Because infertility is a problem that affects
both the male and female partners in a couple, it is
very important that both members be present for the
initial consultation. This meeting typically lasts
30 to 45 minutes and involves multiple components.
The first component is to establish whether or not
an evaluation is warranted. The physician will begin
by taking a complete medical history of both the
female and male partner, which will include details
regarding the menstrual cycle, previous surgeries,
infections and pregnancies and other health
conditions that can impact fertility. These details
are important in trying to establish any
identifiable risk factors for infertility from
either of the partner’s previous medical histories.
Another important component of the initial
consultation is to educate the couple about normal
reproductive function. All too often, the last
exposure that many couples had to any formal
instruction was during high school sex education
classes, and much of their current knowledge may not
be based on fact. Often times, there are many myths
and misperceptions that have to be addressed and
corrected in order to help a couple understand
normal reproductive physiology. This also helps the
couple better understand normal statistics regarding
fertility, the various causes of infertility, and
the rationale for treatment. Preconception
counseling regarding lifestyle and health factors
including smoking, alcohol consumption and exercise
are also addressed at this time. Once the initial
consultation has taken place, the physician will
establish a plan for a diagnostic evaluation.
The goal of the fertility evaluation is to identify
a specific cause or causes of infertility, and to
then recommend appropriate targeted treatments. The
most common cause of female infertility is a
disorder in ovulation. Significant information can
be obtained from a menstrual history including cycle
length and variability, as well as duration of
menstrual flow and age of menarche (your first
period). There are several ways to determine if
ovulation occurs normally, including basal body
temperature charting, ovulation predictor kits, and
serial ultrasonography.
The evaluation of ovarian reserve, which refers to
the number and quality of oocytes remaining in a
woman’s ovary, is often performed as part of the
ovulation assessment. Ovarian reserve testing
typically involves measurement of the hormones
follicle stimulating hormone (FSH) and estradiol
(E2) on cycle day two, three, or four, as well as an
ultrasound evaluation of the number of follicles
within the ovaries early in the menstrual cycle. The
final part of the evaluation of ovulation is a
determination of the length of the post ovulatory,
or luteal, phase. This time frame, which includes
the time from ovulation until the onset of the next
menstrual bleed, should be 12-14 days in length.
The next component of the female infertility
evaluation is an assessment of the uterus and the
fallopian tubes. This is most commonly accomplished
with a procedure called a hysterosalpingogram (HSG),
which involves a radiologic evaluation performed
after a woman’s flow has ceased, but prior to
ovulation. The HSG involves placement of a small
catheter through the opening of the cervix in order
to pass dye into the uterus and the fallopian tubes.
In addition to determining whether the tubes are
open (patent) and normal, the HSG can also diagnose
any type of structural abnormalities of the uterus,
such as congenital anomalies (birth defects), polyps
or fibroids.
In specific situations, such as when a woman has
a history of severe or worsening menstrual cramping
or a strong family history of endometriosis, your
physician may recommend an outpatient surgical
procedure known as laparoscopy for further
evaluation of the pelvic anatomy.
As with the female, the goal of the male fertility
evaluation is to identify a specific cause or causes
of infertility, and to then recommend appropriate
targeted treatment. The basic evaluation consists of
a history – during which time previous fertility,
medical conditions, surgeries, sexually transmitted
diseases, and lifestyle issues will be discussed. A
family history, looking for infertility,
miscarriages, or other diseases will also be
evaluated. The primary test of male fertility is the
semen analysis. This test is critical, as it
evaluates the sperm concentration as well as
motility (the percent of sperm that are alive and
swimming) and morphology (shape). If the semen
analysis is abnormal, or if there is something in
the male’s history that suggests an anatomic
abnormality, then we will probably refer him to a
urologist for a physical examination. We may also
recommend a blood test to check the hormone levels
that influence sperm production, including FSH, LH,
and testosterone.
