The purpose of an infertility evaluation is to determine where the problem in achieving successful pregnancy originates. Fifty percent may be due to male causes and 50 percent may be due to female causes. At the Johns Hopkins Fertility Center both partners will be evaluated, so that the best determination for treatment can be made.
Evaluation of the male factor involves a semen analysis, post coital test, hormonal determinations of testosterone, FSH (when indicated) and urological evaluation.
- Semen analysis — a normal semen analysis includes a volume between two-to-five milliliters, a sperm count greater than 20 million per mL and good motility (over 50 percent). The semen will also have very few white cells.
- Post Coital test — this consists of checking the presence of motile sperm in the cervical mucus of the female partner, six to twelve hours after intercourse around the time of ovulation.
- Hormonal determinations — If the semen analysis shows less than optimal results, blood tests are performed.
- Urological evaluation — this evaluation consists of examination of the male external genitalia to look for varicocele (varicose veins of the scrotum). Varicocele describes a delay of the passage of the blood in testicular veins, which can cause increased temperature within the testes. This increased temperature affects the quality of the sperm and its motility. During the urological evaluation, our doctors will note undescended testes as well as a decrease of size, indicating a previous pathology.
Female evaluation consists of four factors -- the cervix, the endometrium, the fallopian tubes and the peritoneum (surroundings of the ovaries within the abdomen), as well as ovulation patterns.
- Cervix — The cervix is the opening between the vagina and the endometrial cavity. Clear mucus begins to build up around and on the cervix in preparation for ovulation. This clear mucus, often described as similar to egg-whites, makes it easier for the sperm to pass into the endometrial cavity to fertilize the egg. If the mucus does not change around the time of ovulation, it becomes more difficult for the sperm to reach the egg. To check the mucus, your physician may conduct a post coital test, which consists of checking for the presence of motile sperm in the cervical mucus of the female partner six to twelve hours after intercourse. This test is only meaningful if it is done around the time of ovulation.
- Tubal factor — The fallopian tubes are two structures on either side of the uterus that carry the egg, ready for fertilization, from the ovaries into the uterus. Your doctor will want to evaluate the health of your fallopian tubes using a hysterosalpingogram (x-ray of the uterus and tubes). This procedure is done in the week after your period.
This test can be performed in two ways. A small cannula is applied to the tip of the cervix, or a tiny catheter is passed into the uterus for the injection of dye into the endometrial cavity and the fallopian tubes. X-ray machines and fluoroscopy are used to monitor the passage of dye.
A normal result will look like a white triangle shape and two fine white lines at the upper part of the triangle. This shows the normal configuration of the endometrial cavity and the inside of the fallopian tubes. Any obstruction of the tubes is indicative of pathology associated with infertility. A filling defect may indicate fibroids, scar tissue or endometrial polyps.
- Endometrial biopsy — The endometrium is the lining inside the uterus. A biopsy consists of taking a sample of the lining of the uterus two days prior to the menstrual flow. A urinary pregnancy test is given prior to the procedure. If the test is negative, a tiny catheter is passed into the endometrial cavity and suction is used to obtain a small strip of the lining of the uterus.
This sample is sent to the pathologist for endometrial dating. The result is correlated with the beginning of the next menstrual period that occurs within the next few days. The biopsy indicates if there is any progesterone deficiency that may be associated with a history of recurrent pregnancy losses or infertility. It will also indicate the quality of the ovulation and the hormone production surrounding the whole menstrual cycle.
- Fallopian Tubes and Peritoneal Factor — To ascertain the health of the fallopian tubes and the peritoneal factor, your doctor may recommend a diagnostic laparoscopy under general anesthesia. The ideal time for this test is after a period, but before ovulation takes place. Once you receive general anesthesia, three liters of carbon dioxide are injected into the abdominal cavity in order to elevate the abdominal wall away from the bowel.
A trocar is inserted through the navel. Using a laparoscope (small telescope), your doctor can examine the bowel, liver, stomach, appendix as well as the uterus, fallopian tubes and ovaries. A second trocar is passed through a small incision at the pubic hair line. Using that incision, several instruments will be used to mobilize the pelvic organs. Your doctor will examine the pelvic organs and identify potential problems like fibroids, endometriosis, scar tissue or obstructions.
At the same time, a small catheter is placed within the endometrial cavity through the vagina to inject some dye. Watching the passage of the dye, your doctors will be able to see if the tubes are open. If a problem is identified, your doctors may choose to correct it at that time, eliminating the need for another surgery.
- Ovarian Factor — Your ovaries are two organs that sit near your uterus. These organs house your eggs and also control certain hormonal functions associated with fertility. In functioning ovaries, every month, a hormone called FSH is released, preparing a follicle. Inside that follicle is an egg that is ready to be fertilized. LH is another hormone that signals the ovary to release the egg from the follicle. Studying the history of a woman’s menstrual periods – regularity, frequency and duration, give your doctors a better sense of your ovarian functions.
In order to determine if ovulation is taking place, your basal body temperature and blood will be checked for the hormones FSH and LH, as well as progesterone in the second part of the cycle. This part of the evaluation might require frequent pelvic ultrasounds to determine the size of the follicle before ovulation takes place. It may also be performed in conjunction with the endometrial biopsy (above).