CHAPTER 19: Evaluation of the Infertile Couple

Infertility is defined as the inability to conceive after 1 year of unprotected intercourse of reasonable frequency. It can be subdivided into primary infertility, that is, no prior pregnancies, and secondary infertility, referring to infertility following at least one prior conception.

Conversely, fecundability is the ability to conceive, and data from large population studies show that the monthly probability of conceiving is 20 to 25 percent. In those attempting conception, approximately 50 percent of women will be pregnant at 3 months, 75 percent will be pregnant at 6 months, and more than 85 percent will be pregnant by 1 year (Fig. 19-1) (Guttmacher, 1956; Mosher, 1991).

Infertility is common and affects 10 to 15 percent of reproductive-aged couples. Of note, even without treatment, approximately half of women will conceive in the second year of attempting. According to the National Survey of Family Growth, the percentage of married women who reported infertility fell from 8.5 percent in 1982 to 6.0 percent in 2006 to 2010. In comparison, the percentage of women aged 15 to 44 years who had ever used infertility services increased from 9 percent in 1982 to 12 percent in 2002, with a peak of 15 percent in 1995 (Chandra, 2013, 2014). Interpretation of these data is complicated by ongoing changes in marriage rates, intentional delays in childbearing, and socioeconomic and educational status changes in a growing immigrant community. Nevertheless, well-publicized successes in infertility treatment now give patients greater hope that medical intervention will help them achieve their goal.

Most couples are more correctly considered to be subfertile, rather than infertile, as they will ultimately conceive if given enough time. This concept of subfertility can be reassuring to couples. However, there are obvious exceptions, such as the woman with bilaterally obstructed fallopian tubes or the azoospermic male. In general, infertility evaluation is for any couple that has failed to conceive in 1 year. But, several scenarios may prompt earlier intervention. For example, to delay assessment in an anovulatory woman or a woman with a history of severe pelvic inflammatory disease (PID) may not be appropriate. Of particular note, fecundability is highly age-related, with a significant decrease beginning at approximately 32 years of age and more rapid decline after age 37 (American Society for Reproductive Medicine, 2014a). This decline in conception rates is associated with an increase in poor pregnancy outcomes, primarily due to increased aneuploidy rates. Thus, most experts agree that evaluation is considered after only 6 months in women older than 35 years.

Prior to initiating infertility treatment, a patient’s health status must be optimized for an anticipated pregnancy. Ideally, these issues are addressed prior to referral to an infertility specialist whenever possible. Topics include appropriate vaccination; screening for diabetes, infectious diseases, or genetic disorders; folic acid supplementation; weight reduction; and cessation of cigarette smoking or illicit drug use. Additional information is provided later in this chapter and in Table 1-17.

Successful pregnancy requires a complex sequence that includes ovulation, ovum pick-up by a fallopian tube, fertilization, transport of a fertilized ovum into the uterus, and implantation into a receptive uterine cavity. In the male system, sperm of adequate number and quality must be deposited at the cervix near the time of ovulation. Remembering these critical events can aid in developing an appropriate evaluation and treatment strategy.

In general, infertility can be attributed to the female partner one third of the time, the male partner one third of the time, and both partners in the remaining one third. This approximation emphasizes the value of assessing both partners before instituting therapy. Although a complete investigation may not be required before instituting therapy if a clear etiology is present, strong consideration is given to finishing testing if pregnancy is not rapidly achieved. Estimates of the incidence of various causes of infertility are shown in Table 19-1 (Abma, 1997; American Society for Reproductive Medicine, 2006).

Both partners are urged to attend the initial consultation. This time provides an excellent opportunity to educate regarding the normal conception process and methods to optimize their natural fertility. Such efforts may obviate the need for expensive and time-consuming interventions (American Society for Reproductive Medicine, 2013a). Couples are informed of the concept of a fertile window for conception. The chance of conception is increased from the 5 days preceding ovulation through the day of ovulation (Wilcox, 1995). If the male partner has normal semen characteristics, a couple ideally has daily intercourse during this period to maximize the chance of conception. Although sperm concentrations will drop with increasing coital frequency, this decrease is generally too small to significantly lower the chance of fertilization (Stanford, 2002). Couples are also reminded to avoid oil-based lubricants, which are harmful to sperm. Many myths surround the ability to conceive. Examples, such as the importance of coital position and the need to remain horizontal following ejaculation, can add undue stress to an already stressful situation and should be dispelled.

Female History

Gynecologic

As with any medical condition, a thorough history and physical examination is critical (American Society for Reproductive Medicine, 2012a). Specifically, questions cover menstruation (frequency, duration, recent change in interval or duration, hot flushes, dysmenorrhea), prior contraceptive use, coital frequency, and infertility duration. Previous endometriosis, recurrent ovarian cysts, leiomyomas, sexually transmitted diseases, or PID is also pertinent. Because prior conception indicates ovulation and a patent fallopian tube in the patient’s past, this history is sought. A prolonged time to conception may suggest borderline fertility and may increase the chance of determining an etiology. Pregnancy complications such as miscarriage, preterm delivery, retained placenta, postpartum dilatation and curettage, chorioamnionitis, or fetal anomalies are also recorded. Prior abnormal Pap testing may be relevant, particularly if a woman underwent cervical conization, which can diminish cervical mucus and cervical competence. A coital history, including frequency and timing of intercourse, is also obtained. Symptoms such as dyspareunia may point to endometriosis and a need for earlier diagnostic laparoscopy for the female partner.

Medical and Surgical

During medical history inventory, symptoms of hyperprolactinemia or thyroid disease are sought. Symptoms of androgen excess such as acne or hirsutism may point to polycystic ovarian syndrome (PCOS) or much less commonly, congenital adrenal hyperplasia. Prior chemotherapy or pelvic irradiation may suggest ovarian failure. This is also an excellent opportunity to ensure that all indicated vaccinations are current, as several are contraindicated once pregnancy is achieved (American Society for Reproductive Medicine, 2013d). Vaccine indications and schedules are found in Table 1-2.

Questions regarding medications include over-the-counter agents, such as nonsteroidal antiinflammatory drugs, that may adversely affect ovulation. In most instances, herbal remedies are discouraged. Women are encouraged to take a daily vitamin with at least 400 μg of folic acid to decrease the chance of neural-tube defects. In those with a previously affected child, 4 g is taken orally daily (American College of Obstetricians and Gynecologists, 2014b).

Previous pelvic and abdominal surgeries, especially if linked to endometriosis or adhesion formation, can lower fertility. As examples, operations for ruptured appendicitis or diverticulitis raise suspicion for pelvic adhesive disease or tubal obstruction or both. Prior uterine surgery can predispose to pain, bowel obstruction, or extra- or intrauterine adhesions with resultant infertility. When planning surgery, reducing adhesion formation is a priority, and meticulous surgical technique and minimally invasive surgical approaches are favored. Surgical adhesion barriers, described in Chapter 11, lower postoperative adhesion rates. However, no strong evidence exists that their use improves fertility, decreases pain, or lowers bowel obstruction rates (American Society for Reproductive Medicine, 2013b).

Social

A social history focuses on lifestyle factors such as eating habits. Abnormalities in gonadotropin-releasing hormone (GnRH) and gonadotropin secretion are clearly related to body mass indices >25 or <17 (Grodstein, 1994a). An estimated 30 to 50 percent of women, depending on race and ethnicity, are overweight or obese. Most agree that this incidence is increasing (American Society for Reproductive Medicine, 2008c; Hedley, 2004). In these women, infertility is primarily related to an increased incidence of ovulatory dysfunction, but data also suggest that fecundity is lower among ovulatory obese women. Although difficult to achieve, even modest weight reduction in overweight women is correlated with normalized menstrual cycles and subsequent pregnancies (Table 19-2).

