Evaluation & Diagnosis
FTC offers evaluation & diagnosis of all aspects of reproductive care.
Infertility is generally defined as the inability of a couple to conceive a child after one year of unprotected sexual intercourse, the time in which about 90% of couples succeed. When a female is in her 20s, the average time to pregnancy is six months. This time frame reflects not only the limited few days in the middle of a woman’s menstrual cycle when she ovulates and conception is possible, but also the fact that most conceptions do not survive beyond early embryonic development and are lost before a woman’s next menstrual period. In addition, about 15% of couples with a clinical pregnancy go on to a spontaneous miscarriage. The female partner’s reproductive age is also an important determinant of the man’s ability to initiate pregnancy since the length of time required to establish pregnancy increases progressively with advancing maternal age. Fertilization of the egg is more difficult and early pregnancy loss is more frequent as a woman becomes older. Age is just one of a number of factors to consider when evaluating and diagnosing infertility causes.
Other Infertility Evaluation Diagnosis topics include (scroll down to view multiple options):
A menstrual disorder is a physical or emotional problem that interferes with the normal menstrual cycle, causing pain, unusually heavy or light bleeding, delayed menarche, or missed periods. Typically, a woman of childbearing age should menstruate every 28 days or so unless she’s pregnant or moving into menopause. But numerous things can cause irregularities with the normal menstrual cycle, some the result of physical causes, others emotional. These include amenorrhea (the cessation of menstruation), menorrhagia (heavy bleeding), and dysmenorrhea (severe menstrual cramps). Nearly every woman will experience one or more of these menstrual irregularities at some time in her life.
Menopause is defined as the cessation of menstrual cycles. This usually occurs at about the age of 50 in most women. For 2 to 8 years preceding this menstrual cycles may be irregular. This is referred to as the menopausal transition or perimenopause. As estrogen and progesterone levels decline women may experience a variety of symptoms. This is a time when the levels of hormones produced by the aging ovaries fluctuating leading to irregular menstrual patterns (irregularity in the length of the period, the time between periods, and the level of flow) and hot flashes (a sudden warm feeling with blushing). Other changes associated with the perimenopause and menopause includes night sweats, mood swings, vaginal dryness, and fluctuations in sexual desire (libido), forgetfulness, trouble sleeping and associated fatigue.
Polycystic Ovarian Syndrome (PCOS)
PCOS is a condition in which the ovaries secrete abnormally high amounts of androgens (male hormones) that often cause problems with ovulation. Women with PCOS have enlarged ovaries which contain multiple, small cysts. Although PCOS, also called Stein-Leventhal syndrome, can be completely asymptomatic, it more often is associated with symptoms such as irregular periods or amenorrhea (no periods), weight gain or obesity, excessive hair or abnormal hair growth, acne, and oily skin.
Premature Ovarian Failure Syndrome (POF)
POF is associated with an elevated FSH (follicle stimulating hormone) level. Symptoms include hot flashes, increased insomnia, vaginal dryness, irregular periods, or a loss of periods entirely in women less than 40 years of age. POF is actually quite common. There are four sub-types of POF, so the initial medical evaluation should determine which type a patient has. The most common is an autoimmune ovarian failure, in which a patient’s own antibodies “burn out” the eggs and ovaries. The second cause of POF is if a woman has mumps as an adolescent (after age 10), many of her eggs may “burn out,” which oftentimes results in POF. Many women are unaware that they’ve had an ovarian mumps infection until they are diagnosed with POF. The third cause of POF is Savage Syndrome, resulting from abnormal FSH hormone receptors. Finally, POF may be idiopathic, meaning a specific cause cannot be found.
If POF is diagnosed early, and the FSH level isn’t significantly elevated, a patient has a reasonable chance of achieving pregnancy. However, a significant number of women with POF need donor egg IVF to become pregnant. Interestingly, for autoimmune POF patients, birth control pills may work backwards by actually increasing the chances of ovulation and conception, but with a relatively low success rate. An experimental method to treat Savage Syndrome involves laparoscopic removal of half of one ovary, thinly slicing it, removing and maturing the eggs, and then fertilizing them using IVF.
Diminished Ovarian Reserve
Diminished Ovarian Reserve is one of the more difficult diagnoses that a patient can have. That is because such patients are much more difficult to help to achieve pregnancy since the normal tools to achieve pregnancy don’t work as well. Some patients will likely have at most a few years of potential fertility left, so the situation is urgent. Some may have limited or no fertility left, but the process of finding this out, at times, involves a process of trial and error.
A woman is born with one to two million eggs. Although she will only ovulate three to four hundred of them, the rest will essentially wither away until there are none left. She will then be menopausal. Most of the time, the eggs are in a protected state with a small group of them constantly being released from this protection. We do not know what causes the ovary to change the status of these eggs, so we refer to it as a women’s biological clock. Those eggs that have left this arrested state will go on and ovulate provided they receive optimal hormonal stimulation. If they don’t get this stimulation, they soon undergo an actively defined degeneration (called apoptosis).
