Finding the Cause
The first step is to obtain a detailed history and perform a physical exam. Believe it or not, there is a great deal of information that an experienced physician can collect during a consultation. The age of the couple is important. The duration of infertility is very important. Whether or not previous pregnancies of any kind have occurred is consequential. Has there been a previous marriage? Has there been any previous surgery? Is there a history of endometriosis or pelvic infection? All of this information is helpful.
Normal anatomy
After the history is obtained, a physical exam can reveal many clues. Fibroids, endometriosis, cysts are among the most common findings. Frequently also ultrasound can supplement the exam. Vaginal ultrasounds are the most accurate.
Next, 3 basic studies are completed. An x-ray called a hysterosalpingogram (HSG) is performed to rule out tubal blockage. Tubal blockage is one of the most common causes of infertility in the world. This is a basic study that takes a few minutes to complete.
Normal Hysterosalpingogram (HSG)
HSG with blocked tubes
A semen analysis "sperm count" is done to evaluate the male factor. The specimen can either be collected at home or in the andrology (sperm) lab. An andrology lab is more able to evaluate the many properties of sperm than a standard hospital lab.
The third test is a blood progesterone level for the woman which helps to evaluate ovulation. We usually perform this test between days 20 and 22 of the cycle. This replaces the old temperature graphing method which is not as useful. Ultrasound of the developing follicle and menstrual cycle length also give a great deal of information about ovulatory quality.
Frequently, after the above simple testing, we have an accurate idea as to the cause of infertility. Common treatments are in the basic therapy and in vitro sections of this web site.
Sometimes further testing needs to be done. Some patients need to undergo laparoscopy (mini-incision surgery to evaluate the presence of endometriosis or adhesions). Laparoscopy can clearly show the difference between:
Normal
Endometriosis
An actual laparoscopic view of the entire reproductive tract
An actual laparoscopic view of a normal fallopian tube and ovary. The fleshy part of the tube (the fimbria) picks up the eggs. The ovary is the white structure.
A direct laparoscopic view of a blocked fallopian tube that is dilated with fluid, a hydrosalpinx. You can see that there is no open fimbria close to the ovary to pick up eggs.
There are other tests such as the postcoital test which are sometimes useful. Each case is different. We do not want to do all tests for all patients. The challenge is to do the basic tests first and other testing as needed.
In 90% of cases an obvious simple cause can be found. Testing can be completed within 6 weeks. While diagnosis may not be as exciting as therapy, it is an important first step. It is a mistake to begin treatment without a clear understanding of the cause of the infertility.
