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The Basic Fertility Work-up

If you decide to be assessed by a fertility specialist there are a number of tests that are routinely ordered.  With a complete work-up, you should be able to determine if you have all of the essential elements for reproduction.  However, approximately 15% of couples will have a completely normal work-up despite having difficulties conceiving.  Investigations are targeted to the causes of reduced fertility, which include the following:

  1. Abnormalities in sperm counts or “male factor”:  35%
  2. Blocked or scarred fallopian tubes:  35%
  3. Ovulation dysfunction: 15%

For men, there is only one test…..the sperm test.  From a semen sample, the volume, sperm count, motility (or movement), and shape can be assessed.  Normal values are derived from the World Health Organization, and the most recent publication in 2009 gives the following reference values:

1.5mL volume

15 millionsperm/mL

32% progressive motility

4% normal shape or “morphology”

If there are abnormalities found, a repeat sample may be ordered, as well as hormone tests, scrotal ultrasound, and/or genetic testing.  The investigations are chosen based on the
severity of the problem.

For women,the testing is a little bit more complicated…. shocking, I know.   All tests are timed to the menstrual cycle.  Hormones should be evaluated on day 3 and day 21 of the menstrual cycle.  The hormones on day 3 include follicle stimulating hormone (FSH), luteinizing hormone (LH), and estradiol.  These tests together should give an idea of how the brain and ovaries are functioning together.  The day 21 hormone assessment is for a progesterone level, and when elevated, indicates that ovulation has taken place.  Ultrasounds are also part of the work-up.  A baseline ultrasound should be completed in the first week of the cycle to assess the general anatomy, as well as to do an “antral follicle count” or AFC.  The AFC gives an estimate of the overall pool of egg follicles in the ovary and thus, the overall “ovarian reserve”.  Women are born with all of the egg follicles they will ever have, and over time the pool of eggs is depleted.  Therefore an AFC estimate will indicate if a woman has an average number of egg follicles for her age.  Finally an assessment of the fallopian tubes should be done to confirm that they are not blocked.  This is typically done by injecting saline into the cavity of the uterus and watching it flow through the fallopian tubes using ultrasound.  This is known as a saline infusion sonogram.  Using dye and x-ray is an alternative approach to assess the fallopian tubes.

After completing a semen analysis, hormone testing, ultrasound and saline infusion sonogram, a couple will have the information they need to know if there is an issue that may be affecting their ability to conceive.  Although the testing may sound daunting, it can be completed on average in three weeks.

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