Accumulating data also suggest that cigarette smoking lowers fertility rates (American Society for Reproductive Medicine, 2012d). At least one fifth of reproductive-aged men and women in the United States smoke cigarettes (Centers for Disease Control and Prevention, 2014). The prevalence of infertility is higher, and the time to conception is longer in women who smoke, or even those exposed passively to cigarette smoke. Moreover, smoking’s negative effects on female fecundity do not appear to be overcome by assisted reproductive technologies (ART). A 5-year prospective study of 221 couples found that the risk of failing to conceive with ART was more than doubled in smokers. Each year that a woman smoked was associated with a 9-percent increase in the risk of unsuccessful ART cycles (Klonoff-Cohen, 2001).

Toxins in the smoke can accelerate follicular depletion and increase genetic mutations in gametes or early embryos (Zenzes, 2000). Smoking is associated with an increased miscarriage rate in both natural and assisted conception cycles. The mechanism for this is unclear, but the vasoconstrictive and antimetabolic properties of some cigarette smoke components such as nicotine, carbon dioxide, and cyanide may lead to placental insufficiency. Specifically, smoking has been linked to higher rates of abruption, fetal growth restriction, and preterm labor (Cunningham, 2014). In addition, smoking in pregnant women is associated with an increased risk of trisomy 21 that results from maternal meiotic nondisjunction (Yang, 1999). Admittedly, current data do not prove causation, but only correlation, between smoking and infertility or adverse pregnancy outcomes.

The effect of smoking on male fertility is more difficult to discern. Although smokers often have comparatively reduced sperm concentrations and motility, these often remain within the normal range.

Smoking is discouraged for both male and female partners planning pregnancy. The desire for pregnancy can be a powerful motivator toward cessation (Augood, 1998). Education is the most important first step (Table 19-3). If behavioral approaches fail, use of medical adjuncts such as nicotine replacement therapy, bupropion (Zyban), or varenicline (Chantix) may prove effective (Table 1-4). Nicotine preparations are designated as category D. Bupropion and varenicline are non-­nicotine Food and Drug Administration (FDA)-approved agents and carry a category C designation (Fiore, 2008). Ideally pharmacological smoking cessation therapies are best used prior to conception.

Alcohol consumption also should be limited. Heavy alcohol intake decreases fertility in women, and in men has been associated with a decrease in sperm counts and increase in sexual dysfunction (Klonoff-Cohen, 2003; Nagy, 1986). A standardized alcoholic drink is typically defined as 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of hard alcohol. Based on several studies, five to eight drinks per week negatively affects female fertility (Grodstein, 1994b; Tolstrup, 2003). As alcohol is also detrimental to early pregnancy, it is prudent to advise patients to avoid excessive alcohol consumption while trying to conceive.

Caffeine is one of the most widely used pharmacologically active substances in the world. Studies evaluating a potential relationship between caffeine and impaired fertility have varied in design and resulted in conflicting findings. One large prospective trial found no association between either total caffeine intake or coffee consumption and fecundability (Hatch, 2012). Despite this, recommendations of caffeine intake moderation in infertile women seem prudent.

Illicit drugs may also affect fecundability. Marijuana suppresses the hypothalamic-pituitary-gonadal axis in both men and women, and cocaine can impair spermatogenesis (Bracken, 1990; Smith, 1987).

Environmental Factors

Increasing information suggests that some male and female infertility may result from environmental contaminants or toxins (Giudice, 2006). Endocrine-disrupting chemicals (EDCs) have been shown to be reproductive toxicants. Examples are dioxins and polychlorinated biphenyls, as well as agricultural pesticides and herbicides, phthalates (used in making plastic materials), lead, and bisphenol A (used in the manufacture of polycarbonate plastic and resins) (Hauser, 2008; Mendola, 2008). EDC exposure is implicated to underlie a broad range of women’s reproductive disorders. Lower fecundability and lower birthweight show the most solid evidence for this correlation (Caserta, 2011). Although direct links to infertility in humans are not conclusive, clinicians should counsel patients that environmental exposures to toxic substances should be avoided if possible. Currently, these cautions should be discussed carefully to avoid alarm.

Ethnicity and Family History

The ethnic background and family history of both partners influences the need for preconceptional testing. A family history of infertility, recurrent miscarriage, or fetal anomalies may point to a genetic etiology. Although the inheritance pattern is complex, data suggest that both PCOS and endometriosis occur in familial clusters. For example, a woman carries an estimated sevenfold increased risk of endometriosis over that of the general population if a single first-degree family member has the disease (Moen, 1993).

Genetic carrier screening can be offered preconceptionally or following conception. Testing before conception is often more straightforward and less stressful for the couple than delaying until pregnancy has been achieved. However, insurance carriers may decline to reimburse for this evaluation (American Academy of Pediatrics and American College of Obstetricians and Gynecologists, 2012). Preconception carrier screening also allows a couple to consider the most complete range of reproductive options. Knowing the risk of having an affected child, a couple may consider preimplantation genetic diagnosis, prenatal genetic testing, or the use of donor gametes (American College of Obstetricians and Gynecologists, 2014e). In the absence of known family history of genetic disease, it is reasonable to offer genetic carrier screening to the woman first and test the male partner only if the mother has positive results.

Specific recommendations for genetic carrier screening have been published by the American College of Obstetricians and Gynecologists (2009, 2014a,c,d), by the American College of Medical Genetics and Genomics, and by other advocacy groups and societies (Grody, 2013; Gross, 2013; Pletcher, 2006). These opinions have changed over time and continue to vary across organizations. No doubt, screening guidelines will continue to evolve as technology advances and the costs and benefits of obtaining this information become more evident. Certain disorders are more common in specific ethnic groups, although it is essential to note that there are no disorders found uniquely in a certain ethnic or racial group. Many families may be interracial and ethnic background may be unknown. For example, cystic fibrosis screening was initially recommended only for the non-Hispanic white population and those of Ashkenazi Jewish descent. However, this recommendation now extends to all individuals to account for increased numbers of individuals with mixed ethnicity and inaccuracies based on personal reporting (Ross, 2011; Tanner, 2014).

Traditional genotyping methods detect a limited number of mutations, and these tests have been developed to be specific for the more common mutations found in the ethnic group most at risk. Expanded genotyping panels have been developed but are costly and remain limited. More recently, the cost of DNA sequencing has been greatly reduced due to the emergence of next-generation sequencing (NGS) techniques (Hallam, 2014). This allows rapid and efficient testing of many genes and thousands of mutations concurrently. Panethnic population screening by NGS for numerous genetic disorders is now technically feasible. Given that a large number of sequence variants might be identified by NGS that are not disease causing, rigorous analytic and clinical validation is required before widespread clinical application is begun (Prior, 2014).

Male History

Similar attention is paid to assessing the male partner’s potential contribution to infertility (American Society for Reproductive Medicine, 2012b). Questions include abnormalities in pubertal development and sexual function. Erectile dysfunction, particularly in conjunction with decreased beard growth, may suggest decreased testosterone levels. Ejaculatory problems are also evaluated, including a search for developmental anomalies such as hypospadias, which could result in suboptimal semen deposition (Benson, 1997).

