Fertility denotes the ability of a man and woman to reproduce; conversely, infertility denotes the lack of fertility—an involuntary reduction in the ability to produce children. When a couple has been engaging in regular, unprotected sexual intercourse for at least 1 year without conceiving, the couple is considered infertile. In about one third of cases, a male factor is the predominant cause; in another one-third, the female factor predominates; and in another one-third, no cause is found in either partner.
The workup for infertility starts with a complete history and physical examination for both the woman and the man, including their sexual history. A rational approach is to put each partner through a series of tests that generally uncover a vast majority of the contributing factors of infertility. These tests usually take 2–3 months to complete.
Standard pretest and posttest care for couples undergoing fertility testing includes the following:
Provide information and support. Be sensitive to the couple’s need for privacy and confidentiality. Maintain a communication network about new procedures, tests, and treatments. Help couples deal with feelings of sadness and loss. Assist couples to deal with the effects of stress and the financial burden during the diagnostic process. Assist couples in arranging work and testing schedules with the least amount of disruption for the couple. Arrange for counseling with experts who understand the different ways infertility affects someone’s life.
Tests include evaluation of amenorrhea, anovulation, sperm count (angiosperm, oligospermia), hormone testing, hysterosalpingogram, laparoscopy, hysteroscopy, fertiloscopy, semen analysis, postcoital test, endometrial biopsy, and chromosome karyotype to exclude Kallmann syndrome. Hormone testing rules pregnancy in or out (e.g., chorionic gonadotropin, prolactin [PRL], luteinizing hormone [LH], follicle-stimulating hormone [FSH], thyroid-stimulating hormone [TSH], postcoital test, and antisperm antibodies). Also see estrogen testing in Chapter 3.
A postcoital examination is done to assess cervical mucus and competent sperm motility. A specimen is obtained from the endocervical canal within 2–12 hours of coitus and is examined for viscosity (stretching to 6 cm is normal) and for ferning effect of estrogen. The presence of >50% sperm confirms male competence.
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