After reading how reproduction occurs normally, it becomes easy to understand what kinds of tests are required if a couple is having difficulty achieving pregnancy. But one of the first questions is, “When is it appropriate to perform an evaluation?”
Infertility Testing, When is the Right Time?
The textbook definition of infertility is “one year of unprotected intercourse without conception”. This is a good general rule for young couples, under 30 years of age, who have no obvious reason for why conception may not be occurring. There are many exceptions to this rule, including older couples, for whom time is of the essence.
For couples who suspect that there is a reason for why they may have difficulty conceiving, it is perfectly appropriate to evaluate any potential area of difficulty regardless of how long they have been trying to conceive. Sometimes a test may be performed before a couple tries even once. For example, a woman whose menstrual periods are extremely irregular or infrequent (such as once or twice a year) may wish to be evaluated for ovulation right away, rather than trying for a year and then seeking medical advice. Similarly, a man who was born with undescended testicles may wish to have a semen analysis to find out if fertility may be possible.
What to Tests Should be included in Infertility Testing?
In the absence of obvious reasons to do otherwise, the evaluation of infertility proceeds along simple and logical lines: 1) test for eggs, 2) test for sperm, 3) make sure they can get together. This is the basic three-step infertility work-up. Additional tests may be indicated following the completion of this three step process.
In this category, we first check if the woman is ovulating, meaning that her ovaries are producing eggs and that they are being released each month. A simple blood test for progesterone, performed about a week prior to the start of the next menstrual period is sufficient. If the woman is over the age of 35, she should also be tested for ovarian reserve, which is a measure of Egg Quality.
The basic male fertility test for male sperm is the semen analysis. An ejaculated semen specimen is analyzed for volume, sperm concentration, the proportion of motile sperm, and the proportion of normal forms. It is important to understand that quality rather than quantity is important when it comes to sperm; “quality” is equated with “fertilizing potential”. The reason that we perform a semen analysis is because the parameters that are measured in the semen analysis correlate with fertilizing capability. A normal semen analysis does not guarantee fertilization; it just makes it more likely that there will be at least one good sperm that will do the job.
When it is established that the woman is producing eggs and the man is producing sperm, it is essential to make sure that they can get together. The best test for this purpose is the hysterosalpingogram (HSG). This is a type of x-ray, in which liquid is introduced into the uterus with a small flexible catheter. As the liquid is injected by the radiologist, x-rays are taken and since the liquid absorbs the x-rays, the outline of the uterine cavity and fallopian tubes can be seen on the x-ray film. The HSG is therefore useful for demonstrating a normal uterine cavity as well as showing that the fallopian tubes are open. If the fallopian tubes are blocked or if there is an anomaly in the uterus, which may interfere with embryo implantation, surgical correction may be necessary before attempting further fertility therapy.
If any of the three basic tests are abnormal, further testing may be required to establish precise reason for this abnormality. For example, if the woman is not ovulating properly, other hormonal evaluation may be necessary. In the past, a “post-coital test” was included in the routine evaluation of infertility. The couple was asked to have intercourse and the cervical mucus was then analyzed for the presence of sperm. Unfortunately, over time, the post-coital test was found to be too unreliable and it is rarely used today.
In the past, patients would also commonly undergo laparoscopy as part of the infertility evaluation if all of the other tests proved normal. However, careful re-evaluation of this practice revealed that the number of patients who actually benefited from this surgical procedure was very small. Today, laparoscopy is reserved for patients who have a specific reason for having it done. Examples include women with prior pelvic surgery, those with prior tubal pregnancies, or those with unexplained severe pelvic pain.
In addition to fertility-specific testing outlined above, infectious disease testing will be conducted for both partners. Exact tests needed will vary based on fertility treatment required and a patient’s particular health situation or age, however, the basic tests usually conducted include HIV I & II, HTLV I, Hepatitis B Surface Antigen, Hepatitis C Antibody and Rapid Plasma Reagent (RPR for Syphilis).