Sexually transmitted diseases or frequent genitourinary infections, including epididymitis or prostatitis, may lead to vas deferens inflammation and obstruction. Similarly, mumps in an adult can create testicular inflammation and damage spermatogenic stem cells (Beard, 1977). Prior cryptorchidism, testicular torsion, or testicular trauma may suggest abnormal spermatogenesis (Anderson, 1990; Cobellis, 2014). Compared with fertile males, males with unilateral or bilateral cryptorchidism have fertility rates of 80 percent and 50 percent, respectively (Lee, 1993). The reason for poor semen characteristics in these patients is unclear. The relatively warm intraabdominal temperature may cause permanent stem cell damage. Alternatively, genetic abnormalities that led to the abnormal testis location may also affect sperm production.

A history of varicocele is also obtained. A varicocele consists of dilated veins of the pampiniform plexus of the spermatic cords that drain the testes (Figs. 19-2 and 19-3). Varicoceles are believed to raise scrotal temperature, however, the negative affects of varicoceles on fertility are controversial (American Society for Reproductive Medicine, 2014b; Baazeem, 2011; Jarow, 2001). Although 30 to 40 percent of men seen in infertility clinics are diagnosed with a varicocele, nearly 20 percent of men in the general population are similarly affected. If a varicocele is suspected, it should be evaluated by a urologist, preferably one with a specific interest in infertility.

Spermatogenesis, from stem cell to mature sperm, takes nearly 90 days (Fig. 19-4). Thus, any detrimental event in the prior 3 months can adversely affect semen characteristics (Hinrichsen, 1980; Rowley, 1970). Spermatogenesis is optimal at temperatures slightly below body temperature, hence the location of the testes outside of the pelvis. Illness with high fevers or chronic hot tub use can temporarily impair sperm quality. There is no definitive evidence that boxer underwear is advantageous.

Medical questions focus on prior chemotherapy or local radiation treatment that may damage spermatogonial stem cells. Hypertension, diabetes mellitus, and neurologic disorders can be associated with erectile dysfunction or retrograde ejaculation. Several medications are known to worsen semen characteristics, including cimetidine, erythromycin, gentamicin, tetracycline, and spironolactone (Sigman, 1997). Moreover, obesity, cigarettes, alcohol, illicit drugs, and environmental toxins all adversely affect semen parameters (Muthusami, 2005; Ramlau-Hansen, 2007). The increasing use of anabolic steroids also decreases sperm production by suppressing the output of intratesticular testosterone (Gazvani, 1997). Although the effects of many medications are reversible, anabolic steroid abuse may lead to lasting or even permanent damage to testicular function.

Examination of the Female Patient

A physical examination may provide many clues to the cause of infertility. Vital signs, height, and weight are recorded. A particularly short stature may reflect a genetic condition such as Turner syndrome. Hirsutism, alopecia, or acne indicates the need to measure androgen levels. Acanthosis nigricans is consistent with insulin resistance associated with PCOS or much less commonly, Cushing syndrome. Galactorrhea is often indicative of hyperprolactinemia. Additionally, thyroid abnormalities are sought. Many of these diagnoses and their management are discussed in greater detail in other chapters (Table 19-4).

A pelvic examination may be particularly informative. Inability to place a speculum through the introitus may raise doubts about coital frequency. The vagina should be moist and rugated, and the cervix should have a reasonable amount of mucus. Both indicate adequate estrogen production. An enlarged or irregularly shaped uterus may reflect leiomyomas, whereas a fixed uterus suggests pelvic scarring due to endometriosis or prior pelvic infection. Uterosacral nodularity or ovarian masses may additionally implicate endometriosis or less commonly, malignancy.

All women should have cervical cancer screening that is up-to-date prior to treatment. Negative cultures for Neisseria gonorrhoeae and Chlamydia trachomatis are obtained to ensure that cervical manipulation during evaluation and treatment does not cause ascending infection. The breast examination must be normal, and when indicated by age or family history, a mammogram is obtained prior to initiating hormonal treatment.

Examination of the Male Patient

Most gynecologists will not feel comfortable performing a complete male physical examination. Nevertheless, parts of this evaluation are relatively easy to perform, and a gynecologist at minimum should understand the primary focus of the examination. As signs of testosterone production, normal secondary sexual characteristics such as beard growth, axillary and pubic hair, and perhaps male pattern balding should be present. Gynecomastia or eunuchoid habitus may suggest Klinefelter syndrome (47,XXY karyotype) (De Braekeleer, 1991).

The penile urethra should be at the glans tip for proper semen deposition in the vagina. Testicular length measures at least 4 cm and a minimal testicular volume is 20 mL (Charny, 1960; Hadziselimovic, 2006). Small testes are unlikely to produce normal sperm numbers. A testicular mass may indicate testicular cancer, which can present as infertility. The epididymis should be soft and nontender to exclude chronic infection. Epididymal fullness may suggest vas deferens obstruction. The prostate should be smooth, nontender, and normal size. Additionally, the pampiniform plexus of veins is palpated for varicocele (Jarow, 2001). Importantly, both vasa deferentia should be palpable. Congenital bilateral absence of the vas deferens is associated with mutation in the gene responsible for cystic fibrosis and is discussed on page 444 (Anguiano, 1992).

The infertility evaluation can be conceptually simplified into confirmation of: (1) ovulation, (2) normal female reproductive tract anatomy, and (3) normal semen characteristics. The specifics regarding evaluation of each of these categories are detailed in the following sections and shown in Table 19-5.

Of these, ovulation may be perturbed by abnormalities within the hypothalamus, anterior pituitary, or ovaries. Hypothalamic disorders may be acquired or inherited. Acquired disorders include those due to lifestyle, for example, excessive exercise, eating disorders, or stress. Alternatively, ­dysfunction or improper migration of the hypothalamic ­gonadotropin-releasing hormone neurons may be inherited, such as that which occurs in idiopathic hypogonadotropic hypogonadism (IHH) or Kallman syndrome. Thyroid disease and hyperprolactinemia may also contribute to menstrual disturbances. A full discussion of endocrine-related disorders that result in menstrual disturbances is found in Chapter 16.

Clinical Evaluation

A patient’s menstrual history is an excellent predictor of regular ovulation. A woman with cyclic menses at an interval of 25 to 35 days and duration of bleeding of 3 to 7 days is most likely ovulating. Although these numbers vary widely, each woman will have her own normal pattern. Therefore, these figures typically do not vary significantly across cycles for an individual woman.

Probable ovulation is also suggested by mittelschmerz, which is midcycle pelvic pain associated with ovulation, or by moliminal symptoms such as breast tenderness, acne, food cravings, and mood changes. Ovulatory cycles are more likely to be associated with dysmenorrhea. Severe dysmenorrhea may suggest endometriosis.

Basal body temperature (BBT) charting has long been used to identify ovulation. This test requires that a woman’s morning oral temperature be graphically charted (Fig. 19-5). Oral temperatures are usually 97.0° to 98.0°F during the follicular phase. A postovulatory rise in progesterone levels increases basal temperature by approximately 0.4° to 0.8°F. This biphasic temperature pattern is strongly predictive of ovulation (Bates, 1990). Nevertheless, although this test has the advantage of being inexpensive, it is insensitive in many women. Furthermore, for a couple wishing to conceive, the temperature increase follows ovulation, and therefore the window of maximal fertility has been missed (Luciano, 1990). Although this method is discussed here for completeness, most patients are better served by the use of the sensitive and readily available urinary ovulation detection kits described in the next section.

