Infertility Diagnosis
A traditional approach to the management of Reproductive Endocrinology & Infertility problems can be found in any traditional text. However, most texts do not take into account the limited availability of resources within a managed care environment, and do not address the issue of stratification of care into that provided by an OB/GYN generalist and that provided by the reproductive endocrinology subspecialist. To that end, this outline will attempt to focus on what care is best provided by which practitioner. To design a cost-effective, medically appropriate evaluation and treatment plan, we must take the patient’s age into consideration. While there is little necessity to initiate aggressive therapy for the 20 year old with unexplained infertility, those over 35 deserve a more aggressive approach.
Initial Infertility Evaluation Complete history and physical examination
Initial Medical Laboratory Evaluation
Evaluation of Ovulation
Individualized Laboratory Testing
African American:
Sickle screen and thalasmeia as appropriate.
Over 30
FSH values above 10 miu/ml or AMH <0.4 should result in REI review. Ultrasound screening for ovarian volume and antral follicle count on cycle day 3 may enhance the sensitivity of ovarian reserve monitoring
Irregular Menses
Irregular Menses with Hirsutism, Acne or Obesity
- A simple glucose tolerance test without insulin levels would not be adequate to predict who might benefit form therapy with an insulin lowering medication. Obese patients with markedly increased insulin levels may benefit from treatment with insulin injections with weight loss and improved lipid status.
- The free testosterone panel may be helpful to monitor the effectiveness of metformin therapy. Fasting am 17 hydroxyprogesterone is ordered during the follicular phase if adult onset congenital adrenal hyperplasia is suspected.
- Values above 150 deserve referral for cortrysyn stimulation testing. If the patient appears Cushingoid, decadron 1mg is administered at midnight and an 8am fasting cortisol level is obtained the next morning.
- If PCOS is suspected, cardio C-reactive protein, homocysteine and a lipid panel should be ordered.
Low risk for tubal disease
Semen Analysis
- Varicocele repair is controversial and should only be considered if the varicocele is rather large.
- If WBC’s are present, prolonged antibiotic therapy may be considered. A serum prolactin, FSH, testosterone and sperm antibody testing should follow abnormal semen analysis.
- A Sperm Chromatin Structure Assay (SCSA) measures sperm DNA fragmentation and identifies men with low fertility potential.
- An SCSA test may be considered for men with a history of varicocele, cryptorchid testes, chemotherapy, testicular cancer, radiation exposure, pesticide exposure, long distance bike riding or unexplained infertility.
- For those with azoospermia, FSH, free testosterone panel, estradiol, chromosomal analysis and Y microdeletion tests are indicated.
Tubal Factor Infertility
Assessment of Risk Factors:
Dyspareunia
History of PID<
Previous pelvic surgery