Work-up of a Case of Infertility

Snehal Dhobale Kohale

Work-up of a Case of InfertilityCHAPTER 1

Snehal Dhobale Kohale

INTRODUCTION

According to the American Society of Reproductive Medicine, if there is a failure to achieve pregnancy within 12 months of unprotected sexual intercourse or therapeutic donor insemination in women ˂35 years or within 6 months if women ˃35 years is considered as “infertility”.^1,2 Incidence of infertility is approximately up to 15% of couples (one in six couples).³

WHEN TO SEEK HELP OF FERTILITY EXPERT?

Couples as per above definition
Couples having a high risk of infertility.

INDICATIONS OF IMMEDIATE EVALUATION FOR INFERTILITY⁴

Age of women ˃40 years
Age of women ˃35 years and failed attempts of 6 months
If any of the following conditions:
- Oligomenorrhea or amenorrhea
- Known or suspected uterine/tubal/peritoneal disease
- Stage III or stage IV endometriosis
- Known or suspected male infertility
- Previous history of surgery of reproductive organs.

CAUSES OF INFERTILITY

Infertility can be due to male factors, female factors, or a combination of both (Table 1).^5–8

TABLE 1 Factors causing infertility and its incidence.

Factors of infertility	Incidence
Male factor	25–30%
Ovulatory dysfunction	21–25%
Tubal factor	15–20%
Other (cervical, peritoneal, and uterine abnormalities)	10–13%
Combined	40%
Unexplained	25–28%

It is very important to offer detailed information and counseling to couples facing problems to conceive, as a part of the evaluation. Because the anxiety related to infertility tends to cause more stress, decreased libido and thus complicating the issue, thorough counseling plays a vital part in managing cases of infertility.⁸

Work-up of infertility should be carried out for both the partners at the same time and it should involve ruling out all the etiologies one by one (Table 2)2.

TABLE 2 Work-up of infertility.

Female evaluation	Male evaluation
History	History
Physical examination	Semen analysis
Prepregnancy evaluation—to optimize a woman's health and control any comorbidities, if any	Others (only if required): Hormonal evaluation Imaging Sperm DNA fragmentation index Genetic tests
Evaluation of cause of infertility Ovulatory factor: Hormonal tests (AMH; baseline FSH, LH, and estradiol levels) Transvaginal ultrasonography (for antral follicle count and to rule out any abnormality of reproductive organs) TSH and prolactin Tubal factor: Hysterosalpingography Hysterosalpingo-contrast-sonography Saline sonography Laparoscopy and hysteroscopy Uterine factor: Transvaginal sonography Sonohysterography Hysterosalpingography Hysteroscopy	Testicular biopsy
(AMH: anti-Müllerian hormone; DNA: deoxyribonucleic acid; FSH: follicle-stimulating hormone; LH: luteinizing hormone; TSH: thyroid-stimulating hormone)

FEMALE EVALUATION

History

Clinical history involves following points which generally direct further investigations:³

Age of the female partner
Coinhabiting the partner or not/trying since when?
Duration of infertility
Prior evaluation and its results
History of prior treatment of infertility
Menstrual history: Cycle length, regularity, duration and amount of the flow, pain associated with cycle, and premenstrual symptoms
Obstetric history: Prior pregnancies and outcomes, time taken to conceive, fertility treatment for conception, complications, and mode of delivery
History of contraception
Sexual history: Timing and frequency of intercourse, any sexual dysfunction
Gynecological history: History of polycystic ovarian syndrome, pelvic inflammatory disease, sexually transmitted disease, endometriosis, and fibroids
Medical history: History of any illness, hospitalization, long-term medications, and allergies
Surgical history: Previous history of surgeries, especially abdominal and pelvic procedures, indication, surgical details, and outcomes
History of thyroid disease, galactorrhea, hirsutism, dyspareunia, and pelvic or abdominal pain
Family history: History of medical problems, birth defects, developmental delay, early menopause, any fertility-related issues
Occupational history, any known environmental hazard
Substance abuse: Tobacco or nicotine-related products, alcohol, and recreational drugs.

Physical Examination

It includes general examination, pelvic examination, and thyroid and breast examination.

General examination: Vitals (pulse and blood pressure) and body mass index (BMI) (height and weight)
Thyroid examination: Nodule, enlargement, or tenderness
Breast examination: Any secretions, its character, and nodularity
Signs of androgen excess
Tanner staging of breast, axillary, and pubic hairs (in cases of amenorrhea)
Pelvic examinations: Vaginal and cervical secretions or abnormality; uterine size, shape, position, mobility, pelvic, or adnexal mass, tenderness, pouch of Douglas—tenderness and nodularity.

