Standard fertility assessment explained

Emma Maria Adsuar, MD
Fertility gynaecologist , UR Vistahermosa

Fertility Assessment, Male Factor

From this video you will find out:
  • How can I check my fertility?
  • When should I consider my first visit with an Infertility Doctor?
  • What is the definition of infertility? What causes infertility?
  • What are the basic diagnostic tests of infertility for females?
  • What are the basic diagnostic tests of infertility for males?

What tests are done for fertility check in female and male?

In this session, Dr Emma Adsuar, Gynaecologist at Pregen (UR Vistahermosa) has explained what standard fertility assessment should look like, what to check, when and why.

Infertility – definition

It is estimated that 85% of couples can conceive after one year of regular unprotected sex intercourse. When this does not happen, consulting a doctor is suggested. Infertility increases approximately with the woman’s age due to the decrease of the ovarian reserve and deterioration of oocyte quality. For that reason, it is recommended for women who are over 35 years old and have a disease such as ovarian syndrome to visit the doctor before 1 year. In some countries, a differentiation between sterility and infertility is done. In the first place, not being able to conceive is termed sterility, while infertility implies being able to conceive yet not having a live birth.

Causes of infertility

To understand this, it is important to consider the causes of infertility. It was traditionally believed a long time ago that women’s factor was the most prevalent, yet it was proved male factor is equally important. As shown on the graph:

  • 30% of the causes come only from men
  • 20-25% of the unknown causes

Basic diagnosis of infertility – women

Firstly, a clinical history will be the first thing to be consulted by the doctor, which is called anamnesis. Through guided questions of anamnesis, an idea might start to arise about the couple’s problem of having a life. Why is it so important to have a family history? It is said to be important because some women have a history of premature ovarian failure in the family. Therefore, any information regarding the family’s side is fundamental.

Secondly, a personal history will be consulted. It is crafted with questions about diseases the patient is having:

  • Hypothyroidism (affects ovarian function)
  • Polycystic Ovarian Syndrome
  • Autoimmune diseases

It’s also important to ask about any past surgeries, such as appendectomy (it is important because the appendix is close to the ovarian tube). You may be asked about smoking or drugs because it is known these diminish the ovarian reserve. Medication is also known for affecting fertility.

It is essential to know when the patient had the first period in her life, which is called menarche, as it can obscure a genetic problem that possibly indicates a shortage of ovarian reserve. The menstrual formula also is being checked, regular means that the period follows a pattern. If a patient has a period every 35 days, it is correct. If the patient is experiencing very painful periods, it could be explained by suffering from endometriosis. Obstetric history also includes information about previous pregnancies, miscarriages, or abortions.

The second step after the first evaluation is the examination, of BMI (Body Mass Index), whether the patient is experiencing hirsutism or acne. Patients with obesity are known for having problems conceiving. For those patients, a nutritious plan will be given to lose weight before starting treatment more easily. Then, within the general examination, the pelvic exam is also included. Why is this important? It is crucial because some patients may have a hymen perforated so complete intercourse does not occur.

Complementary tests include a transvaginal ultrasound scan (only the uterus and ovaries can be seen. Tubes can only be seen if an abnormality is detected) Normal shape of the uterus as well as fibroid and polyps are detectable. In the same way, the status of the ovary can be analysed.

Depending on the moment, regular blood tests will be ordered to check the status of the patient:

  • Hemogram, Biochemistry, Coagulation
  • Blood group and RH
  • Serology (HIV, hepatitis, syphilis)
  • Hormonal: (anti-Müllerian hormone – AMH) FSH, LH E2, TSH, Prolactin
  • Specific for recurrent miscarriages (Thrombophilia, autoimmune disorder, karyotype).

In case a disease in genetics is detected with a karyotype test, egg donation, and embryo biopsy will be recommended before transferring). Other complementary tests include cervical culture – Chlamydia, Hysterosalpingography (tubes can be perceived), Hysteroscopy (the shape of the uterus and tubes are seen with an X-ray through a cannula in the cervix. If the tube is not open, eggs cannot go through it. Only the uterus can be seen. A polyp or fibroid can affect the endometrium and these can be removable during the test), and Histerosonography (ultrasound test).

Basic diagnosis of infertility – men

During the first visit, the female, and male both must accompany each other because it will facilitate the procedure.
Firstly, the male part is also going to be asked about family history (anamnesis) as there might be genetic factors that affect the quality of sperm.

