Infertility Evaluation: Who, When and How

Handed Physician Notes 2021

Practice-Based Learning and Competency based Approach

Dr Hani S M Salama MBChB MD Hon PhD FABOG FRCOG M SRM PgDipOWM

Senior consultant of Obstetrics and Gynecology
and Reproductive Endocrinology
Infertility Evaluation: By Dr. Hani Salama MRCOG REACH Tutor

Speaking Intelligently

When I see patients for an initial infertility evaluation, I make certain that I
consider all possible causes because multiple infertility factors may be present.
I perform a thorough screening evaluation for all possible known causes of
infertility, including male factor, tubal/ pelvic, ovulatory, cervical, and other,
unexplained causes of infertility. Keep in mind that, in fact, many cases of
infertility are “unexplained” in that there is no obvious diagnosis for the
patient’s inability to conceive once the evaluation is completed. Because the
infertility evaluation is sometimes grueling, my staff and I must include
patients in treatment plan decisions and provide emotional support, and
sometimes financial counseling as well.

PATIENT CARE

Clinical Thinking
• Consider how you can focus the evaluation to arrive at an efficient and timely
diagnosis. Be guided by clues in the history and physical examination,
particularly patient age, menstrual history, and sexually transmitted infection
(STI) history.
• A great majority of patients will have one of the following factors: ovulatory,
male factor (in the cases where the patient has a male partner), or tubal factor.
Other important but less common causes of infertility include a uterine factor
and a cervical factor. Unexplained infertility occurs in up to 5% of patients.
Multifactor infertility is also common. It is critical to make sure that the patient is
evaluated for all these possibilities.
• It is common to see women older than 35 years of age for an infertility
evaluation. They should be given a diagnosis of infertility after 6 months of
attempting conception without pregnancy. Women younger than 35 years are
given the diagnosis after 1 year.
• If there is a male partner it is important to obtain a good history and perform a
semen analysis to screen for male factor. Up to 40% of male partners are found
to have male factor infertility on initial
Infertility Evaluation: By Dr. Hani Salama MRCOG REACH Tutor

SUMMARY

Women who fail to achieve a successful pregnancy after 12 months of

regular, unprotected intercourse should be evaluated with the diagnosis of
infertility. Evaluation should be initiated after 6 months for women >35 years.
If over 40 years of age, or a condition known to cause infertility is present,
evaluation should not be delayed.

Evaluation of women for infertility should be timely, cost effective, and

initially focused on the most common causes of infertility such as ovulatory
dysfunction. If ovulatory function is normal, uterine anatomy and tubal
patency should be investigated. Tests for ovarian reserve can not predict
failure to conceive and therefore should not be used to deny fertility
treatment. Ovarian reserve testing should not be used to predict the
likelihood of spontaneous conception or menopause.

►Indications for Immediate Evaluation Include

• History of oligo / amenorrhea | Known/ suspected uterine, tubal,

peritoneal disease | Endometriosis (stage III/IV) | Known/ suspected
male factor subfertility
►Definition of Unexplained Infertility (30% of infertile couples)

• Above definition of infertility is met

• Infertility evaluation is normal
• Minimum evaluation: Confirm ovulatory function | Tubal patency |
Semen analysis
 Infertility Evaluation: By Dr. Hani Salama MRCOG REACH Tutor

KEY POINTS:

Relevant History
• Infertility related
o Menstrual history
o Pregnancy history
o Previous contraception
o Frequency of intercourse
o Previous evaluations and treatments
o Family history of reproductive problems and birth defects
• Surgical history
• History of endocrine abnormalities such as
o Hypothyroidism
o Hyperprolactinemia
• Abnormal cervical cancer screening and treatments
• Medications and allergies including
o Occupational exposures
o Tobacco, alcohol, drugs

Physical Exam
• Vital signs including BMI
• Thyroid exam
• Breast exam
• Evaluation of androgen excess
o Acne o Male pattern balding
o Hirsutism o Clitoromegaly
o Pelvic examination: including evaluation of cul de sac masses / nodularity
Infertility Evaluation: By Dr. Hani Salama MRCOG REACH Tutor

Ovarian Assessment
Ovulatory Function

• Ovulatory dysfunction accounts for 40% of infertility in women

• Menstrual history of abnormal bleeding / oligo or amenorrhea
o Cycles range from 25 to 35 days,
o If regular cycles and menstrual molimina is present, ovulatory
function is likely to be normal
o History of oligo- or amenorrhea is enough to establish an
ovulation and requires further evaluation
• Serum progesterone approx. 1 week prior to menses
o >3 ng/mL (15.9 nmol per L) indicates ovulation
o Does not assess quality of luteal phase
• Urinary LH (ovulation predictor kits)
• Cervical mucous changes (clear, stretchy)
• TSH (thyroid function)
• Prolactin (hyperprolactinemia): indicated only if galactorrhea,
oligomenorrhea, or amenorrhea
Ovarian Reserve

