Evaluation of Female Infertility
Author: Dr. Anna Kaplan
An infertility evaluation can be started by whichever doctor you see for pap smears and other female issues. Ultimately, you will probably need a gynecologist or even a specialist in reproductive medicine to thoroughly investigate the possible reasons you are having trouble getting pregnant.
The first thing a doctor will do is take a thorough history. If you are being evaluated for infertility, you may want to talk to your doctor without your partner present. There may be things you do not want to talk about in front of him. The doctor will want to make sure that you are having regular intercourse, especially in the middle of your cycle, and that you are not using anything like lubricant that might make it harder to get pregnant.
He or she will ask about your menstrual history. The doctor will also want to know if you have ever been pregnant. If so, did you have the same partner you do now? Did you have a baby, or was your pregnancy terminated spontaneously or by choice? While these may be difficult questions, it is essential that you answer the doctor honestly.
The first thing to establish is whether or not you are ovulating. If you have regular menstrual cycles between 22 days and 35 days, you probably ovulate. If you have pain in the middle of your cycle, you may be having ovulatory pain, called mittelschmerz. Also, if you have premenstrual symptoms, you probably ovulate, since progesterone contributes significantly to those symptoms.
You may already have checked to see if you ovulate. One way of doing this is by measuring basal body temperature, your temperature first thing in the morning. Your temperature may increase from the range of 97 to 98 degrees F to greater than 98 degrees, with the peak being two days after the LH surge that causes ovulation. This temperature increase provides evidence of ovulation.
Most people now use an over-the-counter fertility test instead. These tests measure the spike of LH in your urine. This high level occurs 14 to 48 hours before you ovulate. A measurable LH spike found by one of the tests proves that you are having an ovulatory cycle. This is also useful when you are trying to get pregnant because the test is positive before you ovulate, telling you that it is the best time to try and conceive. The LH level may be the best test to confirm ovulation.
If you have not done either of these things, the doctor may suggest the LH tests and/or a blood test to check the levels of progesterone in the second half of your cycle, between when ovulation is expected and the start of your next period. An appropriately-high progesterone level means that the follicle in your ovary is now producing progesterone in preparation for a pregnancy.
Documentation of ovulation is a key part of an infertility evaluation, and is the one thing you may already know when you get to the doctor. You may know that you ovulate, or you may not have been able to detect ovulation.
If you arrive at the doctor’s office with information indicating that you are not ovulating, the doctor will try and discover why. If you have been ovulating, there will be a different focus. Either way, the doctor will go over your medical history as well as do a number of tests.
Other aspects of your health that need to be considered include:
- Medical history - do you have a known genetic disorder, trouble with your hormones, or have you had infections of your reproductive tract (pelvic inflammatory disease)?
- Medications – for example, are you taking any hormones?
- Potential sexually transmitted diseases – have you been exposed to any STDs or had symptoms of genital inflammation, such as vaginal discharge, pain with urination, abdominal pain, or fever together?
- Substance use – do you use or abuse any medications or drugs, including caffeine and cigarettes?
- Surgical history – have you had surgery involving your bladder, uterus, Fallopian tubes, ovaries, cervix, or anything else in the area?
- Toxin exposure – have you been exposed to chemical or radiologic toxins?
The doctor will do a physical examination to make sure that all your reproductive organs appear to be normal and that your hormonal status seems normal.
If necessary, the doctor will order tests to check for ovulation as previously mentioned. Other laboratory tests depend on what all of the above reveals. If there is a problem with ovulation, there are a number of hormonal tests that will be checked. There may be specific tests done on day 3 of your cycle to see if follicles seem to be developing. Some women may need ovulation to be stimulated with medication to see if their ovaries can develop follicles. Sometimes an ultrasound via the vagina can actually show developing follicles.
If there does not seem to be another problem, or if your history suggests you might have scarring, the final test may be an evaluation of your reproductive tract to make sure there is no scarring and that there is a clear pathway for eggs and sperm. This is usually done by hysterosalpingogram, an x-ray test using dye. This can be followed if necessary by direct observation via laparoscopy, looking into the abdomen, or hysteroscopy, looking into the uterus.
After all of these tests have been done, the doctor will be able to tell you if he or she has found a cause for your infertility, and if so, what can be done to treat it.