Investigation of infertility

Infertility exists when a couple trying

for pregnancy have not achieved this
after 12 months. Eight in 10 healthy
couples will become pregnant in the
first 12 months of trying, so it is
reasonable to commence investigations
if pregnancy has not been achieved in
this time

Physiology

The sperm meets the egg in the tubal ampulla

and an understanding of the complexity of the
process leading to that moment and the
subsequent fertilization (Fig. 1) and implantation
is important to the understanding of infertility.
The human female starts life with many eggs and
'wastes' most:
Fetus
2 000 000 ova at about 20 weeks
Birth
750 000 ova
Puberty
250 000
Reproductive life
200 - 300 ovulations
Menopause
a few residual ova but
unresponsive to follicle
stimulating hormone

Eggs are held in prophase of first meiosis.

Meiotic division resumes as the follicle matures
and is complete by the time of ovulation. A
regular 28-day menstrual cycle results in 13
ovulations per year. Couples should be
encouraged to have regular intercourse
throughout the menstrual cycle.
The early conceptus produces human chorionic
gonadotrophin (hCG) which is necessary for the
continuation of the pregnancy and is the basis
of urine and blood tests to confirm pregnancy.
The production of progesterone by the corpus
luteum is also essential for at least the first 9
weeks of pregnancy, until placental production
takes over this role

Infertility affects 1 in 10 couples with

varying causes predominating in different
countries. The common causes of infertility
in the UK (usually a combination of causes)
are:

unexplained 28%
sperm problem 21%
ovulatory failure 18%
tubal damage 14%
endometriosis 6%
coital problems 5%
cervical mucus hostility 3%
other male problems 2%

In the USA the male factors can account for

40% of cases of infertility
Female factors (e.g. tubal blockage secondary
to pelvic inflammatory disease) are high in
the Caribbean and West Indies. The tendency
for women in 'advanced' countries to delay
childbearing whilst establishing a career may
result in more cases of infertility as fecundity
decreases with increasing maternal age.
There are increasing numbers of anovulatory
cycles and the oocytes are ageing whilst there
is a lower frequency of sexual activity with
increasing age

Investigations

Investigation of an infertile couple (Fig. 2)

needs to rapidly assess ovulation, patency of
tubes and presence of sperm. A diagnosis
allows formulation of a management plan to
help allay anxiety and ensure that older
couples do not miss the chance of assisted
conception

Check the rubella status and offer vaccination if

negative - remember to advise avoiding
pregnancy within 1 month of vaccination.
Advice to take folic acid whilst trying to
conceive is appropriate, along with advice to
stop smoking and reduce alcohol intake to a
minimum. A body mass index (BMI) over 30
necessitates a supervised weight loss
programme. The male partner should also be
advised to stop smoking and limit alcohol to
optimize his reproductive performance.
Intercourse two to three times per week
throughout the cycle should optimize the
chance of conception

Fig. 1 The physiology of fertilization.

Fig. 2 Investigation of the infertile couple.

Semen analysis

The World Health Organization normal values

are:

volume 2-5 ml
sperm count > 20 million sperm per ml
motility > 50% progressive motility
Morphology > 30% normal forms
white blood cells < 1 million/ml
liquefaction time within 30 mins

Counts below 20 million sperm per ml are associated

with lower pregnancy rates. Over recent years
decreased sperm counts have been noted - possibly
due to environmental pollutants such as agricultural
chemicals, stress,intercurrent illness and jet lag. With
azoospermia, luteinizing hormone (LH) and follicle
stimulating hormone (FSH) should be checked - high
FSH suggests failure of sperm production and needs
further investigation with chromosome study. Normal
FSH may imply a blockage to the outflow of sperm. A
sperm migration test will assess the number of viable
sperm with good forward motility (normal value > 5
million/ml). Antibodies can be detected in semen (IgA
and IgG) using immunofluorescent techniques.
Antibodies may be found on the head [affecting ability
to fertilize the egg ortail (affecting sperm motility).

Tests of ovulation

Measurement of serum progesterone in

the mid-luteal phase confirms ovulation if
> 30 nmol/1. Ultrasound 'tracking' of the
ovaries can follow developing follicles
during ovulation induction cycles (Fig. 3)

Tubal function

Hysterosalpingography (HSG) and diagnostic

laparoscopy are complementary methods for
assessment of tubal patency. Before instrumentation
of the uterus, screen for Chlamydia trachomatis or
give appropriate antibiotic prophylaxis. At HSG,
radioopaque dye is introduced through the cervix and
outlines the uterine shape and fallopian tubes,
determining their patency (Table 1)
Laparoscopy allows assessment of the pelvis for
endometriosis (see p. 128) and peritubal adhesions
due to infection (see p. 100). There may be an
obvious corpus luteum (evidence of ovulation) and
free fluid from the pouch of Douglas can be assessed
bacteriologically to rule out pelvic infection. Dye
injected through the cervix can be observed flowing
from the fimbriae of the tubes in healthy cases

Fig. 3 Ultrasound scan showing a follicle being measured

Table 1 Assessing the results of

hysterosalpingography
Findings at HSG

Presumptive diagnosis

Uterine synechiae

Asherman's syndrome

Irregular uterine cavity

Uterine fibroids

Septum in cavity

Congenital abnormality of uterus

Cornual blockage

Spasm of tubes

Tubal distension

Blocked tubes

Peritoneal spread of dye

Normal tubal patency

Investigation of infertility

Infertility investigations can commence

after 12 months of intercourse not
resulting in pregnancy
An investigation plan should enable couples
to learn rapidly the cause of their infertility
Investigation should always be in parallel
for male and female partners