Ovulation Predictor Kits

These kits measure urinary luteinizing hormone (LH) concentration by colorimetric assay. They are widely available in pharmacies, are relatively easy to use, and provide clear instructions regarding interpretation. In general, a woman begins testing 2 to 3 days prior to the predicted LH surge, and testing is continued daily. There is no clear consensus regarding the optimal time of day to test. Some specialists suggest that the concentrated first morning void is a logical time. Others are concerned that this sample may provide a false-positive result and recommend testing the second morning urine. Other clinicians reason that the serum LH peak occurs in the morning and that the greatest likelihood of detecting a urinary peak would be in the late afternoon or evening. Timing is probably not critical as long as the test is performed daily, as the LH surge spans only 48 to 50 hours. In most instances, ovulation will occur the day following the urinary LH peak (Luciano, 1990; Miller, 1996).

If equivocal results are obtained, the test can be repeated in 12 hours. In one study, urine LH surge assays were estimated to have 100-percent sensitivity and 96-percent accuracy. This is undoubtedly an overestimate of typical-use results (Grinsted, 1989; Guermandi, 2001).

Serum Progesterone

Adequate progesterone levels are required for endometrial preparation prior to implantation. This has led to the concept of luteal phase defect (LPD), defined as inadequate endometrial development due to suboptimal progesterone production (American Society for Reproductive Medicine, 2012f).

Midluteal phase serum progesterone levels have long been used to document ovulation, although the sensitivity of this test has been questioned. In a classic 28-day cycle, serum is obtained on cycle day number 21 following the first day of menstrual bleeding, or 7 days following ovulation. Levels during the follicular phase are generally <2 ng/mL. Values above 4 to 6 ng/mL correlate with ovulation and progesterone production by the corpus luteum (Guermandi, 2001). Progesterone is secreted as pulses, and therefore a single measurement does not indicate overall production during the luteal phase. As a result, an absolute threshold for acceptable progesterone levels has not been clearly established. Although some clinicians empirically treat any woman with a progesterone level below approximately 10 ng/mL, the utility of this approach is unproven, and it is costly. Accordingly, the midluteal progesterone level is best regarded as an acceptable test for ovulation but not an absolute indicator of adequate luteal function.

Endometrial Biopsy

Luteal phase endometrial biopsy was hoped to reflect both corpus luteum function and endometrial response, and thereby provide more clinically relevant information than a serum progesterone level alone (Noyes, 1975). Unfortunately, the utility of this test is severely hampered by high intraobserver and interobserver variability during histologic evaluation. An out-of-phase biopsy is found nearly as frequently in fertile as in infertile women, and the overlap in incidence between the two groups is large (Balasch, 1992; Scott, 1993). In its current form, the endometrial biopsy has little predictive value and is no longer considered a routine part of infertility evaluation.

Interestingly, the timing of protein expression in the endometrial glands and stroma is being defined. Potential markers for uterine receptivity include osteopontin, cytokines (leukemia inhibitory factor, colony-stimulating factor-1, and ­interleukin-1), cell adhesion molecules (the integrins), ion channels, and the L-selectin ligand (Carson, 2002; Garrido-Gomez, 2014; Kao, 2003; Lessey, 1998; Petracco, 2012; Ruan, 2014). In the future, endometrial biopsies may again become part of the diagnostic evaluation if expression patterns of these proteins prove to be predictive of endometrial receptivity.

Sonography

Serial ovarian sonographic evaluations can demonstrate the development of a mature antral follicle and its subsequent collapse during ovulation. This approach is time consuming, and ovulation can be missed. However, sonography is an excellent approach for supporting the diagnosis of PCOS. Sonographic criteria for PCOS are found in Chapter 17.

Ovulatory status does not provide a complete picture of ovarian function. A woman may have regular, ovulatory menses but have reduced follicular response to ovarian stimulation compared with other women of similar age due to a decrease in ovarian follicles available for recruitment. In this situation, the woman is said to have decreased or diminished ovarian reserve (DOR) and in more severe presentations, primary ovarian insufficiency (POI). Although most often the result of advancing age, a decrease in ovarian reserve can occur for other reasons including smoking, genetic conditions, or prior ovarian surgery, chemotherapy, or pelvic irradiation (American College of Obstetricians and Gynecologists, 2015; American Society for Reproductive Medicine, 2012e). A more complete discussion of causes of accelerated follicular loss is found in Chapter 16.

Reproductive Aging

There is a clear inverse relationship between female age and fertility (Table 19-6) (American Society for Reproductive Medicine, 2014a). This loss is primarily attributable to a decrease in oocyte quality and quantity, although accumulating risk for the development of medical disorders or uterine and pelvic abnormalities also contributes. A classic study was performed in the Hutterites, a community that eschews contraception. After ages 34, 40, and 45, the incidence of infertility was 11 percent, 33 percent, and 87 percent, respectively. The average age at last pregnancy was 40.9 years (Menken, 1986; Tietze, 1957). Another study evaluated cumulative pregnancy rates in women using donor insemination. In women younger than 31 years, 74 percent achieved pregnancy within 1 year. These rates fell to 62 percent for women between 31 and 35 years, and further declined to 54 percent in women older than 35 (Treloar, 1998).

Ongoing atresia of nondominant follicles proceeds throughout a woman’s reproductive life span (Fig. 14-1). In addition to follicular number decline, the risks of genetic abnormalities and mitochondrial deletions in the remaining oocytes substantially increase as a woman ages (Keefe, 1995; Pellestor, 2003). These factors result in decreased pregnancy rates and increased miscarriage rates in both spontaneous and stimulated cycles. The overall miscarriage risk in women older than 40 years has been estimated to be 50 to 75 percent (Maroulis, 1991).

The follicular loss rate and age at menopause varies between women and is likely genetically determined. For example, a family history of early menopause is correlated with an increased risk of early menopause in an individual woman. In general, the age at last birth in naturally fertile populations averages 10 years prior to menopause (Nikolaou, 2003; te Velde, 2002). However, in most cases, it is impossible to predict the onset of menopause. Therefore fertility testing is ideally performed starting at age 35 in all patients desiring conception. Testing is also seriously considered in any woman with an unexplained change in menstrual cyclicity, family history of early menopause, or risk factor for POI.

An array of serum and sonographic tests has been developed to assess ovarian reserve (American Society for Reproductive Medicine, 2012e). Unfortunately, these tests lack sensitivity and positive predictive value for DOR, particularly if applied to patients at low risk for this process. In addition, these tests are more accurate as predictors of ovarian response to pharmacologic stimulation than as predictors of subsequent pregnancy. Identification of the optimal combination of tests and their appropriate interpretation continues to be refined. Currently, measurement of early follicular FSH and estradiol levels is probably the most cost-effective approach for the general practitioner. However, addition of a serum antimüllerian hormone level is moving into standard practice. Measurement of serum inhibin B levels or use of the clomiphene citrate challenge test has fallen out of favor.

Abnormal test results from any of these methods correlate with a poorer prognosis for achieving pregnancy, and referral to an infertility specialist is advisable. Conversely, a normal test does not negate the impact of a woman’s age on her fertility status. This information may be useful in counseling a couple regarding prognosis. Poor results in an older woman can supply an impetus either to attempt donor oocyte in vitro fertilization (IVF) or to pursue alternatives such as adoption. Borderline results in a younger woman may suggest a need for more intensive treatment.