One way of defining decreased ovarian reserve is when a woman has fewer than 25,000 eggs in her ovaries. Statistically, this occurs around age 38. Fertility is still present until around 42 years old and, for most women, therapy to achieve pregnancy is still a reasonable thing to do. Menopause (no eggs) occurs around age 51. However, these numbers are only averages and these events have a distribution around these averages. For example, many women don’t experience menopause until well past age 51. Similarly about 10% of all women will have decreased ovarian reserve by age 32. In a practice such as mine, where women are self-selected to come here on the basis of not being able to get pregnant, the incidence of decreased ovarian reserve is even higher.
Women with certain histories need to be especially concerned about their reproductive potential. Of greatest concern is a family history of early menopause, certain chemotherapies, and pelvic radiation. Also of concern are a history of (significant) pelvic surgery, pelvic infection, severe endometriosis, and smoking (dose and duration related). FTC performs a complete assessment for those patients at risk for diminished ovarian reserve, and does not exclude these patients from its practice nor have them pay more, as other practices due, because of their situation.
Ovulation Dysfunction or Ovulatory Dysfunction is one of the leading infertility causes and describes a group of disorders in which ovulation fails to occur, or occurs on an irregular basis.
Anovulation (no ovulation)
A disorder in which eggs do not develop properly, or are not released from the follicles of the ovaries. Women who have this disorder may not menstruate for several months. Others may menstruate even though they are not ovulating. Although anovulation may result from hormonal imbalances, eating disorders, and other medical disorders, the cause is often unknown. Women athletes who exercise excessively may also stop ovulating.
A disorder in which ovulation doesn’t occur on a regular basis, and a menstrual cycle may be longer than the normal cycle of 21 to 35 days.
A condition in which endometrial tissue that normally lines the inside of the uterus, grows outside the uterus and attaches to the ovaries, fallopian tubes, or other organs in the abdominal cavity. Blood flow from the endometrial tissue is restricted and can cause inflammation and form scar tissue which can block the fallopian tubes or interfere with ovulation.
Also known as leiomyomas, they can develop from the smooth muscle cells of the uterus and can interfere with pregnancy in many ways. The ones that grow on the inside wall of the uterus can cause changes in the endometrial tissue, making it difficult for a fertilized egg to attach to the uterine wall. Fibroids that develop outside the uterus can interfere with pregnancy by compressing or blocking the fallopian tubes, thereby preventing the sperm from reaching the egg.
Defined as 3 or more consecutive, spontaneous pregnancy losses. Approximately 20 percent of pregnancies end in miscarriage, which is defined as the loss of a pregnancy before 20 weeks of gestation. Most miscarriages occur within the first 12 weeks of gestation. When miscarriage occurs this frequently, there may be underlying causes such as genetic factors, an abnormally shaped uterus, uterine fibroids, or scar tissue in the uterus which may hinder implantation or growth of the fetus. Hormonal imbalances or illnesses such as diabetes or immune system abnormalities may increase the chance of miscarriage.
A syndrome encompassing a wide variety of disorders. In more than half of infertile men, the cause of their infertility is unknown and could be congenital or acquired. Recognition of a male factor influence in an infertile partnership is often delayed because women have traditionally been the primary focus of the infertility evaluation and have ready access to gynecological care; men are much more reluctant to seek advice. Men are also more apt to confuse fertility with sexual potency (the ability to have an erection), ejaculation and ability to perform sexually, and they assume that if they produce seminal fluid at orgasm then they also produce sperm.
Causes of fertility problems in men include sperm disorders, obstructive problems (blockages in sperm-carrying tubes), testicular injury and disease, varicocele, genetic disorders, hormonal problems, general medical disorders that reduce fertility, drugs that reduce fertility, and environmental toxins and radiation.
A test that assesses the formation and maturity of sperm as well as how the sperm interact with the seminal fluid. A fresh semen sample (no more than a half hour old) is collected and then analyzed in a laboratory for a variety of different factors. In order for sperm to be able to fertilize an egg, it is necessary for seminal fluid to be of the correct consistency as well as for sperm to have maximum motility and ideal morphology. If any of these factors are revealed to be less than perfect in a semen analysis, male fertility may be compromised. Male infertility testing is an important part of making an accurate infertility diagnosis.
Genetic factors are proving to be important contributors to male infertility. Inherited disorders can genetically impair fertility.
- Cystic fibrosis patients often have missing or obstructed vas deferens (the tubes that carry sperm) and hence a low sperm count.
- Klinefelter syndrome patients carry two X and one Y chromosomes (the norm is one X and one Y), which leads to the destruction of the lining of the seminiferous tubules in the testicles during puberty, although most other male physical attributes are unimpaired.
- Kartagener syndrome, a rare disorder that is associated with a reversed position of the major organs, also includes immotile cilia (hair-like cells in lungs and sinuses that have a structure similar to the tails of sperm). Germ cells may also be affected by this condition.
What are the fertility options?
After Dr. Craig has reviewed your past medical history and performed a detailed physical examination, he’ll present a variety of options for you and your partner based on your individual needs. Some of those options may include: 1) Additional testing. 2) Ovulation induction medications. 3) Intrauterine insemination. 4) In vitro fertilization. 5) Donor egg or donor embryo. And lastly, 6) Surgical intervention. Armed with excellent information from the initial testing and exams, and with your input, Dr. Craig and the Staff at FTC will help you find the perfect plan to complete your family.