Personal history is also checked:

  • Children
  • Diseases (hypothalamus, Cystic Fibrosis, renal diseases)
  • Surgeries (varicocele, vasectomy)
  • Lifestyle (sports that affect high testicular temperature)
  • Toxics
  • Medication

Physical examination includes BMI (the importance of having a healthy weight as being overweight can increase testicular temperature and affect the quantity and quality of sperm) as well as hydrocele (increment of temperature reduces sperm production), varicocele, and cryptorchidism. A blood test is also required, mostly for safety, as manipulation of sperm will be required.

Semen analysis is also performed, FISH test is requested it can be compared to a karyotype test yet specific to the sperm sample. A karyotype test is also necessary as there can be a genetic condition affecting fertility.

Related reading:

- Questions and Answers

What do you consider irregular menstrual formula?

As I said, 2-3 days more is completely normal. Irregularity means that it doesn’t follow any pattern. The pattern can be, for example, every 25 days, this is regularity, or if the patient has a period sometimes every 28 days, some other time every 40, this is irregularity.

I missed the definition of the two types of infertility.1 – can’t conceive, 2 – can conceive with no live birth as yet. How do you name these to differentiate?

We use this in Spain. Infertility happens when you can conceive, but you are not able to have a live birth. Sterility is when you cannot conceive at all, you haven’t had any pregnancy.

We have been trying for two years and have had two ectopic pregnancies. Does having an ectopic pregnancy count as infertility within 12 months?

Yes, it counts as infertility. The most important thing is if those ectopic pregnancies were in the same tube or not. If its different tubes, I would recommend trying for six more months, but not longer. It also depends on age, but not more than six months, and if it doesn’t happen naturally, then I would visit a fertility doctor.

Do you also request DNA fragmentation analysis in sperm samples?

DNA fragmentation is supposed to be recommended in patients wherein the sperm test, you can see less than 4% of normal sperm.

We have been trying for three years, but when we were trying actively, we conceived twice. We had a miscarriage and an ectopic – should we just keep trying, or should I go for an extensive fertility checkup?

The most important thing is what do you understand about trying actively because some patients get it wrong when they think that, for example, they have been not using any protection for five years, but in the last year, they wanted to have a baby, so they might think they have been only trying to conceive for one year –  but they’re wrong. They have been trying to conceive for five years. You should go to the fertility doctor because if you had three years of unprotected sexual intercourse, even though you were not concerned about your cycles, not thinking that when you were ovulating, and you haven’t had any baby, then I would recommend you to go and visit the fertility doctor.

If we know one tube does not work: how can we progress with only the correct tube?

One is enough. Sometimes, you can see that the patient ovulated in the right ovary, and she got pregnant with the left tube. Nature is really smart, and with one tube, you can get pregnant.

Do you recommend doing REM to the sperm samples? In all the cases before the treatment of fertility?

It depends on if you are thinking of IUI, then yes. It will also give us more information, but if you are going to go directly to IVF, I think it’s not necessary.  REM is done when you are thinking of starting insemination, not when you are thinking of um in vitro.

We have had 2 IVF-ICSI, PGT-A cycles, and they were unsuccessful, both times no pregnancy. Our doctor didn’t find any reason for failure both times. He just asked to try again. In this situation, are there new recommended steps going forward before we embark on a new IVF journey, as we just don’t want to keep repeating the same thing?

I would like to tell you that the success rate is 100 %, but it’s not true. Even with PGT-A sometimes,  the success rate is like 60-70%.  I’m sure your doctor did everything he could. You can use corticoids, you can use intralipids, heparin. There are some therapies that you can add in the following IVF. The most important thing I would say is for the patient to be relaxed and positive because that helps a lot.

If we can conceive naturally but with no live birth, should we look at IVF?

Yes, in my slides, I was talking about specific blood tests for infertility. For example, if you have an autoimmune disorder, thrombophilia, or any of you are a carrier disease, it will not allow you to have a live birth.

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Emma Maria Adsuar, MD

Emma Maria Adsuar, MD

Dr Emma María Adsuar is a fertility specialist at UR Vistahermosa. Graduated in Medicine and Surgery from the University of Elche in Alicante. Trained in Obstetrics and Gynaecology. Dr Adsuar specializes in treating the diseases of the female reproductive organs and women's health during their pregnancy and just after the baby is born. The author of multiple scientific publications and attendee of international congresses in the field of reproductive medicine.
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Caroline Kulczycka

Caroline Kulczycka

Caroline Kulczycka is managing MyIVFAnswers.com and has been hosting IVFWEBINARS dedicated to patients struggling with infertility since 2020. She's highly motivated and believes that educating patients so that they can make informed decisions is essential in their IVF journey. In the past, she has been working as an International Patient Coordinator, where she was helping and directing patients on their right path. She also worked in the tourism industry, and dealt with international customers on a daily basis, including working abroad. In her free time, you’ll find her travelling, biking, learning new things, or spending time outdoors.
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