The Evaluation of the Infertile Couple

One of the most frequent concerns conveyed on this web site involves the thought by many that the infertility evaluation carried out attempting to uncover the "cause" of an infertility problem may have been incomplete or may have overlooked something.

There are many valid approaches to the work up of a couple who have been unsuccessful in their attempts to become pregnant. While the angle of the approach to a fertility problem may vary from physician to physician, and from Center to Center, it is generally felt  by us that there are certain "basics" to be investigated in nearly every couple with an infertility condition. These baseline studies may be slightly modified based on the initial history of the couple involved, but in general, the items presented here are considered very important to us in the study of nearly all couples.

While reading this, it is important to remember that these are generalized protocols and the studies mentioned may not be applicable to every couple. These suggestions represent the protocols in effect at our Centers, and they are not meant to indicate a suggested treatment course. You should always attempt to obtain the most qualified medical help available and work together with your health care providers to obtain the highest quality opinions about your workup.

A SUMMARY OF THE NEW PATIENT INFERTILITY WORKUP AT THE FERTILITY INSTITUTES

At the Fertility Institutes, we ask new patients to complete a very detailed medical history questionnaire prior to presenting for their first appointment. These history forms are forwarded to patients in advance to allow them adequate time to complete the forms at home and to obtain the very detailed information asked for. We include questions related to the patient, details of the pregnancy of the patient's mother (both husband and wife), fertility histories of the patient, brothers, sisters and immediate family members. We question very closely about life styles and diet, history of "health food" ingestion, vitamin history, and any history of food supplement use (herbs, etc.). Questions about possible occupational exposures to hazardous environments or chemicals and high stress environments are included. Possible detrimental effects on fertility of all of the above have been reported. A sexual history is obtained and the correction of any misconceptions or misinformation is carried out and cleared up.

After a complete history has been obtained, we outline a detailed, intense diagnostic program to allow us to arrive at a rapid diagnosis of the underlying fertility problem. While many variations of the protocol are employed to account for items uncovered in the history, we always begin with baseline studies that, if not recently performed elsewhere, include the following:

• Vaginal and cervical viral and bacterial cultures. These are used to detect any possible adverse infections that may be interfering with conception.
• Semen analysis and semen cultures.
• Sperm penetration and sperm function studies (Hamster, etc.).
• Female gonadotropin and other pituitary hormone studies. These studies are performed on the third day of the menstrual cycle in order to allow comparison to fertile "control" subjects whose blood was evaluated on the same day 3. These studies also include thyroid function studies, and evaluations of the adrenal gland, ovaries, lactation hormones and the uterus.
• Hysterosalpingogram. This X-Ray examination is able to uncover many abnormalities in the lining and configuration of the uterus, as well as demonstrating the fallopian tubes and detecting any partial or complete blockage of the tubes. Scarring around the tubes and ovaries can often be detected as well.
• Midcycle testing for the "LH surge". The LH surge is the brain's signal to the ovaries ordering release of the mature egg. Our patients are asked to monitor their urine at home in anticipation of the LH surge that will occur just prior to ovulation. When the patient detects her LH surge, she is asked to have intercourse in the morning, and then is brought in later that day for several very important timed studies:
• Post-coital (after intercourse) examination; a small drop of cervical mucus is taken from the cervix and examined under the microscope for the presence of live, active sperm.
• Midcycle estradiol (E2) and ultrasound. The LH surge signals the bodies "satisfaction" with the status of the mature oocyte (egg). The accuracy of this "decision" by the body is tested by looking at the follicle that contains the egg with ultrasound, as well as by measuring the amount of estrogen (estradiol) that the granulosa cells that nurse the egg are producing. The uterine lining can be seen with ultrasound, and measured to assure that the lining has developed to an adequate degree to support a new pregnancy should one arrive. These are crucial studies and are often found to be abnormal in many patients with otherwise "normal" study results.
• Luteal phase Progesterone level. One week after ovulation, the "scar" left over after the egg releases from the ovary should be producing abundant quantities of Progesterone. Progesterone performs many crucial functions in the second half of the menstrual cycle. It signals the uterus that ovulation has occurred and prepares the uterus for implantation of the new conceptus, should it arrive. It adds vital hormonal support to the uterine lining, preventing premature breakthrough bleeding or "spotting" . Patients with abnormal Progesterone levels may actually conceive, but lose their early pregnancies before they ever know they were pregnant. This condition can usually be detected and corrected with careful monitoring.
• Endometrial Biopsy. A small fragment sampled from the lining of the uterus just before the end of a menstrual cycle can reveal important information about the response of the uterus to all of the hormonal signals that have occurred during the cycle. We ask a pathologist to evaluate the biopsy under the microscope, and to "date" the uterine lining to test for an appropriate response to the hormone signals delivered during the cycle. An "out of sync" uterine lining is a correctable condition that can cause major infertility problems if undetected or untreated.

All of the above represent a sampling of some of the initial studies that we obtain on nearly every patient. As results become available on each study, those results may lead to the need for additional studies. Each fertility problem should be approached as a unique challenge, and should be afforded a complete, highly detailed evaluation. Success rates rely upon the establishment of an accurate diagnosis. We feel that patients should always be provided their underlying diagnosis, and should use that information to assist them in their own evaluation of any proposed treatment plans. 

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