• Goal is to identify women who may be poor responders to

gonadotropin stimulation during treatment; does not imply inability to
conceive or sub fertility
• Ovarian reserve testing may be of help in the following scenarios
(higher risk for diminished ovarian reserve)
o > 35 years
o Unexplained infertility
o Planning ART
o Poor response to GnRH stimulation
o Have family history of early menopause
Infertility Evaluation: By Dr. Hani Salama MRCOG REACH Tutor

o At higher risk of diminished ovarian reserve (e.g., chemotherapy

and/or pelvic irradiation; ovarian surgery for endometriomas)
• Measured by the following
o Basal FSH and estradiol (E2) levels on days 2-5
▪ FSH > 10 IU/L: Lesser response to ovarian stimulation
o Serum anti-Mullerian hormone (AMH) levels (independent of day):
<1 ng/mL
o Antral follicle count on cycle day 2-5 (early follicular phase)
▪ Low count: Fewer than 5 to 7 follicles
• The best surrogate marker for oocyte quality is age
• Note: Unexplained diminished ovarian reserve or elevated FSH <40
years: Offer Fragile X carrier screening for FMR1 premutation
(associated with premature ovarian failure)

Uterine Assessment
• Common causes include polyps, submucosal fibroids, adhesions
• Transvaginal ultrasound is best initial imaging
• Hysteroscopy: Definitive diagnosis under direct visualization, although
more invasive
• Sonohysterography: Can detect abnormal intrauterine pathology
(polyps, submucosal myomas, synechiae)
• HSG: Best for detecting developmental anomalies; also, can show
polyps and myomas, although less sensitive
• 3D ultrasound & pelvic MRI: Confirmation and diagnosis of Müllerian
anomalies

Fallopian Tube Assessment:

• Tubal disease is a major contributor to infertility and should be
excluded;
Infertility Evaluation: By Dr. Hani Salama MRCOG REACH Tutor

HSG (hysterosalpingography): evaluates tubal patency and

architecture | presence of salpingitis isthmica nodosa | shows
presence of fimbrial phimosis or adhesions

o SHG (sonohysterography): also shows tubal patency, but does not

differentiate between unilateral/bilateral; operator dependent
o Chromopertubation: performed during laparoscopy with dilute
methylene blue or indigo carmine
▪ Laparoscopy not recommended for tubal evaluation,
although if already being performed, it is reasonable to
include chromopertubation

Cervical Assessment
• Cervical factors are rarely the primary cause of infertility
o Treat cervicitis if noted
o Post coital tests are no longer recommended

Peritoneal Assessment
• Causes include endometriosis and pelvic adhesions
• Requires laparoscopy for diagnosis — not recommended for routine
evaluation of infertile women unless there is suspected pathology or
another indication

Male Assessment
• ACOG/ ASRM recommends evaluating both partners at the same time
due to high percentage of infertility caused by male factor (40 to 50%)
• Minimal evaluation: Reproductive history and semen analysis
Infertility Evaluation: By Dr. Hani Salama MRCOG REACH Tutor

►Continuous professional Development

Interpersonal and Communication Skills

Listening for Cues to Depression

Half of all women destined to suffer with depression will be diagnosed during the
reproductive years. The emotional stress, self-doubt, and frustration experienced by
many women during an infertility work-up can be contributing and sometimes
triggering factors for a depressive episode. When working with patients going
through this type of work-up, clinicians should be very attentive to the symptoms and
presentations of depression, such as loss of interest in previously enjoyable activities,
persistent physical symptoms such as chronic pain or headaches, exaggerated
depressive response to miscarriages, stillbirth, or infertility, and dyspareunia or
sexual dysfunction. Your patient may not volunteer the information that she is
depressed. She may not recognize her symptoms as depression. Through effective
listening and observing vocal characteristics (e.g., tone, pace, and volume) and body
language, you may be able to recognize a depressive episode. If you suspect
depression, it is likely you will need to use heightened sensitivity not only in phrasing
questions but in “really” hearing what the patient is conveying through words and
actions.

Professionalism

Principle: Commitment to a Just Distribution of Finite Resources

With the field of reproductive endocrinology and infertility rapidly expanding, we are
now able to help many couples with infertility problems to have their own biologic
children. Although the work-up of an infertile patient starts with simple, cost-effective
measures (e.g., effective history taking and behavioral modification), expensive
laboratory and radiographic tests become important very quickly. In our current
model for medical payment, those without medical insurance are often unable to
avail themselves of the more expensive measures used to overcome infertility, and
third-party carriers are often responsible for deciding how to best allocate limited
resources.
It is our responsibility not only to think about judicious use of resources on an
individual level, but to advocate for what we believe to be judicious use of resources
at the level of hospitals, insurance companies, and even entire health care systems.
Infertility Evaluation: By Dr. Hani Salama MRCOG REACH Tutor

References
1-Fertility evaluation of infertile women: a committee opinion (2021) Practice
Committee of the American Society for Reproductive Medicine
DOI:https://doi.org/10.1016/j.fertnstert.2021.08.038

Available at: https://www.asrm.org/globalassets/asrm/asrm-content/news-and-

publications/practice-guidelines/for-non-
members/diagnostic_evaluation_of_the_infertile_female.pdf

2-ACOG and ASRM Committee Opinion 781: Infertility Workup for the Women’s Health
Specialist. Available at : https://www.acog.org/-
/media/project/acog/acogorg/clinical/files/committee-
opinion/articles/2019/06/infertility-workup-for-the-womens-health-specialist.pdf

3-ACOG Committee Opinion 773: The Use of Antimüllerian Hormone in Women Not
Seeking Fertility Care. Available at: https://www.acog.org/-
/media/project/acog/acogorg/clinical/files/committee-opinion/articles/2019/04/the-use-
of-antimullerian-hormone-in-women-not-seeking-fertility-care.pdf

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