Infertility Workup

What Is an Infertility Workup?

When a person waits for months to conceive and pregnancy does not happen as expected, it is natural to wonder what may be causing the delay. To understand the underlying cause, an infertility workup is recommended.

It is a medical evaluation that looks for factors that may affect conception. Infertility can involve male factors, female factors, a combination of both, or no clearly identified cause.

Infertility is the inability to achieve pregnancy after at least 12 months of regular, unprotected sexual intercourse.

The evaluation does not assign blame to either partner. Instead, it helps identify the possible causes of infertility and the factors that may be preventing a couple from achieving pregnancy. Before recommending any tests, a fertility specialist usually begins with a consultation that includes discussing a detailed medical history.

After the discussion, the doctor may recommend selected tests. Remember that not everyone needs every available fertility test.

When Is an Infertility Workup Recommended?

Assessing the inability to get pregnant early can help identify factors that may affect fertility.

• For women aged 35 or younger, an infertility workup is usually recommended after 12 months of regular, unprotected intercourse without pregnancy.
• For women above 35, doctors generally recommend evaluation after 6 months.
• For women above 40, a more immediate evaluation may be advised.

An infertility workup may also be considered when there are concerns such as:

• Irregular or absent menstrual periods
• Known or suspected problems involving the uterus or fallopian tubes
• Previous pelvic conditions or procedures that may affect fertility
• Previous treatment that may affect reproductive function
• Known or suspected male-factor fertility concerns
• Sexual difficulties that may affect conception
• Repeated pregnancy loss

Note: The timing of an infertility workup is not based on the calendar alone. Fertility specialists consider the complete reproductive history, including menstrual patterns, previous pregnancies, fertility-related history, and other relevant factors.

What Happens During an Infertility Workup?

The workup doesn't start with a test or procedure. The doctor first talks to the patient to understand their concerns. They may then ask about menstrual patterns, how long the couple has been trying to conceive, any existing health conditions, and previous pregnancies, if any.

Doctors may also discuss any pelvic or reproductive procedures the patient has undergone. These evaluations help assess:

• Whether eggs are being released regularly
• Ovarian reserve to estimate the remaining egg supply
• Structural features that may affect pregnancy
• Whether the fallopian tubes appear to be open

If the male partner is involved, doctors also assess sperm health through semen analysis, which evaluates sperm characteristics. This helps identify factors, such as changes in sperm structure or quality, that may affect conception.

What are the Tests Used in an Infertility Workup?

No single fertility test can explain every case. Doctors recommend different tests for different concerns.

Female Infertility Tests

1. Medical and Reproductive History

   The first step of the infertility workup is for the doctor to review the patient’s medical and reproductive history. This usually includes the following:

   • Regularity and pattern of menstrual cycles
   • Previous pregnancies and their outcomes
   • How long the couple has been trying to conceive
   • Details of previous fertility evaluations
   • Reproductive and/or pelvic surgical history
   • Any conditions that may affect conceiving
   • Reproductive family history
   • Sexual history and any concerns that may affect the ability to conceive
   • Any issues that may affect their ability to carry a pregnancy

   This information helps the fertility doctor decide which further tests to recommend.

2. Ovulation Assessment

   Ovulation needs to occur regularly for natural conception to happen. The menstrual history may help determine whether ovulation is occurring regularly. If the cycle pattern is unclear or irregular, further evaluation, such as ultrasound monitoring and selected laboratory tests, may be recommended.

3. Ovarian Reserve Assessment

   Ovarian reserve is assessed using blood tests and ultrasound. These tests may include the Anti-Müllerian Hormone (AMH) test and antral follicle count.

4. Uterine Evaluation

   If there are concerns about the uterus's structure or cavity, doctors may recommend a uterine evaluation. Doctors may use hysteroscopy to obtain direct views of the uterine cavity. They may also consider MRI and ultrasound, depending on the condition.

5. Fallopian Tube Evaluation

   A blocked or damaged fallopian tube can interfere with the meeting of the egg and sperm. It can also affect how an embryo moves towards the uterus. This evaluation checks for tubal patency and assesses the shape of the uterine cavity.

Male Fertility Assessment

1. Semen Analysis

   Semen analysis involves checking sperm morphology, count, and motility. It may also help identify signs of infection. Additional tests may assess substances in the semen, such as zinc, nitric oxide, acid phosphatase, and alpha-glucosidase, when clinically indicated.

2. Hormonal Tests

   These tests measure testosterone and follicle-stimulating hormone (FSH) levels. Doctors may also recommend other hormonal tests, such as prolactin and serum luteinising hormone (LH), if needed.

3. Genetic Testing

   Sometimes, hereditary factors may contribute to infertility. Genetic testing may look for Y chromosome abnormalities that can cause male infertility.

4. Ultrasonography

   An ultrasound helps assess the male reproductive system for abnormalities, including varicocele and other structural issues. Depending on the type of ultrasound performed, it may also help identify certain obstructions or abnormalities affecting the testicles.

Why Do Both Partners May Need Evaluation?

Infertility can be because of both male and female factors, and comprehensive evaluation for both partners is essential.

In many cases, especially when the female partner has normal menstrual cycles, it is often assumed that she has no fertility concerns. Similarly, a normal semen analysis does not address all possible concerns related to male factor infertility.

A thorough evaluation for infertility brings these factors into consideration, and based on that, a plan for treatment or use of assisted reproductive technologies is decided.

How Long Does an Infertility Workup Take?

There is no uniform procedure for assessment of infertility. Some tests can be done during the initial visit. However, other tests might require specific timing during the menstrual cycle.

For example, an HSG is often done during a specific phase of the menstrual cycle.

Therefore, the results of these tests might not be immediately available. The specialist can often explain which tests will be done first and when. This gives the person a sense of control over the process and helps allay anxiety.

What Happens After the Evaluation?

After all the tests are done, the fertility specialist integrates the results and studies it. The next step may depend on:

• The person's age
• Duration of infertility
• Ovulation pattern
• Ovarian reserve findings
• Uterine and tubal findings
• Semen analysis results
• Previous pregnancies
• Previous fertility treatment
• Other relevant reproductive factors

Sometimes, a probable cause is identified. In other cases, all routine investigations may appear normal. In such cases, unexplained infertility may be diagnosed.

A diagnosis may not always indicate the next immediate step. The plan is individualised and based on the entire clinical situation of the patient.

Conclusion

A structured approach to assessing infertility is called the infertility work-up. This encompasses evaluation of ovulation, ovarian reserve, the uterus, fallopian tubes, and the health of the male partner’s sperm. Depending on the couple, the same tests may not be needed, or may not be needed at all.

However, it is most important to understand that an infertility evaluation is not to pinpoint the cause of infertility to inflict blame. Instead, the goal is to provide relevant information and help patients make an informed decision about their next step.

Every fertility journey is unique. There is no better example than a couple experiencing unexplained infertility. While the exact cause of the couple’s infertility is uncertain, the evaluation can help point the couple in the right direction for care.