Finding the specific medical reasons that cause infertility is the most important part of the medical evaluation. Most of the tests focus on checking these four critical factors: eggs, sperm, fallopian tubes and the uterus.

In order to understand why pregnancy doesn't occur , we need to examine the four critical areas which are needed to make a baby - eggs, sperm, fallopian tubes and the uterus. The tests, which often seem endless, will actually fall into one of these areas. In 40% of cases, the problem will be with the male, in 40% with the female, and in 10% both partners will have a problem. In some cases, about 10%, no cause can be identified (unexplained infertility) even after exhaustive testing.

Before starting with tests, the doctor takes a detailed medical history from the couple, and also performs a physical examination for both of them, to determine if this can provide clues as to the cause of the problem. The doctor will need to find out details about your menstrual cycle, as well as your sexual habits and past history of surgery or illness; so you should be prepared to answer these questions. Many clinics give patients a form to fill up, so that they can provide all this information. A physical examination can also provide the doctor with useful information, and he will look specifically for important clinical findings such as abnormal hair growth, excessively oily skin, or the presence of a milky discharge from the breast in the wife; and the size of the testes and their location, in the husband.

However, for most couples, investigations are needed to establish a diagnosis. In fact, in a departure from the traditional medical routine, many infertility specialists defer the physical examination until after the results of the tests are available. These specialized tests constitute the infertility workup and they can be completed efficiently in one month . Timing the procedures properly during the menstrual cycle is important and we have found the following strategy useful in our practice.

The first day the bleeding starts is called Day 1, and the semen analysis can be done at this time. The wife's blood tests for measuring the levels of the hormones : prolactin, LH (luteinising hormone), FSH (follicle stimulating hormone) and TSH (thyroid stimulating hormone) can be done between Day 3-5 of the cycle; followed by a hysterosalpingogram (X-ray of the uterus and tubes) between Day 5-7. Ultrasound for ovulation monitoring is done between Day 11-16 ; and this is used for timing the PCT (post-coital test) as well, during which time the cervical mucus is assessed also. A serum progesterone level is then measured on Day 21, about 7 days after ovulation , and this provides information about the quality of ovulation. The laparoscopy can be performed in the same month (Day 20-25) and can be combined with an endometrial biopsy, if desired.

With this strategy, time is not wasted, and couples can be reassured that a possible reason for the cause of the infertility , if it exists, will be detected within one month.

In fact, an even simpler workup uses the following protocol.

  • Day 1 ( or Day 2 or 3) - semen analysis
  • Day 3 ( or Day 4 or 5) - blood tests for FSH,LH,PRL and TSH
  • Day 8 ( after the period stops) - HSG

This means that within 8 days, we can determine if the sperm are normal; assess ovulation and ovarian reserve; and check the uterine cavity and tubal patency. The total cost for these tests in India in 2003 would be less than Rs 4000 ( approximately US $ 100).

The workup should not stop when a single problem is discovered - it is still important to complete the testing, since it is possible that infertile couples may have multiple problems. Remember also that many diseases, such as pelvic inflammatory disease ( PID) which can cause the tubes to get blocked, can be "silent", so that the patient may have absolutely no signs or symptoms.

A single test abnormality does not necessarily mean that a problem exists and the test may need to be repeated , to confirm that it is a persistent problem.

Sometimes it can be difficult for patients to come to terms with the fact that there is a major problem which presents a significant hurdle to getting pregnant. The truth can be bitter , but it's far better to face up to it and deal with it, rather than live in a fool's paradise ! With today's advanced reproductive technology, we can always find a solution, no matter what the problem - but remember that unless you can intelligently identify the problem, you cannot find a solution !

Unfortunately, it is very common to find that tests are done piecemeal - or sometimes, not done at all, so that often treatment is started before coming to a diagnosis. Conversely, some doctors take so long to do the tests that patients get fed up - after all, they want treatment ! It is also common to find that doctors will insist on repeating the tests a previous doctor has performed - and this can be a waste of valuable time and money.

The first rule for infertility testing is that the couple must be seen together, and the first test which should be done is a semen analysis. Sadly, sometimes the wife will have undergone innumerable tests (sometimes repeatedly !); and the husband's semen analysis (where the problem lies) has not been done even once.

It is only after the workup has been completed that a treatment plan can be formulated - and you will then need to make decisions about treatment options.

Authored by : Dr Aniruddha Malpani, MD and reviewed by Dr Anjali Malpani.

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