Workup

An infertility workup includes laboratory and imaging tests to evaluate the cause of infertility and confirm its diagnosis. Components of an infertility workup include a review of the patient’s medical history, physical examination, and other tests as necessary.

What is infertility?

Infertility is the failure to conceive within 12 months of unprotected intercourse or artificial insemination in women younger than 35 years. For women over 35 years the criteria is shifted to 6 months of trying to conceive without pregnancy.

What is an infertility workup?

An infertility workup is a set of tests performed on both partners to determine the reason or risks for infertility. These include:

  • Medical history of the patient to identify possible reasons for infertility
  • Physical examination including thyroid, breast, and pelvis
  • Testing for ovarian structure, function, and reserve
  • Imaging tests to confirm the morphology of the fallopian tube and/or other pelvic organs
  • Male partner’s medical history and semen analysis

Infertility evaluation can normally be accomplished within a few menstrual cycles.

Who should undergo an infertility workup?

Women above age 35 should undergo an infertility workup if pregnancy does not result after six months of unprotected intercourse, or earlier if clinically indicated. Women over age 40 should undergo a more immediate evaluation.

What are some of the clinical indications requiring an immediate workup?

Some indications requiring an immediate infertility workup include:

  • Stage 3 or stage 4 endometriosis
  • Absent or irregular periods
  • Uterine, tubal, or any other peritoneal disease
  • Known male infertility

What are other non-clinical factors that affect fertility?

Age and lifestyle can greatly influence an individual’s fertility. Women in their 20s or early 30s are about 25-30% likely to become pregnant in any single menstrual cycle if the couple is healthy. This probability goes down with increasing age and declines rapidly after about age 37. A woman’s chances of becoming pregnant drop sharply to about 10% after age 40.

Lifestyle factors such as body weight, excess physical stress, alcohol intake, and smoking can reduce fertility. Similarly, in men, these factors can result in reduced sperm count or sperm movement.

Should I be concerned about infertility if I have endometriosis?

Nearly 50% of women with endometriosis may experience infertility. This is because endometriosis can alter several aspects of the reproductive tract, both physically and biochemically. This can impede fertilization and/or pregnancy. Endometriosis can also adversely affect egg quality leading to low ovarian reserve.

Can endometriosis still cause infertility even without other symptoms?

About 20-25% of endometriosis cases are silent or asymptomatic and the only symptom a woman experiences can be infertility or recurrent miscarriages. Unexplained infertility happens in about 15-30% of cases when parameters such as semen health, ovulation, fallopian tube health, and ovarian reserves seem normal but fertility remains elusive. Internal changes that endometriosis causes including an altered immune state or anatomical distortions can lead to unexplained infertility.

What do doctors look at during a physical exam?

Physical features that your doctor is looking for during an infertility evaluation include:

  • Bodyweight, body mass index (BMI), blood pressure, and pulse rate
  • Thyroid structure and the presence of nodules and tenderness
  • Breast secretions
  • Staging of breast and secondary sexual characters
  • Vaginal and cervical examination, secretions, and discharge
  • Pelvic anatomy
  • Uterine structure and position
  • Extra growth (adnexal masses) near the uterus or ovaries
  • Masses and nodularity of the cul-de-sac (internal area between the pelvic organs and the rectum)

How do doctors evaluate is ovarian function in the infertility workup?

Doctors can evaluate the ovarian function and correlate it with reduced ovarian reserve using the following criteria:

  • levels of antimüllerian hormone (AMH) less than 1 ng/mL
  • antral follicle count less than five to seven
  • history of poor response to in-vitro fertilization (IVF) stimulation (less than four oocytes during egg retrieval)

Other tests that can indicate ovulatory dysfunction include levels of progesterone, levels of luteinizing hormone in the urine, basal body temperature, and changes in the cervical mucus. Anovulation due to polycystic ovary syndrome (PCOS) is also considered.

What are some of the imaging tests that doctors use during an infertility workup?

Imaging tests can help your doctor evaluate tubal and uterine factors that could result in infertility. Hysterosalpingography (HSG) helps visualize the fallopian tubes and the uterus with the help of a radiopaque dye. If dye is passed through the tubes successfully, this is detected on X-ray simultaneously as the dye is being infused. The HSG has a negative predictive value of 98% and positive predictive value of 38% of tubal disease.

Sonohysterography (or a saline sonogram) is another imaging technique by which doctors can see the uterus and adnexal tissues. It can identify features such as endometrial polyps, submucosal fibroids, and intrauterine adhesions. Sonohysterography has a sensitivity of 91% and a specificity of 84% for detecting intrauterine polyps and fibroids. The results of sonohysterography can be confirmed by hysteroscopy, which allows direct visualization of the inside of the uterus. Transvaginal ultrasonography is also useful to identify fibroids lining the uterine cavity.

Hysterosalpingo-contrast sonography is a relatively newer technique that uses a contrast agent with air bubbles to identify blocks in the fallopian tubes. Its sensitivity for tubal patency ranges between 76% and 96% while its specificity ranges between 67% and 100%.

What should I keep in mind while opting for an infertility workup?

Given the various factors that can lead to infertility, you may need to undergo a slew of tests to determine the actual cause of your infertility. However, some of the testing and diagnosis can be redundant, unnecessarily expensive, have poor reproducibility, or not advisable in most cases and should not be routinely ordered upon initial workup. These include:

  • Routine diagnostic laparoscopy for unexplained infertility when results of hysterosalpinogram are already available
  • Advanced sperm function testing
  • Postcoital testing
  • Thrombophilia testing
  • Routine immunological testing
  • Karyotyping/chromosomal analysis
  • Administration of exogenous testosterone for men
  • Endometrial biopsy for routine infertility evaluation
  • Prolactin testing for women with regular menses

While these are some of the redundant tests, your doctor may still have strong reasons to recommend one or some of them. Check with your doctor and ask them to explain to you the reason for ordering any of these tests.

How can infertility due to endometriosis be treated after the workup?

The results of the workup can give your healthcare provider vital clues into the reasons for your infertility. Additional tests such as BCL-6 testing can also predict infertility and possible endometriosis. Often, silent endometriosis is the cause of unexplained infertility. It is thus important to check for endometriosis lesions if you received a diagnosis of infertility.

A skilled surgeon can effectively remove endometrial lesions using laparoscopic deep excision surgery, the gold standard in endometriosis treatment. . The surgeons at Seckin Endometriosis Center have years of experience in the proper identification and removal of such lesions including deep-infiltrating ones. Our Aqua Blue Contrast (ABC) technique allows us to visualize and remove all endometrial lesions.

Laparoscopic deep excision surgery also helps eliminate all lesions that are the source of inflammation in the female reproductive tract and helps unblock the fallopian tubes if they are blocked. Patients, therefore, now have the options of natural or assisted reproduction open for them, which were previously unavailable due to silent endometriosis.

Do you suffer from infertility? Have you had an infertility workup? Please do not hesitate to share your experience below our post on Facebook or Instagram.

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