Fig. 1: Evaluation related to etiology of infertility. (FSH: follicle-stimulating hormone; LH: luteinizing hormone; TSH: thyroid-stimulating hormone)

Evaluation Related to Etiology of Infertility (Fig. 1)

These tests focus on structured problems, ovulatory dysfunction, and ovarian reserve. These include laboratory and imaging tests. Even though cervical factor plays minor role, test for evaluation of cervical mucus is not reliable and is not helpful for management of infertility in clinical practice.⁶

Tests of Ovarian Reserve

Ovarian reserve represents number of oocytes available for potential fertilization at a point of time. It predicts response to ovarian stimulation.⁹ The tests of ovarian reserve are interpreted in the background of patient's age.

Hormonal Tests for Ovarian Reserve

Day 2 to day 5 serum estradiol and serum follicle-stimulating hormone (FSH):
- FSH value ˃10 IU/L is associated with low response to ovarian stimulation.¹⁰
- Basal estradiol level should be ˂60–80 pg/mL.
- High estradiol level suppresses FSH level. So high estradiol and normal FSH is associated with diminished ovarian reserve.³
Serum anti-Müllerian hormone (AMH): AMH is produced by granulosa cells of preantral and antral follicles thus it specifically correlates with egg reserve. It does not fluctuate in the menstrual cycle so can be assessed on any day of the cycle.^11,12 AMH and antral follicle count (AFC) has the similar abilities to predict ovarian stimulation response and live birth.⁹
Ultrasound assessment AFC:
- AFC is the number of follicles measuring between 2 and 10 mm diameter in the ovaries on a transvaginal sonography done during baseline scan.
- AFC below 5–7 is considered as low and is associated with poor response to stimulation.¹³3
  
  Fig. 2: Categories of ovulatory dysfunction as per the World Health organization (WHO). (FSH: follicle-stimulating hormone; TSH: thyroid-stimulating hormone)
- But AFC is relatively poor indication for prediction of future fertility.¹⁰
- AFC is elevated in polycystic ovary syndrome (PCOS) and decreased in women with hypothalamic amenorrhea and those taking hormonal contraceptive pills¹⁴

Ovarian reserve tests are good predictors of response to ovarian stimulation but poor results do not necessarily predict inability to achieve a live birth.^3,15,16

Tests for Ovulatory Dysfunction

Generally menstrual history is enough to predict ovulatory function. Majority of ovulatory cycles will have regular menstrual periods between 25 and 35 days along with premenstrual symptoms. Even with the regular cycle, up to one-third of women may be anovulatory. So, ovulation needs to be confirmed with various tests.¹⁷

Ovulation can be objectively detected by:

Cervical mucus changes
Biphasic basal body temperature
Positive luteinizing hormone kit
Midluteal progesterone measurement.

In women of regular menstrual cycles, serum progesterone is tested at day 21 for confirmation of ovulation.⁸ In women with irregular cycles, testing is done 7 days prior to presumed date of onset of periods and repeated weekly till periods resume. Ovulation is confirmed with progesterone level of 5 ng/mL or more.^6,18

In cases of anovulation; obesity, hypothalamic-pituitary dysfunction, PCOS, and other causes have to be ruled out.

The World Health Organization (WHO) categorizes ovulatory dysfunction into three groups (Fig. 2).⁸

PCOS is most common cause of ovulatory infertility.^19,20
Thyroid disease and hyperprolactinemia can cause ovulatory dysfunction ranging from luteal phase insufficiency, oligomenorrhea to anovulation, and amenorrhea.

Fig. 3: Tests of tubal factor. (HSG: hysterosalpingography; HyCoSy: hysterosalpingo-contrast-sonography)
In women with ovarian insufficiency or failure on elevated FSH level before 40 years, fragile X carrier screening is recommended to rule out FMR 1 gene premutation.²¹

Tests of Tubal Factor (Fig. 3)

Hysterosalpingography (HSG): It is most commonly used procedure for determining tubal patency. Radio-opaque contrast medium is injected through the cervix. Uterus and tubes are evaluated through fluoroscopy. It can detect proximal and distal tubal occlusions, peritubal adhesions, and salpingitis isthmica nodosa.

