In general, infertility is defined as the inability to get pregnant (conceive) after one year (or longer) of unprotected sex. It is indicated to initiate an infertility evaluation if couples have been trying 1 full year with no success in getting pregnant. The process of testing can be trying for couples. Remember, most couples will be pregnant within 6- 9 months of trying which is why we recommend waiting a full year before working up this issue. Ovulation predictor kits, tracking cycles with apps and having timed sex every other day during the fertile time are helpful for many. However, they can be stressful; so they are not necessary for younger couples early in their fertility attempts.
Since fertility in women is known to decline steadily with age a work up may be indicated after 6 months of trying if the woman is closer to 35. If a patient is 40 or older an immediate referral to a reproductive specialist is indicated due to their high risk of having a baby with a chromosomal abnormality and decreased ovarian reserve. This is because women are born with all the eggs they will ever have; unlike men who continually make sperm. These eggs, as they get older, have a higher risk of genetic abnormality when fertilized. Patients over 40 will have a better chance of getting pregnant with a healthy baby with immediate intervention and will be given options of getting pregnant and adding genetic testing to limit their high risk of having a baby with chromosomal abnormality.
When evaluating fertility 30% of cases are male factor (caused by male), 30% are female factor, and 30% are unknown. A fertility work up can be very expensive and not covered by insurance so there are some basic tests that need to be done before any decision can be made for treatment. A detailed review of the medical history of both patient and partner is a must. For the female partner a pelvic ultrasound, lab work to determine ovarian reserve, imaging to determine if the fallopian tubes are open are the first tests ordered. At the same time a semen analysis is ordered for the male partner. A pelvic ultrasound can determine if there are any gross abnormalities of pelvic anatomy causing infertility. A hysterosalpingogram is an imaging test to tell if the tubes are blocked. A Anti Mullerian Hormone level is an index that predicts success with fertility treatments and ovarian reserve. These tests are necessary to rule out the need for immediate referral to specialist. If the fallopian tubes are blocked - there is no sense in giving patients ovulatory medications and incur unnecessary risks as the sperm can’t get to the egg if there is tubal blockage. In turn, if the semen analysis shows abnormality the same applies. Sometimes there can be disparity between ejaculates but major abnormalities in semen analysis would necessitate referral to urology for treatment. In addition, we also offer patients genetic testing for evaluation of genes that affect reproductive potential. All of these tests are available to be done and ordered by our provider in our office.
When all these tests are completed we recommend a consultation to discuss treatment with medications for 3-6 months. These treatments will also require day 21 Progesterone levels to assess ovulation monthly in our office. Lab appointments can be made for easy access during the day for these patients on site.
Our approach to resolve fertility issues offer patients the ability to gain important information in determining infertility reasons without excessive cost prior to referral to specialists in most cases.