Follicle-stimulating Hormone and Estradiol

Measurement of serum follicle-stimulating hormone (FSH) levels in the early follicular phase is a simple and sensitive predictor of ovarian reserve (Toner, 1991). Frequently termed a “cycle day 3” FSH, this may reasonably be drawn between days 2 and 4. With declining ovarian function, the support cells (granulosa cells and luteal cells) secrete less inhibin, a peptide hormone that is responsible for inhibiting FSH secretion by the anterior pituitary gonadotropes (Chap. 15). With loss of luteal inhibin, FSH levels rise in the early follicular phase. A value >10 mIU/mL indicates significant loss of ovarian reserve and prompts a more rapid evaluation and more intensive treatment. In a large study evaluating IVF cycles, a day-3 FSH level exceeding 15 mIU/mL predicted significantly lower pregnancy rates (Toner, 1991).

Many clinicians also measure serum estradiol levels simultaneously (Buyalos, 1997; Licciardi, 1995). Addition of an estradiol measurement may decrease the incidence of false-negative results in FSH values alone. Somewhat paradoxically, despite the overall depletion of ovarian follicles, estrogen levels in older women are elevated early in the cycle due to increased stimulation of ovarian steroidogenesis by elevated FSH levels. An early-follicular serum estradiol level >60 to 80 pg/mL is considered abnormal. Notably, reference levels for estradiol and FSH can vary between laboratories. Thus, every clinician should be familiar with their own laboratory’s normal values.

Antimüllerian Hormone

This is the most recent circulating factor to be analyzed as an ovarian reserve predictor (La Marca, 2009). As suggested by its name, antimüllerian hormone (AMH) is expressed by the fetal testes during male differentiation to prevent development of the müllerian system (fallopian tubes, uterus, and upper vagina) (Chap. 18). AMH is also expressed by the granulosa cells of small preantral follicles, with limited expression in larger follicles. This suggests that AMH plays a role in dominant follicle recruitment.

Because AMH is thought to vary minimally across the cycle, measurement of AMH levels provide an advantage compared with FSH testing. However, new studies demonstrate larger fluctuations than originally reported (Gnoth, 2015). In addition, recent or ongoing use of hormonal contraceptives may affect serum AMH levels (Johnson, 2014). At this point, it is reasonable to obtain an AMH level during the follicular phase coincident with measuring an FSH level. Notably, these recommendations may change in the near future.

Recent studies suggest that AMH levels correlate with ovarian primordial follicle number more strongly than do levels of FSH or inhibin (Hansen, 2010). Furthermore, AMH levels may drop prior to observable changes in FSH or estradiol levels, providing an earlier marker of waning ovarian function. Seifer and colleagues (2011) reported a steady decline in AMH serum levels across the reproductive life span. The median level approximated 3 ng/mL at age 25, and this dropped to 1 ng/mL at age 35 to 37. Several AMH assays are commercially available, and thus patient results are interpreted relative to normative data provided for the selected assay. Interestingly, AMH levels are increased two- to threefold in women with PCOS compared with normal cycling women (Hornburg, 2014). This observation is consistent with the multiple early follicles found in these patients.

Antral Follicle Count

Sonographic evaluation of the follicular phase antral follicle count (AFC) is commonly used as a reliable predictor for subsequent response to ovulation induction (Frattarelli, 2000; Maseelall, 2009). The number of small antral follicles reflects the size of the resting follicular pool. Antral follicles between 2 and 10 mm are counted in both ovaries. The total AFC usually ranges between 10 and 20 in a reproductive-aged woman. A count <10 predicts poor response to gonadotropin stimulation.

Tubal and Pelvic Factors

Symptoms such as chronic pelvic pain or dysmenorrhea may suggest tubal obstruction, pelvic adhesions, or both. Adhesions can prevent normal tubal movement, ovum pick-up, and transport of the fertilized egg into the uterus. Etiologies include tubal disease, especially pelvic infection; endometriosis; and prior pelvic surgery.

Approximately one third to one fourth of all infertile women are diagnosed with tubal disease in developed countries (Serafini, 1989; World Health Organization, 2007). In the United States, the most common cause of tubal disease is infection with C trachomatis or N gonorrhoeae. With PID, tubal infertility has been estimated to follow in 12 percent, 23 percent, and 54 percent of women following one, two, or three cases of PID, respectively (Lalos, 1988). Nevertheless, an absent PID history is not overly reassuring, as nearly one half of patients who have tubal damage have no clinical history of antecedent disease (Rosenfeld, 1983).

In contrast, in developing countries, genital tuberculosis may account for 3 to 5 percent of infertility cases (Aliyu, 2004; Nezar, 2009). As a result, this diagnosis is considered in immigrant populations from countries with endemic infection. In these cases, tubal damage and endometrial adhesions are underlying causes. Genital tuberculosis typically follows hematogenous seeding of the reproductive tract from an extragenital primary infection. The likelihood of a return to fertility after antitubercular treatment is low, and IVF with embryo transfer remains the most reliable approach (Aliyu, 2004).

With endometriosis, chronic inflammation and intraperitoneal bleeding can lead to pelvic adhesions and subsequently impaired oocyte pick-up, compromised oocyte or embryonic uterotubal transport, or frank tubal obstruction. Endometriosis also is thought to diminish fertility via an increase in peritoneal fluid inflammatory factors, alterations in endometrial immunologic function, poor oocyte or embryonic quality, or impaired implantation (American Society for Reproductive Medicine, 2012c).

Salpingitis isthmica nodosa is an inflammatory condition of the fallopian tube, characterized by nodular thickening of its isthmic portion. Histologically, smooth muscle proliferation and diverticula of tubal epithelium contribute to this ­thickening. This uncommon condition typically develops bilaterally and progressively leads to ultimate tubal occlusion and infertility (Saracoglu, 1992). Treatment options include those for proximal tubal occlusion, discussed in Chapter 20.

Of note, a prior ectopic pregnancy, even if treated medically with methotrexate, implies the likelihood of significant tubal damage. Residual adhesions are common after even the most meticulous surgery for any pelvic pathology. This is particularly true in cases with associated pelvic inflammation due to blood or infection. Irritation caused by mature cystic teratoma (dermoid) contents may be particularly damaging.

Uterine Abnormalities

Uterine abnormalities can be either inherited (congenital) or acquired. Common congenital anomalies include uterine septum, bicornuate uterus, unicornuate uterus, and uterine didelphys. With the possible exception of a large uterine septum, the fertility effects of these anomalies have been difficult to verify, although a subset are clearly associated with pregnancy complications. As a uterine septum can now be removed relatively simply and safely with hysteroscopy, most infertility specialists will proceed with surgery if this anomaly is identified. Clinical findings and management of congenital reproductive tract anomalies are fully described in Chapter 18.

Acquired anomalies include intrauterine leiomyomas, polyps, and Asherman syndrome. Of these, leiomyomas may diminish fertility by proposed mechanisms including endometrial cavity distortion with associated changes in blood flow and endometrial maturation; endometrial inflammation; disordered uterine contractility that may hinder sperm or embryo transport; obstruction of the proximal fallopian tubes; or interference with ovum capture (American Society for Reproductive Medicine, 2008b; Makker, 2013; Metwally, 2012; Pritts, 2001; Samejima, 2014). Thus far, no algorithm incorporating tumor number, volume, or location accurately predicts the need to remove them, either to improve implantation rates or to decrease pregnancy complications. Of these, miscarriage, placental abruption, and preterm labor are potential problems. Nevertheless, although not supported by definitive evidence, most experts suggest removal of submucosal fibroids that significantly distort the endometrial cavity. In addition, many consider surgical excision of leiomyomas larger than 4 to 5 cm or multiple smaller tumors in this range regardless of location. Importantly, surgical benefits are weighed against postoperative complications that lower subsequent fertility. These include pelvic adhesion formation, creation of Asherman syndrome following large submucous leiomyoma removal, or the need for cesarean delivery if the full myometrial thickness is transected.

