The basic infertility evaluation consists of a handful of tests. The woman typically undergoes a transvaginal ultrasound, hormone blood tests, and an assessment of the fallopian tubes and uterus (by x-ray or by laparoscopic surgery). The man gets off relatively easily as he usually only undergoes a semen analysis.

Transvaginal ultrasound allows the physician to assess the appearance of the uterus and the ovaries. During this examination, the physician may discover uterine abnormalities such as fibroids (benign growths of the muscle of the uterus) or uterine polyps (benign growths of the lining of the uterus). Ultrasonography can also identify the location of the ovaries and determine the number of follicles present (antral follicle count), which correlates with the woman’s response to fertility medications. In addition, examination of the ovaries may reveal the presence of abnormal ovarian cysts such as endometriomas, dermoid cysts, or—in rare cases— precancerous and cancerous lesions.

In addition to the routine vaginal ultrasound, an assessment of the fallopian tubes and the uterine cavity is appropriate when the woman is having trouble conceiving. This examination is usually accomplished through a hysterosalpingogram (HSG: see Figure 2), an x-ray test that is performed under fluoroscopy by a gynecologist, a reproductive endocrinologist or a radiologist. Although it may sometimes cause mild uterine cramping, the vast majority of patients tolerate this procedure without difficulty. The individual physician performing this test can make a huge difference in the experience for a typical patient. For example, we utilize a soft catheter which is held in place against the cervix but is not actually passed into the uterine cavity. The use of this instrument, rather than a balloon type catheter that must be introduced through the cervix and into the uterus, can markedly reduce patient discomfort with this test. Similarly, only a small volume of dye is needed to fill the uterus and fallopian tubes. Excessive pressure and volume of dye can lead to much greater cramping and rarely improves the diagnostic accuracy of the test.

Alternatives to the hysterosalpingogram include laparoscopy and hysteroscopy; these outpatient surgical procedures are described in Questions 11 and 12.

Laboratory tests on the female partner of an infertile couple usually include routine screening tests such as those for blood type, blood count, and rubella immunity. In addition, most physicians perform tests that check the woman’s prolactin and thyroid-stimulating hormone (TSH) levels. Additional reproductive hormone testing for ovarian reserve is usually part of the routine evaluation as well (see Question 9).

Routine testing of the male partner of an infertile couple includes a basic semen analysis evaluating the volume of semen, the concentration of sperm (sperm count), the percentage of moving sperm (sperm motility), and the percentage of normally shaped sperm (sperm morphology). (See Table 2.) Although some clinics perform reaction and hypo-osmotic swelling test, the overall benefit of these two tests remains somewhat controversial. Both of these tests attempt to predict the functional ability of the sperm in terms of its ability to fertilize an egg. Ultimately, however, the best evidence of normal sperm function is a recent pregnancy or normal fertilization during a cycle of IVF.

Tests to detect the presence of antisperm antibodies in the blood of the female partner or coating the individual sperm may sometimes be recommended. Female antisperm antibodies may cause infertility that is best treated by IVF. Antisperm antibodies present on the sperm themselves may inhibit normal fertilization. In such cases, collecting a semen sample in media for use in artificial insemination may be considered, but these patients are usually recommended to pursue IVF with intracytoplasmic sperm injection (ICSI).

Kristin comments:

Despite having a diagnosis of PCOS when I was referred to an RE, I still had to go through the regular battery of blood tests, ultrasounds, and an HSG. It was a really scary time because none of my friends had ever gone through any of the tests and I really felt like a pincushion. Besides the physical toll of the tests, it was definitely emotionally draining. I think the initial tests in some ways prepare you for the weeks of daily blood draws and ultrasounds that accompany IUI [intra-uterine insemination] and IVF. Before IVF I was terrified of needles, but within days I was a pro at giving myself shots.