Following are predictive values of HSG for demonstrating tubal patency:²²
- Positive predictive value 38%
- Negative predictive value 94%
As it has low positive predictive value, HSG showing nonpatency of tube may require further tests like laparoscopy to confirm tubal occlusion.²³
4Saline sonography: Saline is infused through transcervical catheter. Uterus and adnexa is visualized ultrasonographically. Use of Doppler adds accuracy to it.
Hysterosalpingo-Contrast-Sonography (HyCoSy): In this test, contrast agent with air bubbles is used for visualization of tubes sonographically. The agents used are perflutren lipid microsphere as well as agitated saline. Accuracy of this test is more dependent on operator experience. Its sensitivity for determining tubal patency ranges from 76 to 96% and specificity ranges from 67 to 100%.^24,25
Laparoscopy and hysteroscopy: Women with risk factors for tubal obstruction like endometriosis, previous pelvic infection, or ectopic pregnancy might require laparoscopy to rule out other pelvic pathology. It allows diagnosis and treatment at the same time for structural abnormalities of uterus like fibroids.

Tests for Uterine Factor (Fig. 4)

Uterine factors contributing to infertility are endometrial polyp, intrauterine adhesions, submucous fibroids, and Müllerian anomalies.

Transvaginal ultrasonography: It helps in detection of fibroids distorting endometrial cavity. Use of three-dimensional ultrasonography improves detection of Müllerian anomalies and is comparable to pelvic magnetic resonance imaging (MRI) for accurate diagnosis of this condition.²⁶
Sonohysterography: It can be used to diagnose endometrial polyps, submucous fibroids, and intrauterine adhesions. It has 91% sensitivity and 84% specificity for diagnosing polyp or fibroid.
HSG: It has limited ability to diagnose uterine cavity masses or adhesions as these structures are not radio-opaque. It has only 50% sensitivity for diagnosing polypoid lesions.²⁷

Fig. 4: Tests for uterine factor. (HSG: hysterosalpingography; SIS: saline infusion sonography TVS: transvaginal scan)
Hysteroscopy: It is the most definitive method of diagnosis as well as treatment of endometrial polyps, intrauterine adhesions, and submucous fibroids. Though it is not used as first-line test, it is indicated to confirm and treat intracavity lesions detected by other imaging techniques.

Other Tests

Postcoital cervical mucus test is no longer recommended as it cannot predict the inability to conceive as well as it does not affect clinical treatment of patient.²⁸
Endometrial biopsy is nowadays not used as histological endometrial dating as neither it is reliable nor it is predictive of infertility. It should be performed only in women with suspected pathology like chronic endometritis or neoplasia and to rule out genital tuberculosis.^6,22

EVALUATION OF MALE

About 40–50% of infertile couples may have male factor infertility.²⁹ Minimum evaluation of male includes reproductive history and semen analysis.³⁰ Any abnormalities in basic evaluation requires examination by specialist—reproductive urologist or andrologist.³⁰

History

Following key points are noted in history:³⁰

Duration of infertility
Prior fertility
Coital frequency and timing
Any evidence of sexual dysfunction including erectile or ejaculatory problems
Developmental history
Childhood illness
History of previous surgery (e.g., cryptorchidism with or without surgery)
Medication use e.g., anabolic steroids and supplements like testosterone
History of sexually transmitted diseases
History of allergies
History of exposure to gonadal trauma or toxins
Smoking, alcohol, or substance abuse.

Physical Examination

General examination:
- Built, height, weight, and BMI
- Hair distribution
- Rule out any gynecomastia
Local examination:
- Bilateral testis—size and consistency
- Epididymis (any fullness/nodularity/tenderness)
- Presence of bilateral vas deferens
- Any evidence of genital infections.5

TABLE 3 The WHO 2010 semen analysis reference guidelines.³¹

Semen characteristic	Lower reference limit
Volume, mL	1.5
Sperm concentration, 10⁶/mL	39
Total sperm number, 10⁶	15
Total motility (PR + NP), %	40
Progressive motility (PR), %	32
Vitality (live spermatozoa), %	58
Sperm morphology (normal forms), %	4
pH	≥7.2
Seminal fructose, μmol/ejaculate	≥13
(PR: progressive motility; NP: non-progressive motility) (Source: WHO laboratory manual)

Semen Analysis

It is the quantitative microscopic evaluation of sperm parameters. Semen sample is obtained by masturbation in laboratory collection room with 2–5 days of abstinence. As sperm generation time is just over 2 months, it is recommended to wait for 3 months before repeat sampling.⁸

The WHO 2010 guidelines are currently followed for determining normality of semen parameters (Table 3).³¹

Abnormalities in Semen Analysis

Oligospermia: Sperm count ˂15 million per mL
Asthenozoospermia: Total sperm motility ˂40% or rapid progressive motility ˂32%
Teratozoospermia: Normal morphology ˂4% (as per strict Krugerberg criteria)
If an individual has all three low sperm conditions, it is known as oligoasthenoteratozoospermia (OAT) syndrome, which is typically associated with an increased likelihood of genetic etiology of the infertility.
Azoospermia: Absence of sperms in semen

In cases of abnormal semen parameters further evaluation is needed. Hypogonadism is suspected when there is oligospermia or azoospermia.

