Evaluation of Couples
Fertility in men and women is regulated by a series of tightly coordinated and synchronized interactions within the hypothalamic-pituitary-gonadal axis. The operational characteristics of the reproductive axis leave little room for error. Reproductive tract structures are also at risk for the development of diseases that render them unfit or compromised in their primary role of reproduction. Disorders at any level of the system may lead to involuntary infertility, which affects approximately 15% to 20% of couples or approximately 11 million reproductive-age people in the United States. Infertility therapy has been evaluated carefully in the last decade as new medical and assisted reproductive techniques have gained widespread approval. Advancements in the basic science of gamete physiology, conception, and implantation have also added greatly to our knowledge base, while at the same time have introducing a number of controversies in the treatment of infertile couples.
Primary infertility occurs in couples with no previous history of conception. Secondary infertility exists when a prior conception has been, at a minimum, documented by a positive human chorionic gonadotropin (hCG), histology, or ultrasound. The causes of infertility are equally distributed between males and females and often the physician encounters multiple etiologies during the investigation. Most infertile couples have one or more of three major causes: a male factor, ovulatory dysfunction, or tubal-peritoneal disease.
Males without stigmata of endocrinopathies or general medical illnesses require an analysis of their semen as the minimum initial step of evaluation. Those suspected of deficient androgen production and/or action and those with abnormal sperm counts, motility, and/or morphology need assessment of their serum concentrations of selected reproductive hormones.
When these initial investigations are negative and there are no demonstrable etiologic female factors underlying the state of infertility, specialized sperm function and sperm allergy testing needs to be performed. The initial investigation of the female partner is best served by assessing the frequency of ovulation and adequacy of corpus luteum function.
Women without ovulatory defects should be assessed for the presence of the hostile cervical mucus and structural anomalies of the reproductive tract. Investigations of patients with menstrual dysfunctions should be based upon the presence or absence of hirsutism, changes in body weight, and evidence of other endocrinopathies or medical illnesses. Following the identification and normalization of causes of anovulation, further work-up of patients who remain infertile is similar to those with regular menstrual cycles. The diagnosis of idiopathic infertility is essentially by exclusion of all other causes. Algorithms for the diagnostic evaluation of most infertile couples are provided.