Infertility
by Akisha Pinkerton – PAC, Kalispell OB/GYN
Understanding Infertility
Each year many couples try to conceive and most are successful within the first year; however, approximately 10 – 15% of couples will struggle with infertility. In order to fully understand infertility, it is important to understand the definition of infertility, when to be evaluated and what tests are available for you.
What is infertility and when should I be evaluated?
Infertility is the inability to conceive after 12 months of regular unprotected intercourse. us, a diagnostic evaluation is indicated in couples who have been trying to get pregnant for one year. If a woman is older than 35, infertility is considered after 6 months of trying to conceive without success and a diagnostic evaluation is indicated at that time. Other factors may warrant a diagnostic evaluation sooner than 6-12 months regardless of age. These can include but are not limited to irregular menses, damaged or blocked fallopian tubes, stage III-IV endometriosis, a family history of early menopause, history of certain cancer treatments and male subfertility.
Where do we start?
If you are having difficulty conceiving or concerned about your fertility, you should talk with your healthcare provider about the plan that is best for you. Infertility can be an overwhelming journey. Understanding the diagnostic tests and options will help you manage your treatment and prepare you for the road ahead.
Initial Visit: Physical Exam and History
At the initial visit your healthcare provider will review your history and perform a physical exam. The provider will also gather information about your partner if applicable. The female and male should both be evaluated as part of the initial testing. Following the history, your healthcare provider will order testing to determine the cause of your infertility. e testing should be done in a focused and cost-effective way and should take the couple’s preferences, the duration of infertility, the woman’s age and specific factors revealed through the medical history and physical examination into account.
Overview of Infertility Testing:
Ovarian Reserve Testing: Ovarian reserve testing is used to help the healthcare provider predict whether the patient can produce an egg or eggs of good quality. In order to do this, the woman will have blood tests done on cycle day 3 of her menstrual cycle. The blood tests commonly used to assess ovarian reserve include follicle-stimulating hormone (FSH), luteinizing hormone (LH) and estradiol levels. These are key hormones for the development and quality of eggs. On the day of the blood tests, the woman may also have a transvaginal ultrasound to count the number of antral follicles (egg sacs). is is done by placing an ultrasound probe into the vagina and counting the number of antral follicles in each ovary. e physician may also recommend another blood test called an antimullerian hormone (AMH) to help assess the patient’s ovarian reserve.
Transvaginal Ultrasonography: A transvaginal ultrasound not only helps assess ovarian reserve as described above, but is also useful in evaluating the woman’s uterus and ovaries. is can rule out abnormalities such as uterine fibroids or ovarian cysts.
Hysterosalpingogram (HSG): is test is used to see if the fallopian tubes are open and to assess the shape of the endometrial cavity (the inside part of the uterus). An HSG is performed by injecting contrast into the uterus while using X-Ray to visualize the contrast filling the endometrial cavity and entering the fallopian tubes. If a woman’s fallopian tubes are open, contrast will be seen outlining the length of the tubes and spilling out each end into the abdomen.
Sonohysterography: is procedure is done to assess the inside part of the uterus. It is done by inserting a small catheter into the uterus and injecting sterile saline. Once the catheter is in place, an ultrasound probe is placed into the vagina and pictures are taken. The saline distends the endometrial cavity and aids in the detection of intrauterine problems including but not limited to endometrial polyps and uterine fibroids.
Hysteroscopy: is a surgical procedure used to examine the uterus and diagnose and treat conditions such as internal fibroids, polyps and scar tissue. A hysteroscopy is performed by passing a lighted telescope-like instrument (hysteroscope) through the cervix and into the inside of the uterus.
Laparoscopy: is is a surgical procedure used to evaluate the pelvic cavity for conditions such as endometriosis, pelvic adhesions and other abnormalities. A laparoscopy is performed by inserting a lighted telescope-like instrument (laparoscope) through the wall of the abdomen into the pelvic cavity. is is not routinely performed during an infertility evaluation but rather performed in patients with evidence or strong suspicion of endometriosis or pelvic adhesions.
Other Blood tests: Problems with infertility may be caused by thyroid disorders or high levels of prolactin (hyperprolactinemia). Thus, a thyroid- stimulating hormone (TSH) and prolactin level may also be ordered by your healthcare provider. In a patient who has increased hair growth (hirsutism) additional blood tests may be ordered including dehydroepiandrosterone sulfate (DHEAS), 17 – hydroxyprogesterone and total testosterone. In order to check for ovulation, a blood progesterone level may also be drawn in the second half of the menstrual cycle. A patient may also be instructed to use an over-the-counter “ovulation predictor kit” to detect the presence of LH in the urine and help with the timing of intercourse.
Male Partner Semen Analysis: The semen analysis is an essential part of the infertility evaluation and should be done even if the male partner has fathered a child previously. A sample is obtained from the male partner and is evaluated under a microscope for sperm count, motility and shape, among other factors.
The testing described above can help identify many different causes of infertility including ovulatory dysfunction, uterine fibroids, uterine polyps, adhesions, damaged or blocked fallopian tubes, polycystic ovary syndrome (PCOS), thyroid disease, high prolactin levels and sperm abnormalities, among others. Once the diagnostic testing is completed, you should schedule a follow-up appointment with your healthcare provider to discuss your test results and treatment options.
In conclusion, if you are having difficulty conceiving or are concerned about your fertility, talk with your healthcare provider and the two of you can discuss the plan that is best for you. If you would like more information on this topic please visit ReproductiveFacts.org, the patient education website of the American Society for Reproductive Medicine.
Alisha joined Kalispell OB/GYN in June of 2015, relocating to the Flathead Valley from Ford City, Pennsylvania. She received her undergraduate degree from the University of Pittsburgh and her Master of Physician Assistant Studies from Chatham College, both in Pittsburgh, Pennsylvania. For eight years prior to joining Kalispell OB/GYN, she practiced as a Certified Physician Assistant at the University of Pittsburgh Medical Center in the Center for Fertility and Reproductive Endocrinology.
Alisha Pinkerton, PA-C