The Infertility Evaluation

The Basic Infertility Evaluation

When to Begin Testing

The decision of when to begin an evaluation for infertility is based on the couple's potential to achieve a pregnancy on their own. Since women under the age of 35 without any known fertility-related medical problems have a relatively high pregnancy rate, infertility testing is usually reserved for couples that have failed to conceive a pregnancy after one year of unprotected intercourse. However, due to the known decrease in fertility potential for women as they enter their later thirties and especially their early forties, an infertility evaluation should be considered after six months of unprotected intercourse in women aged 35 or higher, in order to to prevent any further delay in the diagnosis and treatment of any potential problem.

These timeframes apply to any couple that has discontinued the use of any type of protection, including barrier methods (condoms, spermicides); hormonal contraception (injections, pills, patches or rings) or IUDs. Even if a couple is not actively trying to conceive in their own mind, regular, unprotected intercourse should generally result in a pregnancy within several months.

Regardless of age, couples should seek early evaluation and treatment when there is a history of very infrequent or irregular menstrual periods, prior pelvic infection or endometriosis, or any other medical condition in either partner that could result in decreased pregnancy rates.

Semen Analysis

Specimen Collection

Since infertility may be related to a problem with the male partner in up to 40 percent of couples, a semen analysis should be one of the first tests performed in an infertility evaluation. The semen sample is obtained by masturbation into a sterile container or during intercourse with the use of a special condom made for sperm collection. Collection of the sperm by withdrawal during intercourse is not recommended, because the first part of the ejaculate, which contains a high concentration of sperm, may not be included in the sample submitted for analysis. Also, regular condoms purchased in the store cannot be used since they contain a spermicide that will kill the sperm.

In order to obtain a fresh high-quality specimen for analysis, the sample should be produced between two and seven days after the last ejaculation and submitted for testing within one hour after collection. The specimen should be kept warm if transported from home.

Normal Values

The semen analysis measures the concentration of sperm present (sperm count); the percentage of sperm that are moving (motility), as well as the quality of their movement; the percentage of sperm that appear normal in shape (morphology); the number of white blood cells, which may indicate the presence of infection; the volume of the semen; and its ability to liquefy in a timely manner following ejaculation.

A normal semen analysis consists of at least 20 million sperm per cc of semen, of which about 50 percent are moving with good forward progression. There are two sets of criteria available to measure morphology. The more general criteria employed by most laboratories requires that about 40 to 50 percent of sperm appear normal in shape. The more strict (Kruger) criteria employed by specialty laboratories, which involves taking specific measurements of individual sperm, has a much lower normal range for sperm morphology but appears to correlate more strongly with the ability of sperm to fertilize a woman's eggs.

Treatment Options for Decreased Sperm Count or Motility

It is important not to become discouraged if the initial test is abnormal since both the sperm count and motility can vary from week to week. Many normally fertile men will have an occasional temporary decrease in their sperm count and/or motility. If the initial semen analysis is abnormal, it should be repeated monthly for up to three months because this is the amount of time necessary for new sperm developing in the testes to appear in the ejaculate. During this time, you should refrain from any activities that are known to decrease sperm production, including hot tub use, excessive alcohol intake and the use of recreational drugs such as marijuana.

As the sperm count or motility begin to decrease slightly below the normal levels, there is a gradual decrease in fertility potential that can sometimes be treated with a combination of medication to increase egg production from the ovaries along with intrauterine insemination (IUI). With a more severe and persistent decrease in sperm count below 10 million sperm per cc, a marked decrease in the percentage or quality of sperm motility and/or an abnormally low number of normally-shaped sperm as measured by strict criteria, in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) or the use of donor sperm may become necessary, since in the majority of cases there is no other food, supplement or hormone treatment available to effectively improve sperm quality more directly.

When There is No Sperm Present in the Ejacultate

The complete absence of sperm in the ejaculate is known as azoospermia. This can result from failed development or blockage of the sperm ducts that transport the sperm from a normally functioning testes or from a lack of sperm production due to missing or damaged sperm-producing cells within the testes or decreased hormonal stimulation of these cells by the pituitary gland in the brain.

In some cases, obstructed sperm ducts can be opened surgically. If this is not successful or if a portion of the the sperm duct is absent, sperm can often be obtained by aspiration of the fluid within the portion of the sperm duct between the testes and the blocked or missing portion of the duct, a procedure known as percutaneous sperm aspiration (PESA), and used for IVF.

Insufficient hormone stimulation of the testes, although not very common, is often the easiest problem to treat because correction of the underlying hormone deficiency should result in restored sperm production. If the sperm-producing cells of the testes are absent or damaged, this is generally irreversible. However, in some cases, testicular sperm extraction (TESE) can provide a sufficient number of sperm for IVF if localized areas of persistent sperm production can be identified during an open biopsy of the testes.

Ovarian Reserve (Day 3 FSH)

Although women continue to ovulate on their own as they age into their late thirties and forties, there is a gradual decline in the functioning of the ovaries as women begin to approach menopause. This results in a relative decrease in the ability of the ovaries to respond to the medications that are used to stimulate egg production during a cycle of artificial insemination or in vitro fertilization (IVF). This drug-induced extra output of eggs and estrogen by the ovaries, beyond their normal function, has been termed ovarian reserve.

