Women under the age of 35 who have been trying to get pregnant for one year or women over the age of 35 who have been trying to get pregnant for six months should see their fertility physician for an evaluation. Women who have had endometriosis, pelvic or gynecologic surgery, chemotherapy or radiation therapy should also consult their fertility physician before trying to get pregnant.
The fertility evaluation includes gathering a medical and fertility history from the patient and her partner, and conducting four different types of tests which includes a hormone (endocrine) evaluation, a pelvic ultrasound, a hysterosalpingogram and a semen analysis. In general, 60-70% of fertility challenges have female causes, 30-40% of fertility challenges have male causes and in 20% of couples each partner has a contributing factor.
After your complete your initial paperwork, Dr. Krotz will meet with you to learn more about you and your desire to build a family. He will gather a detailed history about any prior or current medical conditions, surgery, medications, smoking history, prior pregnancies, and any prior fertility treatments and outcomes. Your medical history will give clues to what may be causing your infertility and will help guide. For the first visit, it is helpful if your partner can attend with you so we have an opportunity to meet with them and their complete medical and fertility history can be gathered. Your history is the first step in allowing us to tailor a plan specifically to your needs.
The main reason for performing a hormone evaluation is to gain a basic estimate of the number of eggs (oocytes) a woman has and her ability to release eggs from her ovary (ovulate). The two tests that allow us to assess the number of oocytes and reproductive “age” of a woman are the Anti-Mullerian Hormone (AMH) which can be checked at any day during your cycle and the Follicle Stimulating Hormone (FSH) which is checked on day 2-5 of your cycle. These two test can be used to determine the amount and type of medication used, and also determine if Timed Intercourse, Intrauterine Insemination (IUI) or In Vitro Fertilization (IVF) is the appropriate option for treatment. Thyroid hormones (TSH & T4), Prolactin (PRL) and Testosterone levels may be checked as well, depending on your history, because abnormalities in these hormone levels can interfere with ovulation, cause irregular or heavy menstrual cycles and increase the chance of a miscarriage. Abnormal levels of these hormones are typically treated with medication alone.
The pelvic ultrasound is used to evaluate the uterus and ovaries as part of the initial evaluation, and also to monitor your progress during the course of treatment. Performing a pelvic ultrasound will allow Dr. Krotz to assess your ovaries to determine if there are cysts which may interfere with ovulation and also to estimate the number of oocytes (eggs) and your reproductive “age.” This information can be used in the same manner as AMH or FSH to determine the type and amount of medication, and the type of fertility treatment that is the most appropriate for you.
The pelvic ultrasound can also be used to evaluate your uterus to determine if there are fibroids or polyps which may prevent the embryo (fertilized egg) from implanting (attaching to) in the uterus. The pelvic ultrasound is often performed with saline (salt water) in a procedure called a sonohystogram or saline infusion sonogram (SIS) to allow better visualization inside the uterus. If a polyp or fibroid is detected it can then be removed during an in-office procedure (hysteroscopy) or in the hospital, depending on its location and size, to increase your chances of getting pregnant. A polyp is small, fingerlike growth inside the uterus. A fibroid is a non-cancerous (benign) tumor present in 20-70% of women that can grow inside the uterus or in the wall of the uterus. A pelvic ultrasound can also detect uterine malformations (abnormally shaped uterus) in 1-5% of patients which can then be sometimes may require an in-office procedure (hysteroscopy) to correct.
A hysterosalpingogram is a type of x-ray that is used to determine if a woman’s fallopian tubes are open and is performed on cycle day 5 – 11 of a woman’s menstrual cycle. The fallopian tubes are where the sperm and egg (oocyte) meet, and once a fertilized egg (embryo) is formed, the fallopian tubes carry the embryo to the uterus where it can implant and grow. If the fallopian tubes are blocked, typically from infection, prior surgery or endometriosis, then it will not be possible for the sperm and egg to meet in that fallopian tube. If both fallopian tubes are blocked, a patient may require In Vitro Fertilization to get pregnant. The hysterosalpingogram also evaluates the inside of the uterus, similarly to a sonohystogram, and can indicate if there is a polyp, fibroid or uterine anomaly that needs to be removed prior to fertility treatment.
The semen analysis is performed on all male partners. Problems with sperm including genetic problems can account for 30-40% of the reason why couples cannot conceive and is called Male Factor Infertility. When a semen analysis is performed the male partner must abstain from intercourse for two days then provide a sample for laboratory evaluation. The sample is evaluated for the concentration and total number of sperm, the percentage of moving sperm, for signs of infection or immature sperm, and the number of perfectly shaped sperm (strict morphology). A strict morphology less than 4% may indicate a decreased ability of sperm to fertilize the egg and will require In Vitro Fertilization. Men can increase their sperm count by eating a healthy, low-fat diet, limiting alcohol intake to less than 2 drinks per day and avoiding all types of smoking.
Male patients with very low sperm counts or low function are referred to a male fertility specialist (urologist with additional training) who will perform a medical history, an exam and hormone evaluations. Depending on the results of the testing, the male fertility specialist may recommend treatment with Clomiphene (Clomid), Human Chorionic Gonadotropin (hCG) injections, surgery to remove dilated testicular veins (varioceles) or procedures to extract sperm for use in In Vitro Fertilization (IVF).