Initial Evaluation of the Infertile Couple

Complete history and physical examination
VITALAB encourages patients to obtain all previous medical records for treatment related to infertility, hormonal or menstrual disturbances, anovulation, gynaecologic surgery, or pelvic infection. Appropriate medical information should also be gathered on the husband i.e. previous semen analysis and prior hormone tests and x-rays. Particular attention is directed toward a review of medications that may interfere with fertility (i.e. Calcium channel blockers and non-steroidal anti-inflammatory preparations in males) or those that might be teratogenic (harmful to the foetus).

Initial Medical Laboratory Evaluation
On the 2nd and 3rd day of the menses, a basic hormone profile is performed (FSH, LH, Thyroid function, Prolactin), together with a sexually transmitted disease profile (HIV, Hepatitis B, VDRL) and assessment of immunity to German Measles.

An androgen profile is performed. A fasting insulin and glucose may also be required. Some PCOS patients may benefit from Metformin (Glucophage) therapy. A simple glucose tolerance test without insulin levels is not adequate to predict who may benefit from treatment with insulin lowering medication.

Low risk for tubal disease.
In those patients without a history of pelvic pain, surgery, dysmenorrhoea (painful periods) or dyspareunia (pain with intercourse), a serum chlamydia IgG antibody is obtained. As tubal disease or peritubal adhesions are frequently a result of asymptomatic chlamydia infection, a more aggressive evaluation of the fallopian tubes and pelvis is required, if a raised chlamydia IgG is noted.

Semen Analysis.
Testing should be obtained before any invasive procedure such as HSG, laparoscopy, or ovulation induction is considered. A semen analysis is considered current if it has been obtained within the last 12-18 months and performed by a reputable laboratory using acceptable criteria. Abnormal values should be rechecked no sooner than 4-8 weeks. If, on repeat testing, the total motile count per sample is greater than 5 million, ovulation induction and intrauterine insemination may be of benefit. Smokers should be placed on antioxidant supplementation (Vitamin C 1gm/day and Vitamin E 400ugmday. Varicocele (scrotal varicose veins) is looked for and treatment is individualised. A bacteriology culture of the semen may be indicated, and if an infection is present, this will be treated with the appropriate antibiotics. A serum prolactin, FSH, testosterone, TSH and sperm antibody testing may follow abnormal semen analysis. In very specific circumstances, genetic studies may be undertaken.

Tubal Infertility
Assessment of Risk Factors

1. Dysmenorrhoea (pain with menses), if associated with pelvic tenderness, uterosacral nodularity or perimenstrual diarrhoea, should be considered evidence of endometriosis
2. Dyspareunia (pain with intercourse)
3. Previous pelvic or lower abdominal surgery
4. IUCD (intra-uterine contraceptive device) complications such as removal for pain, bleeding or infection
5. History of Pelvic inflammation
6. Elevated Chlamydia IgG titers

Evaluation of Tubal Factor

1. Over 35, > 3 years infertility & risk factors: Laparoscopy should be considered early in the evaluation. Tubal patency as assessed by an X-ray (HSG – hysterosalpingogram) should be determined preoperatively to rule-out proximal tubal obstruction which may be treated during the initial laparoscopic procedure. This X-ray will also exclude pathology within the uterine cavity.
2. Low risk factors, anovulatory infertility or AID (artificial insemination with donor sperm) candidates: After an initial HSG, ovulation induction or AID (donor insemination) may be considered for 3-4 cycles before considering a diagnostic laparoscopy.

Post-coital Testing
This test evaluates the interaction between the sperm and the cervical mucus at mid-cycle. Depending on the couple's history, this test may not be performed.

Endometrial Biopsy
The routine use of endometrial biopsy to assess the adequacy of luteal phase has poor predictive value for the management of infertility and is only indicated for those patients with regular cycles and recurrent pregnancy loss. Routine endometrial biopsy therefore is not indicated in the diagnosis of infertility.

Treatment
Empirical Treatment.
Female patients are treated with pre-conceptual folic acid-5mg per day.

Preconception Counselling.
The risks of genetic abnormalities are discussed for those with a family history or age > 35. Smoking cessation, alcohol reduction, weight loss, marital counselling are recommended as indicated.

Treatment Options
Medical
Ultrasound timed intercourse
Ultrasound timed artificial insemination with or without ovulation induction.
IVF - ET

Surgical
Outpatient laparoscopy and hysteroscopy
Laparotomy with microsurgery

1. No patient should be taken to surgery without a current semen analysis or recent day 3 FSH and estradiol if over 35 years of age.
2. Patients with damage to both ends of the fallopian tubes, are unlikely surgical candidates with pregnancy rates lower than 5%.
3. Repeat operations to the fallopian tubes are rarely successful and should be avoided.