Ovarian reserve can be evaluated by a blood test that measures follicle stimulating hormone (FSH) on days 2, 3 or 4 of a menstrual period. An increased level of FSH, which can be seen at any age but which is more common in the late thirties and forties, is consistent with a decrease in ovarian reserve and is predictive of lower pregnancy rates overall. Once the FSH concentration enters the high teens or twenties, especially in women in their late thirties and forties, few if any pregnancies are seen with the use of a woman's own eggs. In this setting, IVF with the use of donor eggs from a younger woman is strongly recommended. Although FSH levels may fluctuate from cycle to cycle, experience has shown that once the FSH becomes elevated in a given cycle, pregnancy rates are decreased from that point on, even if subsequent FSH testing is normal.

Independent from ovarian reserve, as measured by FSH, is the increasing tendency of a woman's eggs to produce genetically abnormal embryos as she moves from her late thirties into her forties. This increased potential for producing genetically abnormal embryos also results in a decrease in overall pregnancy rates, an increase in the miscarriage rate, which reaches about 50 to 60 percent in women over the age of 40, and an increased risk of possible birth defects such as Down’s syndrome. Testing for genetically abnormal embryos, although not routine, can be done in selected cases through the use of IVF and a procedure known as preimplantation genetic diagnosis (PGD). Alternatively, amniocentesis or chorionic villus sampling (CVS) can be performed during the early stages of a pregnancy to diagnosis potential genetic abnormalities in the baby.

Pelvic Ultrasound/Sonohysterogram

An ultrasound (sonogram) examination of the uterus and ovaries is usually performed for several reasons. First, the ultrasound will determine whether there are any fibroid tumors within the uterus that need to be removed before pregnancy occurs. If the presence of fibroids or polyps within the uterine cavity is suspected, a sonohysterogram, an ultrasound with the additional injection of saline through the opening of the cervix, may be recommended to expand the uterine cavity for proper visualization. The ultrasound examination also allows the ovaries to be inspected for any abnormal cysts that may need to be removed and provides an antral follicle count. The number of antral follicles, which contain the immature eggs that are waiting to be released in the future, provides another indication of ovarian reserve in addition to the day-three FSH measurement. Unfortunately, ultrasound cannot generally see the fallopian tubes or scar tissue within the pelvis and usually cannot visualize endometriosis unless it forms a discrete cyst within the ovary.

Hysterosalpingogram (HSG)

The hysterosalpingogram (HSG) is an x-ray procedure that is performed to ensure that the cavity of the uterus is normal and also to confirm that the fallopian tubes are open. The test is performed in the radiology department of the hospital just after the menstrual bleeding has stopped in order to prevent x-ray exposure during an early pregnancy. Special dye, which is opaque to x-ray, is injected through the opening of the cervix. With the fluoroscope, the dye can be seen to outline the cavity of the uterus and flow into the fallopian tubes. If the tubes are open, the dye will spill freely into the abdominal cavity.

The water-based dye is absorbed over the next several hours. Cramping may occur both during and after the examination and can be reduced by taking three tablets of Advil or Motrin about one hour before the test. You may notice some light bleeding after the test. There is a small chance that infection may occur following this test and you should call if you experience increasing abdominal pain or fever after the procedure. The HSG cannot be performed if you have a severe allergy to contrast material that contains iodine.

The hysterosalpingogram may reveal abnormalities in the way the uterus was formed or deformities of the uterine cavity due to scar tissue or fibroids. Failure of the dye to enter the fallopian tubes may result from temporary spasm of the tubes due to the discomfort of the test or from actual blockage of one or both tubes at their junction with the uterus. A tubal blockage near the uterus can sometimes be opened by passing a very thin catheter through the opening of the cervix and into the fallopian tube to relieve the obstruction. If the tubes are blocked at their far end, dye will be seen within the tube, which then begins to dilate since the dye cannot pass into the abdominal cavity. Correction of this condition requires surgery. The x-rays will not visualize the ovaries or any scar tissue that may be present on the outside of the uterus, tubes or ovaries. Endometriosis cannot be diagnosed by this x-ray.


Laparoscopy is an outpatient surgical procedure performed in the operating room of the hospital under general anesthesia to determine whether pelvic scar tissue or endometriosis may be the cause of a woman's infertility. Small incisions are made in the belly button and the lower abdomen for insertion of the laparoscope and other instruments. The laparoscope is a telescope which allows for direct visualization of the outside of the uterus, tubes and ovaries along with the removal of any scar tissue and/or endometriosis that may be present.

A laparoscopy takes approximately one to two hours to perform, depending on how much treatment needs to be done. After a short stay in the recovery room you will be allowed to go home and most people are back to their normal routine within two to three days. Although it is the most difficult test in the evaluation, it provides important information that cannot be obtained by any other test since scar tissue and endometriosis are not visible with x-ray or ultrasound. The complication rate of laparoscopy is quite small but may include infection, internal bleeding and perforation of the bladder or intestines. There are also risks from the administration of general anesthesia, which in a young, healthy individual are also very small.

Hysteroscopy is also an outpatient surgical procedure that is performed when an abnormality of the uterine cavity is seen during a hysterosalpingogram or ultrasound. When necessary, hysteroscopy can be performed at the same time as a laparoscopy. The hysteroscope is a telescope that is inserted through the opening of the dilated cervix to visualize the cavity of the uterus and remove scar tissue, polyps or fibroid tumors from within the cavity. It is also used to visualize and remove a uterine septum, a band of fibrous tissue that should normally disappear during the normal development of the uterus, which can be a cause of recurrent miscarriage.

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