The following gives a summary of the basic infertility evaluation process. This will obviously be modified based upon the individual problems a particular couple might have. A couple can be evaluated in this way in 6-8 weeks. Establishing a proper diagnosis quickly permits a plan of therapy to be devised without wasting a lot of time. Given the highly emotional environment of infertility, shortening the process as much as possible is in the best interest of the infertile couple.
The first thing you must evaluate is your insurance coverage.
SECTION I - Evaluation of Ovulation
If the woman has regular menstrual cycle, a mid luteal phase progesterone level should be drawn. If the level is over 15, normal ovulatory function probably exists. If the level is less than 10, there is probably a problem. Levels between 10 and 15 fall into a gray zone.
If the woman’s menstrual cycles are so irregular that a mid luteal phase progesterone cannot be accurately timed, this is strong presumptive evidence that an ovulatory problem exists.
SECTION II - Evaluation of Pelvic Factors
At the time of the initial office visit a full history and exam is performed and a vaginal ultrasound is also carried out.
A blood test to determine the presence or absence of Anti-Chlamydia Antibody is also obtained.
If the Anti-Chlamydia Antibody test is positive, a hysterosalpingogram should be carried out. If the test is negative, a hysterosalpingogram is not necessary.
A hysteroscopy should also be done. This is a procedure in which a small lighted instrument is inserted into the uterus to inspect the uterine cavity. It is the best test currently available to determine whether any abnormalities exist inside the uterus. It is done in the office with local anesthesia and takes about 10 minutes to perform.
If the woman has any of the following, a laparoscopy is indicated:
- Significant pain with the menstrual flow;
- significant pain between periods;
- any deep pain with intercourse;
- significant pelvic tenderness on exam;
- a history of Pelvic Inflammatory Disease (PID);
- a history of previous pelvic surgery, particularly if done “open”, but even if done by laparoscopy;
- a history of a ruptured appendix;
- a history of an ectopic pregnancy;
- any abnormality seen on ultrasound;
- an abnormal hysterosalpingogram;
- a long history of “unexplained” infertility
- a positive Chlamydia antibody
- anything else that raises the suspicion that some pelvic problem exists.
SECTION III - Evaluation of Male Factor
The main tests for evaluating male factor infertility are the semen analysis and the postcoital test.
The postcoital test also allows evaluation of the cervical mucus.
If the post-coital test is “super-normal” (more than 25 actively motile sperm per High Power Microscopic Field), a semen analysis is not necessary.
Many other tests can be done but probably will not change the overall management and therefore should be reserved for highly special circumstances.
WITH THE DEVELOPMENT OF IVF AND ICSI, MANY NOW BELIEVE THAT THERE IS NO SUCH THING AS MALE INFERTILITY AND THE ONLY PURPOSE OF A SEMEN ANALYSIS IS TO SEPARATE THOSE MEN WITH NO SPERM FROM THOSE WHO HAVE AT LEAST ONE. WHILE THIS MAY SEEM LIKE AN EXAGGERATION, IT IS DEFINITELY WHERE THE FIELD OF MALE INFERTILITY IS HEADED. THE ONLY OBSTACLE FOR MANY COUPLES IS THE COST.
IVF WITH ICSI NOW COSTS $10,000-12,000 PER ATTEMPT