Endometrial polyps are found in an estimated 3 to 5 percent of infertile women (Farhi, 1995; Soares, 2000). The prevalence is higher in women with symptoms such as intermenstrual or postcoital bleeding. Although these complaints typically prompt hysteroscopic removal, most data have not clearly demonstrated an indication for removing polyps in otherwise asymptomatic women (Ben-Arie, 2004; DeWaay, 2002; Jayaprakasan, 2014). Of note, however, one study suggested that removal of even small polyps (<1 cm) may improve pregnancy rates following intrauterine insemination (Perez-Medina, 2005).

The presence of intrauterine adhesions, also called synechiae, is termed Asherman syndrome. This diagnosis is discussed in Chapter 16. Asherman syndrome develops most frequently in women with prior uterine dilation and curettage, particularly in the context of infection and pregnancy (Schenker, 1996). The clinical history will often include an acute postsurgical decrease in menstrual bleeding or even amenorrhea. A woman with an intrauterine device (IUD) complicated by infection or a woman with genital tuberculosis is also at high risk for intrauterine adhesions. Treatment of Asherman syndrome involves hysteroscopic lysis of the scar tissue as described in Chapter 20 and Section 44-19.

Anatomy Evaluation

Several approaches for evaluating pelvic anatomy are: (1) hysterosalpingography (HSG), (2) transvaginal sonography (TVS) with or without saline instillation, (3) 3-dimensional (3-D) TVS, (4) hysteroscopy, (5) laparoscopy, and (6) pelvic imaging by magnetic resonance (MR) imaging. As shown in Table 19-7, each has its own advantages and disadvantages.

Hysterosalpingography

This radiographic tool can display the shape and size of the uterine cavity and define tubal status. Hysterosalpingography is generally performed on cycle days 5 through 10. At this time, few intrauterine clots should remain to block tubal outflow or give the false impression of an intrauterine abnormality. Furthermore, a woman theoretically has not ovulated or possibly conceived. For this test, iodinated contrast medium is infused through a catheter placed into the uterus. With fluoroscopy, dye is visually followed as it fills the uterine cavity, then the tubal lumen, and finally spills out of the tubal fimbria into the pelvic cavity (Fig. 19-6).

In a large metaanalysis, HSG was demonstrated to have 65-percent sensitivity and 83-percent specificity for tubal obstruction (Swart, 1995). Tubal contractions, particularly cornual spasm, can give the incorrect impression of proximal fallopian tube obstruction (a false-positive result). Much less commonly reported is a scenario in which a false-negative result is obtained when the fallopian tube is seen as patent by HSG, although subsequently it is determined to be blocked. Many causes of tubal disease affect both tubes, and thus unilateral disease is unusual. Unilateral obstruction with a normal contralateral tube is most likely due to the dye following the path of least resistance during the HSG procedure. However, laparoscopy with chromotubation is considered prior to treatment to confirm a final diagnosis.

HSG is not reliable in detecting peritubal or pelvic adhesions, although loculations of dye around the tubes may be suggestive. Thus, HSG is an excellent predictor of tubal patency but is less effective at predicting normal tubal function or the presence of pelvic adhesions. Pregnancy rates have been reported to be increased following HSG and are thought to follow flushing of intratubal debris. However, these reports described evaluation with oil-based dyes rather than water-based dyes, which are currently preferred.

HSG also provides analysis of the intrauterine cavity contour. A polyp, leiomyoma, or adhesion within the cavity will block dye diffusion and create an intrauterine “defect” in dye opacity on the radiograph (Fig. 19-7). Although false-positive results may originate from blood clots, mucus plugs, or shearing of the endometrium during placement of the intrauterine catheter, HSG accurately identifies intrauterine pathology. In one study of more than 300 women in which hysteroscopy was the gold standard, HSG was determined to be 98-percent sensitive and 35-percent specific and have a positive predictive value of 70 percent and a negative predictive value of 8 percent. Most misdiagnoses were due to an inability to distinguish polyps from submucous leiomyomas. Other studies have reported much less impressive results. For example, Soares and coworkers (2000) reported sensitivity and positive predictive values of only 50 and 30 percent, respectively, for endometrial polyp and submucous leiomyoma detection in asymptomatic patients. Nevertheless, it is clear that HSG is a helpful tool for uterine cavity evaluation.

HSG can also define developmental uterine anomalies (Fig. 19-8). A Y-shaped uterus identified during HSG may represent either a uterine septum or bicornuate uterus. In these cases, the external contour of the uterine fundus must be evaluated using MR imaging, high-resolution sonography, 3-D TVS, or laparoscopy. With a uterine septum, a smooth fundal contour is found, whereas with a bicornuate uterus, a cleft between the two uterine horns is seen. This is an important distinction, as a septum is often resected, but a bicornuate uterus is usually not treated. In general, uterine anomalies do not cause infertility but may be associated with miscarriage or later fetal loss. Accordingly, it may be reasonable to surgically treat a uterine anomaly to improve pregnancy outcome. However, a couple must be carefully counseled that the conception rate itself is unlikely to be affected. A further discussion of the fertility effects of congenital anomalies is found in Chapter 18.

Sonography

Transvaginal pelvic sonography may be helpful in determining uterine anatomy, particularly during the luteal phase, when the thickened endometrium acts as contrast to the myometrium. Now more widely available, 3-D sonography is advancing discriminatory abilities (Chap. 2).

Infusion of saline into the endometrial cavity during sonography performed in the follicular phase provides another approach to create contrast between the cavity and uterine walls. This procedure has many names including hysterosonography, sonohysterography, or saline infusion sonography (SIS). Details of this procedure are described in Chapter 2. SIS has a reported sensitivity of 75 percent and specificity of more than 90 percent for detecting endometrial defects. It has an acceptable positive predictive value of 50 percent and an excellent negative predictive value of 95 percent, which greatly exceeds the negative predictive value of HSG (Grimbizis, 2010; Seshadri, 2015; Soares, 2000). Moreover, SIS may be more sensitive than HSG in determining whether a cavitary defect is a pedunculated leiomyoma or a polyp (Figs. 8-7 and 9-5). Perhaps more importantly, SIS can help determine what portion of a submucous leiomyoma lies within the cavity. Only those with more than 50-percent of their mass within the cavity are considered for hysteroscopic resection.

The primary limitation of SIS is that it does not provide information regarding the fallopian tubes, although rapid loss of saline into the pelvis is certainly consistent with at least unilateral patency. SIS is generally less painful than HSG and does not require radiation exposure. Thus, it is preferred if information about tubal patency is not required, such as in patients who are known to require IVF for other reasons such as severe oligospermia.

Laparoscopy

Direct inspection provides the most accurate assessment of pelvic pathology, and laparoscopy is the gold standard approach. Chromotubation may be performed, and a dilute dye is injected through an acorn cannula placed against the cervix or through a balloon catheter positioned within the uterine cavity. Tubal spill is evaluated through the laparoscope (Fig. 19-9). Indigo carmine dye, if available, is preferable to methylene blue, as the methylene blue rarely may induce acute methemoglobinemia, particularly in patients with glucose-6-phosphate dehydrogenase deficiency. One 5-mL vial of indigo carmine is mixed with 50 to 100 mL of sterile saline for injection through the cervical cannula. Laparoscopy allows both diagnosis and immediate surgical treatment of abnormalities such as endometriosis or pelvic adhesions. Laparoscopic ablation of these lesions may increase subsequent pregnancy rates (Chap. 10).