Primary hypogonadism: Decreased level of total testosterone (morning level) and increased level of FSH
Secondary hypogonadism: Decreased level of total testosterone and decreased level of FSH (normal ranges: total testosterone—240–950 ng/dL; FSH—1.5–12.4 mIU/mL).

Sperm Deoxyribonucleic Acid Fragmentation Index

The integrity of deoxyribonucleic acid (DNA) present in the sperm is very crucial for the process of fertilization and normal embryo development. It has been observed that the sperm DNA fragmentation (SDF) is higher in infertile men compared to fertile men. When the DNA which carries the genetic material with all the instructions to the baby is fragmented, it can lead to poor fertilization, poor embryo development, and miscarriage. Also, if the fertilization happens with the DNA fragmented sperm, there is a high risk of genetic disease in the baby.

Fragmented DNA is usually can be caused by various reasons such as:

Infection
Smoking and alcohol
Use of recreational drugs and medications
Stress
Increased BMI and poor diet
Exposure to toxins and radiation
Advanced age
Varicocele (enlarged veins inside the scrotum)
Increased testicular temperature.

Semen analysis is the standard test to assess the sperm quality. But it is not a fool proof test as it neither provides information regarding all the sperm functions nor the fertility potential of sperm. In addition to semen analysis, SDF test can be done to measure the sperm integrity and the damage to the DNA.

Sperm DNA Fragmentation Index (%)

15% or less fragmentation—excellent sperm DNA integrity
15–25% DNA fragmentation index (DFI)—good to fair
25–50% DFI—fair to poor
50% or greater DFI—extremely poor sperm DNA integrity.

Other Tests

Semen culture: Assessment of semen sample for bacterial infections:
- It is indicated in patients with clinical signs of genitourinary infections or leukocytes ˃1 million/mL in semen analysis.
Hormonal evaluation: Assessment of FSH, LH, and testosterone levels
- It is indicated in patients showing abnormal semen parameters like severe OAT or azoospermia.
Genetic testing—karyotyping, Y chromosome microdeletion, single gene defect testing, and cystic fibrosis transmembrane regulator (CFTR) mutation:
- Genetic testing is done when examination is showing Klinefelter phenotype (small testes, tall stature, gynecomastia, and learning disabilities)
- Y chromosome microdeletion is done in cases of azoospermia or severe oligoasthenospermia.
- CFTR gene mutation is tested when clinical examination shows the absence of vas deferens.6
Testicular biopsy:
- It is done in cases of azoospermia (to know the cause of nonobstructive azoospermia by histology of testicular tissue).

Postcoital testing and antisperm antibody testing are not considered useful in male evaluation.^28,32

Unexplained infertility may be diagnosed in as many as 30% of infertile couples. At a minimum, these patients should have evidence of ovulation, tubal patency, and a normal semen analysis.

Principles of Evaluation

It should be systematic, expeditious, and cost-effective manner.
It should identify all relevant factors.
The initial emphasis should be on least invasive methods for detection of most common causes.
The investigations which are chosen should be tailored to the needs of the individual patient.

Key Learning Points

Infertility work-up is offered to the couple fulfilling “infertility” definition criteria or having a high risk of infertility and it should be offered to both the partners at the same time.
Immediate evaluation is needed in women older than 40 years or those having conditions known to cause infertility.
A comprehensive medical history and targeted physical examination for the partner is the key to offer appropriate investigations to the couple and thus ruling out causes of infertility one by one.
Female partner's tests focus on ovarian reserve, ovulation test, checking for ovulatory dysfunction, structural abnormalities of reproductive organ, and tubal patency.
Male is referred to reproductive urologist or andrologist if indicated from history or having abnormal semen parameters.
A careful history and physical examination can identify symptoms or signs suggesting a specific cause for infertility and thereby help to focus subsequent diagnostic evaluation on the factor(s) most likely responsible.

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Chapter Notes

Work-up of a Case of InfertilityCHAPTER 1

Key Learning Points