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Fertility Evaluation

Approximately 85% of couples should achieve a pregnancy within one year of regular unprotected intercourse.  This translates into about 12-15% of couples seeking some form of fertility investigation at some point during their lifetime.  It is extremely common and you are definitely not alone.  The diagnosis of sub fertility is immensely anxiety provoking and stressful.  At JCRM, we have extensive experience not only in the realm of diagnosis and the surgical and medical management of sub fertility, but also in managing the stress and anxiety that this diagnosis brings.  We have a comprehensive approach that will enable couples to know all of the options.  You have a choice and it should be a well informed and knowledgeable one made only after understanding the underlying diagnosis and all of the available options.   

When to evaluate?

Recommendations for an evaluation stem mainly from age, duration of sub fertility, and whether there are additional underlying factors that may impact reproductive success.  For instance, a woman that is under 35 years of age with regular menstrual cycles and no other diagnoses that has been attempting to conceive with a healthy partner for over a year should seek an evaluation. Women over 35 years of age should seek a specialist after 6 months if everything else seems normal. Couples should seek assistance immediately if menstrual cycles are irregular/unpredictable, they suffer from pelvic pain, or the partner is known or suspected to have a potential health factor that may impact the quality of sperm.  Many times a brief history can uncover issues that have never been addressed.  

At JCRM we also believe that we are able to reduce the stress associated with infertility by evaluating a couple when they are concerned that there may be a problem, regardless of the time interval over which fertility has been attempted.  Some are reassured in knowing that ovulation is efficient, the fallopian tubes and uterus are normal and the sperm quality is optimal.  At JCRM, we offer a fertility assessment that addresses these concerns.  It is also an excellent option for women that may not have a serious partner as of yet, however, would like to determine how to optimize fertility for the future.  Please see our “fertility check” link.

What does an evaluation entail?

Any fertility specialist should investigate four primary areas that impact fertility.  This must include the following:

1.  Ovulation: The regular, efficient release of the egg.  Many women have cycles that although seem regular may have subtle changes that impact the quality of ovulation and the hormonal support of the luteal phase (phase after ovulation).  We evaluate this area by performing a progesterone level on cycle day 21 which not only confirms ovulation but allows us to determine whether the ovary is producing the optimal amount of hormone for a pregnancy.  This is one of the most common reasons for sub fertility.  Many women have irregular cycles and the goal is to determine the reason and correct the underlying condition.  Nutrition, stress, exercise, as well as a variety of hormonal issues can impact ovulation – we at JCRM address all of these aspects.

2.  Anatomic:  It is essential to make sure that the egg will be able to meet the sperm within the fallopian tube to foster fertilization.  Some women may be at increased risk of having a tubal factor if they have had surgery in the past, a history of an infection or ectopic pregnancy.  A hysterosalpingogram (HSG) is a radiologic test that only takes approximately five minutes and allows us to verify tubal patency.

3.  Ovarian Reserve:  Many know that fertility potential is largely based on age.  This is due to the fact that women are born with all of the eggs they will ever have.  As a matter of fact, at 20 weeks gestation the female fetus has 5-7 million eggs.  By birth she is down to 1-2 million and by puberty approximately 400,000.  Every month hundreds of eggs are lost.  Natural fertility begins to decline around the age of 32 years and in some circumstances even sooner.  We have the ability to test this reserve through a number of different laboratory avenues as well as ultrasound.  Baseline FSH and estradiol measurements, Clomiphene Citrate (Clomid) Challenge Testing, Anti-mullerian hormone, and antral follicle count may be used for this purpose.  A reduced ovarian reserve in a young patient may in fact be associated with endometriosis.  Although endometriosis is a surgical diagnosis, we are able to increase our clinical suspicion significantly through a detailed history and laboratory evaluation.

4.  Male factor:  A semen analysis performed with a 2-5 day abstinence interval will enable the physician to determine whether we would need to go any further on the male side.  Men contribute to the fertility issue in approximately 40% of the cases.  We also find that much of the time it may be associated with a hormonal issue.  Men with a history of taking testosterone almost always have a reversible abnormality in sperm production.  We also manage men with low testosterone in ways that are not detrimental to sperm production.

How long does this take?

At JCRM, we take one menstrual cycle to figure out all of the underlying problems.  In women with irregular cycles we would stimulate a menstrual cycle prior to the investigation. Each test is performed at a particular point in the cycle.  After a short time (usually a few weeks), we have all of the information back.  We would then sit down and go over each test and what options are available for the particular conditions.  Success rates from continuing to try on your own through aggressive treatments would be discussed along with our own recommendations.  It is readily apparent that many couples get “pressured” into aggressive treatment like IVF (In Vitro Fertilization) when it is often not needed.  By far the majority of our patients achieve a healthy pregnancy with less aggressive means.