As laparoscopy is an invasive procedure, it is not advocated in place of HSG as part of the initial infertility evaluation. Exceptions include women with a history or symptoms suggestive of endometriosis or prior pelvic inflammation. However, even in these women, a preliminary HSG may be informative (De Hondt, 2005).

If laparoscopy is clearly indicated, then hysteroscopy can also be performed to evaluate the uterine cavity while the patient is under anesthesia. Moreover, in operative hysteroscopic cases, laparoscopy can help direct surgery and avoid perforation, for example, during septal incision.

Laparoscopy also may be considered in patients who fail to conceive with clomiphene or gonadotropin ovulation induction. If pelvic disease is found and treated, progression to IVF may be avoided. With improvements in IVF success rates, this latter argument is becoming less justifiable, as the cost of surgery well exceeds the cost of an IVF cycle.

Hysteroscopy

Endoscopic evaluation of the intrauterine cavity is the preferred method to define intrauterine abnormalities. Hysteroscopy can be performed in an office or operating room. With improved instrumentation, the ability to concurrently diagnose and treat abnormalities in the office is increasing. However, substantially more extensive hysteroscopic surgery is possible in the operating room. A fuller discussion of hysteroscopy and its indications is found in Chapter 41.

Cervical Factors

The cervical glands secrete mucus that is normally thick and impervious to sperm and ascending infections. High estrogen levels at midcycle change the quality of this mucus. It becomes thin and stretchy and has an increased sodium chloride concentration (Fig. 19-10). Estrogen-primed cervical mucus filters out nonsperm components of semen and forms channels that help direct sperm into the uterus. Midcycle mucus also creates a reservoir for sperm. This allows ongoing release during the next 24 to 72 hours and extends the potential time for fertilization (Katz, 1997).

Abnormalities in mucus production are most frequently observed in women who have undergone cryosurgery, cervical conization, or a loop electrosurgical excision procedure (LEEP) for treatment of cervical neoplasia. Cervical infection may also worsen mucus quality, but data are conflicting. Implicated agents include C trachomatis, N gonorrhoeae, Ureaplasma urealyticum, and Mycoplasma hominis (Cimino, 1993). Although there may be no advantage in terms of mucus quality, obtaining cultures for C trachomatis and N gonorrhoeae seems prudent to avoid causing ascending infection during HSG or intrauterine inseminations.

The postcoital test, also known as the Sims-Huhner test, was used historically to evaluate cervical mucus. For this test, a couple is requested to have intercourse on the day of ovulation. A subsequent sample of the cervical mucus is evaluated for elasticity (Spinnbarkeit) and the number of motile sperm per high-power field. This test has been hampered by a limited consensus on the definition of a normal test (Oei, 1995). Moreover, in a prospective, randomized trial, a normal postcoital test did not predict increased cumulative pregnancy rates (Oei, 1998).

Many infertility specialists recommend bypassing the cervix with intrauterine insemination (IUI) in any woman with prior cervical surgery, especially if she has noted a decrease in midcycle mucus production. The remaining utility of the postcoital test is for the rare couple who will not consider intrauterine insemination or do not have intrauterine insemination readily available. In regions of the world in which more specific testing cannot be obtained, a postcoital test will provide basic information regarding mucus production, appropriate intercourse practices, and presence of motile sperm.

Causes of male infertility can roughly be categorized as abnormalities of sperm production or sperm function or obstruction of the ductal outflow tract.

Normal Spermatogenesis

During evaluation of a male infertility patient, the basics of male reproductive physiology should be understood. Analogous to the ovary, testes have two functions: the generation of mature germ cells (sperm) and the production of male hormones, primarily testosterone. The seminiferous tubules contain developing sperm and support cells called Sertoli cells or sustentacular cells (see Fig. 19-4). The Sertoli cells form tight junctions that produce a blood-testis barrier. This avascular space within the seminiferous tubules protects sperm from antibodies and toxins but also makes these cells dependent on diffusion for oxygen, nutrients, and metabolic precursors. Located between the seminiferous tubules are Leydig cells, also called interstitial cells, which are responsible for steroid hormone production. In simplistic terms, Leydig cells are similar to the theca cells of the ovary.

Unlike the ovary, testes contain stem cells that allow ongoing production of mature germ cells throughout a male’s life. In a fertile male, approximately 100 to 200 million sperm are produced each day (Sigman, 1997). The process begins with a diploid (46,XY) spermatogonial cell, which grows and becomes a primary spermatocyte. The first meiotic division produces two secondary spermatocytes, and completion of meiosis results in four mature sperm with a haploid (23,X or 23,Y) karyotype. During this developmental process, most sperm cytoplasm is lost, mitochondria that provide energy are positioned in the sperm midpiece, and sperm flagella develop.

Production of sperm requires approximately 70 days. An additional 12 to 21 days is needed for sperm to be transported into the epididymis. Here, they further mature and gain motility (Heller, 1963; Hinrichsen, 1980; Rowley, 1970). Importantly, due to this prolonged developmental period, the results of a semen analysis reflect events during the past 3 months, not a single point in time.

To fertilize an oocyte, human sperm must undergo a process known as capacitation. Capacitation results in sperm hyperactivation (an extreme increase in movement) and the ability to release acrosomal contents, which allow penetration of the ovum’s zona pellucida.

Normal spermatogenesis is dependent on high local levels of testosterone. LH from the anterior pituitary gland stimulates production of testosterone by the Leydig cells. FSH increases LH receptor density on the Leydig cells, thus indirectly contributing to testosterone production. In addition, FSH increases production of sex hormone-binding globulin, also called androgen-binding protein. Androgen-binding protein binds testosterone and maintains high concentrations of this hormone in the seminiferous tubules (Sigman, 1997).

In addition to hormone levels, testicular volume often reflects spermatogenesis, and a normal volume is between 15 and 25 mL. Most of this volume is provided by the seminiferous tubules. Thus, decreased testicular volume is a strong indicator of abnormal spermatogenesis.

Spermatogenesis is directed by genes on the Y chromosome. Autosomal genes also provide important contributions, which continue to be elucidated. Therefore, genetic abnormalities may adversely affect this process, as discussed later.

Male fertility likely decreases modestly with increasing age. Several studies have demonstrated that pregnancy rates decline and time to conception lengthens as male age increases. Studies of semen parameters across age suggest that sperm concentration is maintained, however, sperm motility and morphology progressively worsen (Levitas, 2007). The clinical significance of this change is unclear (Kidd, 2001). In short, although advancing male age may lower fertility, it is probably insignificant compared with aging changes in women.

Semen Analysis

Collection

This is a core test in male fertility evaluation. For this test, the male is asked to refrain from ejaculation for 2 to 3 days, and a specimen is collected by masturbation into a sterile cup. If masturbation is not an option, then a couple can use specially designed Silastic condoms without lubricants. Importantly, the sample should arrive in the laboratory within an hour of ejaculation to allow for optimal analysis.

The sample undergoes liquefaction, or thinning of the seminal fluid, due to enzymes from the liquid contribution of the prostate gland. This process takes 5 to 20 minutes and allows more accurate evaluation of the sperm contained in the seminal fluid. Ideally, two semen samples separated by at least a month are analyzed. In practice, frequently only a single sample is analyzed if parameters are normal.

