Infertility Evaluation and Treatment

What Is an Infertility Evaluation?

An infertility evaluation includes an exam and tests to try to find the reason why you and your partner have not become pregnant. If your doctor can identify the reason, it may be treated. In many cases, doctors can successfully treat infertility even if they can’t find a cause.


When Should I Get One?

Consider having an infertility evaluation if any of the following apply to you:

  • You’ve been having regular sexual intercourse without the use of birth control for a year and haven’t gotten pregnant
  • If you are older than age 35 years and have not become pregnant after trying for six months without using birth control
  • You’re over 40 and haven’t become pregnant within six months of trying without using birth control.
  • You have irregular menstrual cycles.
  • There is a known fertility problem in you or your partner


What Types of Doctors Treat Infertility?

Your obstetrician-gynecologist (ob-gyn) usually will do the first assessment. You also may choose to see a specialist. Infertility specialists are ob-gyns with special training in evaluating and treating infertility in women and men. These specialists are called reproductive endocrinologists. A urologist can evaluate and treat men. Some urologists have special training in male infertility.


What Causes Infertility?

The most common cause of female infertility is lack of or irregular ovulation. The most common causes of male infertility are problems in the testes that affect how sperm are made or how they function.

Other factors in women include problems with the reproductive organs or hormones. Scarring or blockages of the Fallopian tubes may contribute to infertility. This may be the result of past sexually transmitted infections (STIs) or endometriosis. Problems with the thyroid gland or pituitary gland also may contribute to infertility. In men, blockage of the tubes that carry sperm from the testes may cause infertility.


How Does Age Affect Fertility?

For healthy couples in their 20s or early 30s, the chance that a woman will become pregnant is about 25–30 percent in any single menstrual cycle. This percentage decreases rapidly after age 37 years. By age 40, a woman’s chance of getting pregnant drops to less than 10 percent per menstrual cycle. A man’s fertility also declines with age, but not as predictably.


Can Lifestyle Affect Fertility?

In women, being underweight, being overweight, or exercising too much may be associated with infertility. Drinking alcohol at moderate or heavy levels may be a factor in infertility for both men and women. Smoking cigarettes and marijuana can reduce a man’s sperm count and movement.


What Should I Expect During My First Visit?

The first visit with a fertility specialist usually involves a detailed medical history and a physical exam. You will be asked questions about your menstrual period, abnormal bleeding or discharge from the vagina. Your doctor will also as you about pelvic pain and disorders that can affect reproduction such as thyroid disease. You and your partner will be asked about the following health issues:

Medications (both prescription and over-the-counter) and herbal remedies

  • Illnesses, including STIs and past surgery
  • Birth defects in your family
  • Past pregnancies and their outcomes
  • Use of tobacco, alcohol, and illegal drugs
  • Occupation

You and your partner also will be asked questions about your sexual history:

  • Methods of birth control
  • How long you have been trying to become pregnant
  • How often you have sex and whether you have difficulties
  • If you use lubricants during sex
  • Prior sexual relationships


How Will My Doctor Test for Infertility?

Tests for infertility include laboratory tests, imaging tests and certain procedures. Imaging tests and procedures look at the reproductive organs and how they work. Laboratory tests often involve testing samples of blood or semen.


What Does the Basic Testing for a Woman Include?

Laboratory tests may include a urine test, a progesterone test, thyroid function tests, a prolactin level test, and tests of ovarian reserve. Imaging tests and procedures may include an ultrasound exam, hysterosalpingography, sonohysterography, hysteroscopy, and laparoscopy. (See below for more on these tests.) You may not have all of these tests and procedures. Some are done based on results of previous tests and procedures. You also may track your basal body temperature (BBT) at home.


Why Should I Track My Basal Body Temperature?

A woman’s temperature increases around the time of ovulation and stays elevated for the rest of her menstrual cycle. To track ovulation, you will need to take your temperature by mouth every morning before you get out of bed. You record your temperature on a chart for two or three menstrual cycles.

Charting monthly temperature changes can confirm ovulation but it cannot predict it. Some women also monitor their cervical mucus while charting BBT. Just before ovulation, a woman’s cervical mucus becomes thin, slippery, and stretchy. Cervical mucus monitoring is a natural way to help a woman identify her most fertile days.


What Do Results From a Urine Test Determine?