For some couples, achieving a pregnancy is
relatively easy; having the pregnancy continue to
the point of viability, on the other hand, is very
difficult. Such patients have a condition called
recurrent miscarriage (also known as recurrent
abortion or recurrent pregnancy loss). A woman is
diagnosed with recurrent miscarriage once she has
had three or more consecutive clinical pregnancy
losses without a live birth. In couples with this
condition, a thorough evaluation will identify a
definitive problem in approximately 60% of cases. In
the other 40%, we may not be able to identify a
specific cause.
Most cases of recurrent miscarriage fall into one of
six different categories. The most common problem is
a genetic or chromosomal abnormality in the fetus.
This is typically a random event, but in rare
instances, it may be caused by a genetic abnormality
in one or both of the parents. We can definitively
identify this condition, if present, by analyzing
the chromosomes of both members of the couple. This
analysis, called a karyotype, enables us to identify
problems that could continue to cause chromosomally
abnormal pregnancies - such as balanced
translocations or chromosomal inversions.
Another common cause of recurrent miscarriage is a
uterine abnormality, a condition in which the uterus
fails to form normally when a woman is developing in
her mother’s uterus. There are a variety of
different abnormalities, and each can typically be
identified with a hysterosalpingogram. The most
common abnormality associated with recurrent
pregnancy loss is a large uterine septum, which,
once excised, results in an 85% chance of term
delivery in subsequent pregnancies.
Hormonal issues including oversecretion of prolactin,
hypothyroidism, and chronically insufficient levels
of progesterone production in the luteal phase have
also been associated with recurrent miscarriage. A
less well-established, but potentially important
cause of recurrent miscarriage is infection in the
genitourinary system, which can decrease the
likelihood that a pregnancy will successfully attach
(implant) within the uterus. Although we typically
diagnose this condition by performing a culture of
the woman’s cervix, such cultures are only accurate
approximately 65% of the time. Therefore, following
the culture, we prefer to treat both members of the
couple simultaneously with a broad spectrum
antibiotic – regardless of the culture results.
Autoimmune factors have also been implicated as a
cause of recurrent miscarriage. If a woman has an
autoimmune problem, she may make antibodies that
lead to the formation of blood clots in the small
blood vessels of the placenta. When these clots
form, they can block the flow of oxygen and
nutrition to the fetus, as well as prevent the
transfer of waste products back from the fetus to
the mother for processing and excretion. The most
common autoimmune problem associated with recurrent
miscarriage is the presence of antiphospholipid
antibodies. This condition can be diagnosed through
a simple blood test. Other clotting disorders, such
as lupus anticoagulant, protein S deficiency,
protein C deficiency, antithrombin III deficiency
and Factor V Leiden have also been implicated in
recurrent miscarriage. Typically, these conditions
lead to pregnancy losses that occur in the second
trimester and beyond.
An integral part of the female fertility evaluation
is an assessment of the reproductive anatomy –
specifically the fallopian tubes, the uterus, and
the ovaries. If an abnormality is discovered, it is
usually correctable through the performance of a
relatively minor surgical procedure, such as
laparoscopy or hysteroscopy. Each of these
procedures is discussed in great detail in the
surgical section of our web site.
If we determine that you need surgery, we will refer
you to our surgical coordinator whose sole job is to
handle all of the details involved in scheduling
your procedure – answering your questions as well as
coordinating the scheduling of the surgery between
your physician, the surgery center or hospital, and
your insurance company. The surgical coordinator
will also arrange for a preoperative evaluation with
your physician who will thoroughly discuss your
procedure with you in detail, including the risks of
the procedure, the expected outcome, and what you
can expect following surgery. Our nursing staff
calls every surgery patient following surgery to
ensure that you are recovering as expected, to
review the intraoperative findings with you, and to
answer any additional questions that you may have.
At that time, they will also schedule a
postoperative visit with your physician.
Once the diagnostic portion of the fertility
evaluation has been completed, the physician will
typically schedule a meeting with you and your
partner to review all of the results of the testing
and to discuss treatment recommendations. This is
another opportunity for you to discuss the success
rates and risks of any recommended treatment, as
well as the costs and time commitment required for
each. Following your consultation, a treatment plan
will be established and you will begin your
fertility journey.