Our comprehensive, compassionate and successful approach is what sets us apart from the rest.  Please feel free to read “Why Choose Us” under Patient Resources.

 

At JCRM we offer a complete couple oriented fertility diagnostic evaluation.  Ideally, we like to see both the male and female partners for a new patient visit where we conduct thorough medical interviews and plan for diagnostic testing.  Having both of you there, allows a more global assessment and more direct communication.  At this visit, it is most helpful to have all prior medical records .  These records are best obtained by patients themselves.  Pictures of prior surgeries or at least operative reports are helpful and in addition, ultrasounds, HSG reports, and any laboratory testing results are the primary studies we need to understand your prior work up. 

► FEMALE EVALUATION (for those without prior testing)

Three primary areas of focus are utilized in the overall evaluation: Tubal/Peritoneal, Ovulation and Male factor. 

Some historical factors might be best considered before the visit so that records can be reviewed and the availability of time to remember specific facts.  A careful menstrual history will be taken.  The most important factor in your history is knowing the interval from start of one cycle to the start of the next cycle at times in your life when you were not on birth control pills or other hormones.  Your mother’s age at menopause will often be asked as well as family history of diabetes and endometriosis.  These are the questions patients find it toughest to answer on the spot in the office. 

For ovulation, we generally will perform an ultrasound on cycle day 12 to look for an appropriately sized follicle and check a blood progesterone level on cycle day 21.  If cycles are dramatically abnormal, it may not be necessary to test for ovulation since we know by history that there is an ovulation disorder.  To evaluate tubal and peritoneal problems, (endometriosis and adhesions) an HSG (hysterosalpingogram) is done.  Tubal occlusion or suspected adhesions would be the most common findings in this test. Laparoscopy is another way to evaluate the pelvis for endometriosis and adhesions.  Patients with other symptoms consistent with endometriosis or an abnormal HSG might be candidates for further evaluation via laparoscopy.  Laparoscopy is an outpatient minimally invasive surgery that offers both diagnostic information and the potential for therapeutic intervention.  Endometriosis can be resected and tubal scarring can in some cases be successfully repaired. 

Other tests that may be performed include the Clomid Challenge Test(CCCT) and metabolic testing to further evaluate ovulation disorders.  The CCCT is a test to evaluate for diminished ovarian reserve or premature ovarian aging.  In this test, clomid, an oral ovulation drug, is given to stimulate the ovaries to function at their best and hormone studies are done at three separate time points in the cycle and a mid cycle ultrasound is done to evaluate the number of follicles in response to the clomid. From these results, we can learn more about ovarian reserve.  These results help us plan other diagnostic studies and treatment strategies. 

Metabolic testing relates to ovulatory disorders and specifically PCOD.  If a patient’s history suggests the possibility of an ovulatory disorder of this type, metabolic testing will be recommended.  The most significant of these tests is the 3 hour glucose tolerance test with insulin levels.  Insulin resistance is the underlying metabolic disorder responsible for PCOD and hyperandrogenic anovulation.  If you have irregular cycles (>30 day intervals), acne, facial hair, oily skin or scalp hair loss, you may have this disorder. 

► MALE EVALUATION:  

 The male evaluation is much less rigorous than the female testing sequence.  Two areas are studied for all males.  The semen (sperm) analysis and a basic hormonal profile.  The semen parameters in most men vary significantly from day to day.  In order to have an accurate assessment of the average state of the semen, two studies are performed.  The accuracy of semen analyses is very much related to the operator’s skill in performing the test.  Most commercial labs do a poor job with this test, so when possible, we prefer the testing in our laboratory.  This gives us the most accurate look at this parameter.

The basic hormonal evaluation includes testing testosterone and the two hormones that stimulate sperm and testosterone production in the testicle.  Some sperm problems are a result of blockage in the spermatic tubules and can be suspected with histories of infection or prior injury.  Some males are born with blockage of both vas deferens.  With obstruction, sperm can almost always be recovered with surgery and correction of certain obstructions is possible.  When applicable, genetic studies might be necessary to make a final diagnosis. 

If the semen analysis and basic testing is normal, no specific recommendations would be made regarding sperm. 

► PLAN OF TREATMENT APPOINTMENT:

For most couples, we evaluate simultaneously the male and female.  This process can be completed in one cycle or approximately one month.  At the end of this process, we meet with both members of the couple for a plan of treatment appointment where we review all lab testing and studies performed.  At this visit, we will be able to make specific recommendations for treatment.  Our goal is to help you have a safe and successful pregnancy.  We do our best to minimize diagnostic studies in order to avoid costly unnecessary diagnostic studies.  Moving to treatment early is our goal to focus our efforts and resources on achieving pregnancy.