A urine test tells your doctor when and if you ovulate. It does this by detecting an increase in the levels of luteinizing hormone (LH) in the urine. A surge in the level of LH triggers the release of an egg. If the test result is positive, it suggests that ovulation will occur in the next 24-48 hours. This gives you an idea of the best time to have sex to try to get pregnant.


How Is a Progesterone Test Done?

For a progesterone test, a sample of blood is taken about one week before you expect your menstrual period or day 21 of your cycle. The level of progesterone is measured through labwork. An increased level shows that you have ovulated.


Why Would My Doctor Do a Thyroid Test?

Problems with the thyroid gland may cause infertility problems. If a thyroid problem is suspected, levels of hormones that control the thyroid gland are measured to see if it is working normally.


What Is a Prolactin Level Test?

This test measures the level of the hormone prolactin. A high prolactin level can disrupt ovulation.


What Are Tests of the Ovarian Reserve?

The term ovarian reserve refers to a woman’s supply of eggs. Blood tests are used to check the remaining number of eggs. Anti-mullerian hormone is a blood test that directly measures ovarian reserve.


Why Are Imaging Tests and Procedures Done?

Different imaging tests and procedures are used to look at the uterus, ovaries, and Fallopian tubes to find problems. Some procedures also are used to treat certain problems if they are found. The procedures that you may have depend on your symptoms as well as the results of other tests. Common imaging tests for female infertility include the following:

Ultrasound exam — This test can predict when ovulation will occur by viewing changes in the follicles.

Sonohysterography — This special ultrasound exam looks for scarring or other problems inside the uterus.

Hysterosalpingography — This X-ray procedure shows the inside of the uterus and whether the Fallopian tubes are blocked.

Hysteroscopy — The procedure uses a camera with a thin light source that is inserted through the cervix and into the uterus. This can show problems inside the uterus and help guide minor surgery.

Laparoscopy — This procedure uses a camera with a thin light source that is inserted through the abdomen. This can show the Fallopian tubes, ovaries, and the outside of the uterus.

What Does the Basic Testing for a Man Include?

Testing for a man often involves a semen analysis. This analysis is done to assess the amount of sperm, the shape of the sperm, and the way that the sperm move. Blood tests for men measure levels of male reproductive hormones. Too much or too little of these hormones can cause problems with making sperm or with having sex. In some cases, an ultrasound exam of the scrotum may be done to look for problems in the testes.


How Long Does it Take To Complete an Infertility Evaluation?

An infertility evaluation can be finished within a few menstrual cycles in most cases. Some insurance companies may cover the cost of an infertility evaluation. It is a good idea to call your insurance company to find out before you start your evaluation.


Treatment for Infertility

The medical community defines infertility as not having become pregnant after one year of having regular sexual intercourse without the use of birth control. If you are older than 35 years, your doctor may recommend an evaluation and possible treatment after six months of trying. If you are over 40, your doctor may recommend an evaluation and possible treatment before you reach the six-month mark.


What Causes Infertility?

The most common cause of female infertility is lack of or irregular ovulation. The way the testes function, and how much sperm they produce, most commonly causes infertility in men.

Age is a major factor in infertility. For healthy couples in their 20s or early 30s, the chance that a woman will become pregnant is about 25–30 percent in any single menstrual cycle. By age 40 years, a woman’s chance of getting pregnant decreases to less than 10 percent per menstrual cycle. A man’s fertility also declines with age, but not as predictably.

Lifestyle factors also can play a role in infertility. Being underweight, being overweight, or exercising too much may be associated with infertility in women. Drinking alcohol at moderate or heavy levels may be a factor in infertility in both women and men.


Treatment Options

Your treatment options will depend on the cause of your infertility. Lifestyle changes, medication, surgery, or other approaches may be recommended. Your doctor may combine some treatments to improve results. Often, doctors can successfully treat infertility even if they can’t find a cause.

Lifestyle changes — Staying at a healthy weight and eating a healthy diet can be helpful for both men and women with infertility. If you and your male partner smoke, use illegal drugs, or drink alcohol, you should stop.

Treating infertility with surgery — In women, surgery may be able to repair blocked or damaged Fallopian tubes. Your doctor may also use surgery also to treat endometriosis, which commonly goes along with infertility. Women with polyps or fibroids in the uterus also may have surgery.

Surgical treatment for men — A common problem that leads to male infertility is the enlargement of a vein in the scrotum. A doctor sometimes can treat it with surgery.

