Testing In Infertility
The vast majority of tests that are carried out to evaluate an infertile couple are simple to perform and carry a very low risk. Most carry no risk at all. Nonetheless, a great deal of misunderstanding and apprehension has arisen around these tests for a number of reasons. First of all, some of the tests, if not performed properly, are painful. Furthermore, virtually all the tests have an emotional impact because of the stresses involved in an infertility evaluation.
It is my hope that in this section, by explaining these tests more fully, some of the misunderstanding and concern will be eliminated.
At the time of your first office visit, a full history and physical examination will be carried out. Blood tests will be drawn and a vaginal ultrasound done.
Although no one finds having blood drawn to be a pleasant experience, the vast majority of people can tolerate it without undue difficulty.
If you have had a problem in the past having blood drawn from you, please let us know and I will try to accommodate your concerns.
A vaginal ultrasound is done at the time of your initial visit as it is done frequently during the evaluation and treatment of any infertile woman. With occasional exceptions, there is little justification to perform an abdominal ultrasound using a “full bladder technique”. The vaginal ultrasound is a far more accurate technique giving much better resolution and much better identification and evaluation of the uterus and other pelvic structures. Furthermore, by avoiding the full bladder, women usually find the vaginal ultrasound to be a more comfortable technique.
Nowadays, the abdominal ultrasound is mainly reserved for young girls who have not yet become sexually active.
Post Coital Test
The post coital test is one of the most common tests in infertility, it is one of the easiest tests to perform , and yet it is one of the most misunderstood.
From a technical point of view, it is very simple. The couple will have intercourse and the woman will then come to the office. At the time of the office visit, blood tests will be drawn for hormone levels, a sample of the mucus will be removed from the cervix, and then a vaginal ultrasound will be carried out. This is a totally painless procedure.
The problems with the post-coital test arise mostly from the emotional stress associated with the tests. In order to complete the test satisfactorily, a couple must have intercourse “on demand”. This frequently creates problems.
It has been frequently said that if you are trying to have a baby, you can either make love or you can have sex, but you can’t do both. The post coital test is perhaps the most classic example of this principle that I can think of.
First, I am asking you and your partner to have intercourse at a time when neither one of you may really be in the mood. Furthermore, many men “wilt under pressure” and therefore are unable to satisfactorily have intercourse.
Under ideal circumstances, a couple should have intercourse somewhere between 8 and 12 hours prior to the office visit. However, this may not always fit into each couples work schedule. I therefore have to frequently bend the rules. Therefore, initially, all that I will require is that intercourse occurs sometime within 24 hours prior to the visit. For a totally normal test, a large number of moving sperm can be seen in the cervical mucus as long as 48 or even 72 hours following intercourse.
If the initial test shows a problem, then it will have to be repeated with a shorter time interval between intercourse and the actual office visit. However, I individualize this as much as humanly possible to the requirements of each particular couple.
One common area of confusion centers around what the woman should or should not do following intercourse before she comes to the office.
There are many myths concerning sex and pregnancy. These myths are covered in another handout.
Basically the woman should carry out her normal activities and nothing special need be done.
The woman may shower or take a tub bath following intercourse. Neither of these procedures will affect her ability to become pregnant and will not affect the post coital test.
The one thing that must not be done is douching. There is no medical reason for a woman to douche - ever. It does not accomplish anything and, for the woman trying to become pregnant, it will definitely interfere. First of all, douching will kill sperm. Furthermore, there is good evidence that women who douche have a higher incidence of pelvic infections which of course can, in turn, damage the fallopian tubes and lead to infertility.
Another thing that a woman should not do is use a bidet if she is going to have a post coital test or if she is actively trying to become pregnant. Some of the water may be forced high enough into the vagina to compromise the test and the woman’s fertility.
The semen analysis and the post coital test are the two main tests of male fertility. Properly performed, the semen analysis offers a great deal of information concerning a man’s potential to father a child.
To gain the maximum information possible, the semen analysis must be performed in a proper manner (as with any test).
In addition to the proper performance of the semen analysis itself, there are other factors that can influence the information obtained. Furthermore, there are a variety of myths associated with the semen analysis, as there are for many other test and procedures in infertility.
Three principal pieces of information are looked for in the performance of a semen analysis - the count, the motility, and morphology.
The count refers to the number of sperm per cubic centimeter of semen. A normal count is anything over twenty million.
Motility refers to the number of actively moving sperm - those sperm that are showing good vigorous forward motion. In a normal semen analysis, 50% of the sperm have good motility.
Morphology refers to the shape of the sperm. Again, in a normal semen analysis, 50% or more of the sperm will be normally shaped.
If any of these criteria are not met, that semen is said to be “infertile”. It is important however, to recognize that no man produces normal semen every time he ejaculates. Totally normal fertile men will frequently produce very infertile semen. Therefore, if a semen analysis is performed on a man and it is totally normal, no other testing need be done at that time. If however, the first specimen is subfertile or infertile, repeat testing is mandatory. In some men, it may take four or five or more semen analyses to accurately determine what that mans’ fertility potential is.
Of all the criteria that are looked for in the assessment of a semen analysis, the motility is the most important, although everyone pays more attention to the count. In fact, a man with good motility and a low count has a much better chance of fathering a child than a man with a high count and poor motility.