Treating abnormal hormone levels — Abnormal levels of hormones can cause irregular ovulation or lack of ovulation. Your health care professional may check your levels of certain hormones. If hormones cause a problem, your doctor can treat them. This treatment also may improve your chances of becoming pregnant.

Inducing Ovulation

Ovulation induction is the use of drugs to help your ovaries release an egg. Doctors use this if you don’t ovulate at all, or ovulate irregularly, and they’ve ruled out other causes. They may also use ovulation induction with other infertility treatments.

Oral drugs used to induce ovulation include clomiphene citrate, aromatase inhibitors, and insulin-lowering drugs. While taking these drugs, you will monitor your cycle to see if and when ovulation occurs. You can do this by tracking your menstrual cycle or with an ovulation-predictor kit (an at-home urine test). Your doctor may also ask you for a blood test or ultrasound exam.


Clomiphene citrate or other drugs might not successful. If that happens, your doctor may use drugs called gonadotropins to induce ovulation. You might also take gonadotropins also when you need many eggs are needed for infertility treatments.

You’ll take gonadotropins in a series of shots early in the menstrual cycle. Your doctor will use blood tests and ultrasound exams to track the development of the follicles. When test results show that the follicles have reached a certain size, you may get another drug to signal a follicle to release its matured egg.

Risks With Inducing Ovulation

Twins occur in 5–8 percent of women treated with clomiphene citrate and aromatase inhibitors. Triplets or more are rare. Your risk of multiple pregnancy rises when you use gonadotropins. Up to 30 percent of pregnancies achieved using gonadotropins are multiple. If too many eggs are developing, your health care professional may postpone the cycle to reduce the possibility of a multiple pregnancy.

Ovulation induction, especially with gonadotropins, can lead to ovarian hyperstimulation syndrome. If you’re undergoing ovulation induction, your doctor will monitor you for this condition.

Another risk of using gonadotropins is ectopic pregnancy. This is a pregnancy that begins to grow in a place other than the uterus, usually in one of the Fallopian tubes. Ectopic pregnancy requires treatment with medication or surgery.

Intrauterine Insemination

In intrauterine insemination (IUI), your doctor will place healthy sperm in the uterus as close to the time of ovulation as possible. You can use IUI with ovulation induction. The woman’s partner or a donor may provide the sperm. If your partner collected and froze sperm earlier, you can use it.

Multiple pregnancy can occur if you use ovulation drugs with IUI. If too many eggs develop at the time of insemination, the insemination may be postponed.

Assisted Reproductive Technology

Assisted reproductive technology includes all fertility treatments that involve both eggs and sperm. ART usually involves in vitro fertilization (IVF). In IVF, a technician combines the sperm with the egg in a laboratory. Later, the laboratory transfers the embryo  to the uterus. Your doctor may recommend IVF for:

  • Damaged or blocked Fallopian tubes
  • Some male infertility factors
  • Severe endometriosis
  • Premature ovarian failure
  • Unexplained infertility

In Vitro Fertilization

Infertility specialists do IVF in cycles. It may take more than one cycle to succeed. The first step in IVF is obtaining an egg. Gonadotropins usually trigger ovulation usually so the body produce more than one egg. You may also get an egg a from a donor, or use eggs that you froze previously.

When your mature, your health care provider will remove the mature eggs from the ovaries. In the laboratory, sperm can fertilize the egg in two ways. The lab can either add the sperm to the eggs, or inject sperm into each egg.

The lab checks the eggs the following day to see if they have been fertilized. A few days later, you’ll have a procedure to place one or more embryos in the uterus. Medical professionals call this step embryo transfer. The embryo also may come from a donor. You may freeze healthy embryos and store them for later use.

If you do have IVF, your risk of multiple pregnancy goes up. Your health care professional can recommend several things to help prevent multiple pregnancy. If test results suggest that too many eggs are developing, the shot that triggers ovulation may be delayed or not given. Your health care professional also may limit the number of embryos transferred to your uterus.

Some studies show a link between IVF and a slightly increased risk of birth defects. Other studies show that this increase may be related to the underlying cause of infertility or to the older age at which some infertile couples have children. For families concerned about birth defects, you may have ultrasound monitoring to look for possible problems with your pregnancy.

More Information

Infertility treatment takes time, and it can have high costs. It takes a big commitment from both partners. Some treatments are expensive and your insurance company may not cover them.

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