One of the principal things that will affect motility is frequency of ejaculation. Contrary to popular myth, a man can not “save it up”. In fact, the more frequently a man ejaculates, the better semen quality he will produce. This is particularly true of men with normal semen quality. Men whose semen quality is impaired may not be able to ejaculate daily but certainly every other day, on average, is and should be attempted if the couple is trying to have a baby.
A man should not even produce a semen specimen for analysis if he has not ejaculated within the previous 3-4 days. If a man is told to abstain more than 24 hours prior to giving a specimen, he is being improperly instructed.
Another factor that significantly influences semen quality is cold. Low temperatures immobilize sperm very quickly. Every so often, a couple will bring a semen specimen into the office for analysis. I will be told that there was a delay in getting to the office so they put the specimen into the refrigerator to preserve it until they could come in the office. Nothing is more guaranteed to stop the sperm from moving. I mentioned this simply to make sure that the sperm is kept as close to body temperature during transport as possible.
Another factor that affects the quality of the semen is the method by which it is produced. Traditionally, semen analyses have been carried out on specimens produced by masturbation. However, there is now good data to show that the quality of semen that a man produces during intercourse is better than the quality of semen produced by masturbation. Therefore, whenever possible, intercourse, using a special condom to obtain the semen specimen is preferred.
To carry out a semen analysis, the following rules should be followed:
- The specimen should be collected using the special kit that I will have provided you in the office. This kit comes with instructions. The kit contains a special condom that does not kill sperm. It also contains a small funnel, a small plastic vial, with a screw top cap.
- Usually intercourse will occur in the morning. However, although it does not matter what time of day the specimen is brought to the office, I would like to know in advance that you are coming in, depending upon how busy my office hours may already be scheduled for that time.
- After having intercourse with the special condom, hold the condom over the funnel which has been placed into the top of the plastic vial. Cut the end off the condom and allow the semen to run down through the funnel into the vial.
Seal the vial with the screw top lid. Then put the vial in side your shirt and get it to the office as soon as humanly possible. No more than two hours should elapse but the shorter the time interval, the better.
Putting it inside your shirt will prevent the semen from being too hot or too cold depending upon the season of the year and weather or not your car is air conditioned. Any of these factors may affect the quality of the semen.
- Because frequency of ejaculation will affect semen quality, I would prefer that you not have intercourse the day before you are going to bring the semen specimen into the office. However, I must also insist that intercourse will have last occurred no more than three days prior to the semen specimen being submitted. In other words, if it has been four or five days or more since you last had intercourse, the length of time may adversely affect the quality of the semen and lead us to draw erroneous conclusions about the fertility potential. If the interval is too long, the semen analysis should be postponed.
In the office, the volume of the semen specimen is measured, the count is obtained, and the sperm are looked at under the microscope to determine their motility and morphology. Although it can take some time to carry out the full analysis, a quick “eyeball” look at the specimen can often allow me to give you at least a general idea whether the semen quality is good, bad or in between.
It is important to understand that with some exceptions, the purpose of the semen analysis is not to determine if any therapy is of benefit for the man - it usually isn’t.
The purpose of the semen analysis (along with the post-coital test) is to help decide which therapy is best for that couple. If both the semen quality and post-coital test are good, the woman should be able to conceive by natural intercourse (providing of course that other problems have been corrected).
If the semen is impaired and/or the post-coital test is poor, IUI will be necessary.
If the semen quality is very poor, the couple should by-pass all the traditional therapies and go straight to IVF with ICSI.
As with everything in medicine, just when you think you have the answers, someone changes the questions. The “normal” values for a semen analysis are listed above. However, as noted in the discussion that many men with subnormal semen values will father children, a large study was done looking at fertile and infertile couples, the semen parameters, and whether a pregnancy was achieved.
While this is not really new information, it does help put things in a better perspective. As a result of this study, a man is defined as being “subfertile” if his count is less than 14 million and the motility is less than 32%. They also used the cut-off of 9% for morphology but this is using what is call “strict criteria” - something that is more of a research tool since it is very time consuming to perform.
A man is considered “fertile” if his count is greater than 50 million and the motility is greater than 60%. Normal morphology is greater than 12% - not that much different than the subfertile range.
Anything thing in-between is call “indeterminate”.
The message to be gotten from this - men with counts that were previously considered “too low” are really far more capable of fathering a child than we had believed to be the case. By setting the levels lower, it allows us to focus more carefully on what may really be causing that couple’s infertility rather than blaming on the man, who may not be at fault.
Pelvic Infection and Pelvic Damage
Pelvic damage from prior pelvic infection is a major cause of infertility. The vast majority of the these infections are cause by the bacteria “Chlamydia” - the 2nd most common sexually transmitted disease in the U.S. It is the most common sexually transmitted bacterial disease reported to the Center for Disease Control (CDC).
At the time of your first visit, I routinely perform a blood test to determine if you have ever had a Chlamydia infection. The blood test does not tell when the infection occurred. The blood test, like most antibody tests, remains positive for your whole life. It only tells if an infection has occurred.
A positive blood test for a Chlamydia infection is a very sensitive screening tool for tubal damage, probably the best office test currently available. If a woman has a positive blood test, then she has had an infection and the possibility of tubal damage is high. A woman with a positive test should have a hysterosalpingogram followed by a laparoscopy. If the blood test is negative, there is no reason to perform the X-ray before a laparoscopy.