Semen Analysis Results

The reference values for the semen analysis are shown in Table 19-8. A clinician should remember several critical aspects of this test. First, semen characteristics vary across time in a single individual. Second, semen analysis results, particularly morphologic interpretation, differ between laboratories. Thus, reference ranges for the laboratory being used should be known. Note that the concept of “reference” range is more appropriate than “normal” range. Although total motile sperm count correlates with fertility, not all males with “normal” semen parameters display normal fertility (Guzick, 2001). Conversely, patients with semen analysis results outside the reference range may achieve pregnancy. The lack of absolute predictive value for this test is likely due to the fact that it does not provide information regarding sperm function, that is, the ultimate ability to fertilize an oocyte.

Most semen analysis reports will indicate semen volume, pH, and presence or absence of fructose. Nearly 80 percent of semen volume comes from the seminal vesicles. Seminal fluid is alkaline and is thought to protect sperm from acidity in prostatic secretions and in the vagina. Seminal fluid also provides fructose as an energy source for sperm. An acidic pH or lack of fructose is consistent with obstruction of the efferent ductal system (Daudin, 2000).

Of parameters, low semen volume often simply reflects incomplete specimen collection or short abstinence interval. However, it may indicate partial vas deferens obstruction or retrograde ejaculation. Partial or complete vas deferens obstruction may be caused by infection, tumor, prior testicular or inguinal surgery, or trauma. Retrograde ejaculation follows failed closure of the bladder neck during ejaculation and allows seminal fluid to flow backward into the bladder. Retrograde ejaculation is suspected in men with diabetes mellitus, spinal cord damage, or prior prostate or other retroperitoneal surgery that may have damaged nerves (Hershlag, 1991). Medications, particularly β-blockers, may contribute to this problem. A postejaculatory urinalysis can detect sperm in the bladder and confirm the diagnosis. If urine is properly alkalinized, these sperm are viable and can be retrieved to achieve pregnancy.

Sperm counts may be normal, or males may have low sperm counts (oligospermia), or no sperm (azoospermia) (Sharlip, 2002). Oligospermia is defined as a concentration less than 15 million sperm per milliliter, and counts below 5 million per milliliter are considered severe. The prevalence of azoospermia is approximately 1 percent of all men. Azoospermia may result from outflow tract obstruction, termed obstructive azoospermia, such as that which occurs with congenital absence of the vas deferens, severe infection, or vasectomy. Azoospermia may also follow testicular failure (nonobstructive azoospermia). In the latter case, careful centrifugation and analysis may identify a small number of motile sperm adequate for IVF use. Alternatively, this latter group may have viable sperm obtainable through either epididymal aspiration or testicular biopsy. As described later, endocrine and genetic evaluation is indicated for men with abnormal sperm counts.

Sperm movement is also assessed, and decreased sperm motility is termed asthenospermia. Some laboratories will distinguish between rapid (grade 3 to 4), slow (grade 2), and nonprogressive (grade 0 to 1) movement. Total progressive motility is the percentage of sperm exhibiting forward movement (grades 2 to 4). Asthenospermia has been attributed to prolonged abstinence, antisperm antibodies, genital tract infections, or varicocele. To differentiate between dead and nonmotile sperm, a hypoosmotic swelling test can be performed. Unlike dead sperm, living sperm can maintain an osmotic gradient. Thus, when mixed with a hypoosmotic solution, living, nonmotile sperm with normal membrane function swell and coil as fluid is absorbed (Casper, 1996). Once identified, these viable sperm may be used for intracytoplasmic sperm injection.

Abnormal sperm morphology is termed teratospermia or teratozoospermia. Kruger and colleagues (1988) developed a detailed characterization of normal sperm morphology, which showed improved correlation with fertilization rates during IVF cycles. Their criteria require careful analysis of the shape and size of the sperm head, the relative size of the acrosome in proportion to the head, and characteristics of the tail, including length, coiling, or presence of two tails. Significantly decreased fertilization rates are seen when normal morphology of the sample falls below 4 percent.

Round cells in a sperm sample may represent either leukocytes or immature sperm. White blood cells (WBCs) can be distinguished from immature sperm using various techniques, including a myeloperoxidase stain for WBCs (Wolff, 1995). True leukocytospermia is defined as greater than 1 million WBCs per milliliter and may indicate chronic epididymitis or prostatitis. In this scenario, many andrologists consider empiric antibiotic treatment prior to obtaining a repeat semen analysis. A common protocol would include doxycycline at a dosage of 100 mg orally twice daily for 2 weeks. Alternative approaches include culture of any expressible discharge or of the semen sample.

Unless a general obstetrician-gynecologist has developed a particular interest and expertise in the area of infertility, persistent abnormal semen analysis findings are an indication for referral to an infertility specialist. Although the partner may be referred directly to a urologist, it may be more reasonable to refer the couple to a reproductive endocrinologist, as the female will also require evaluation. Treatment is likely to be more complex in these couples and will typically be directed to both partners. The reproductive specialist can determine the need for further referral of the male partner to a urologist for investigation of a genetic, anatomic, hormonal, or infectious abnormality.

DNA Fragmentation

During the past 10 years, interest in elevated sperm DNA fragmentation as a cause of male factor infertility has increased (Sakkas, 2010; Zini, 2009). Although some degree of DNA damage is likely repaired during embryogenesis, the location and extent of damage may lower fertilization and increase miscarriage rates. Increased levels of DNA damage are associated with advanced paternal age and external factors such as cigarette smoking, chemotherapy, radiation, environmental toxins, varicocele, and genital tract infections. Studies have observed increased levels of reactive oxygen species in sperm samples with abnormal DNA fragmentation rates. In response to this observation, dietary supplementation with the antioxidants vitamin C and vitamin E has been proposed. However, data are currently lacking regarding the efficacy of this approach.

Numerous tests are currently available to analyze for DNA integrity and include the Sperm Chromatin Structure Assay (SCSA), the terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) assay, the single-cell gel electrophoresis assay (COMET), and the sperm chromatin dispersion test (SCD) (American Society for Reproductive Medicine, 2013c). Each of these tests provides semiquantitative data on DNA structure. For example, the SCSA is based on the increased susceptibility of DNA with single-strand or double-strand breaks to denature in weak acid. The TUNEL assay exploits the ability of labeled nucleotides to intercalate into DNA breaks for subsequent measurement. These tests are currently hampered by a lack of consensus regarding appropriate threshold values and by conflicting data regarding their ability to predict successful pregnancy. As a result, currently evidence is insufficient to recommend the routine use of these tests in infertile couples. Nevertheless, the concept that sperm DNA integrity can be adversely affected through multiple mechanisms provides useful insight into a previously underappreciated cause of male infertility.

Additional Sperm Testing

Antisperm antibodies may be detected in as many as 10 percent of men. However, controversy exists regarding the negative fertility effects of antisperm antibodies found in semen. These antibodies may be particularly prevalent following vasectomy, testicular torsion, testicular biopsy, or other clinical situations in which the blood-testis barrier is breached (Turek, 1994). Treatment historically included corticosteroids, but it is unclear if this approach improves fertility. Moreover, significant side effects, including aseptic necrosis of the hip, have been reported in treated patients. Current data suggest that antisperm antibody assay does not need to be a routine component of infertility evaluation.

Numerous assays have been developed to test sperm function. These include the mannose fluorescence assay, hemizona assay, sperm penetration assay, and acrosome reaction test. The predictive significance of these assays is questionable, as they are based on highly nonphysiologic conditions and results vary widely from infertility center to infertility center. Most are no longer used and are not considered part of a basic infertility evaluation.

Hormonal Evaluation of the Male

Hormonal testing in the male is analogous to endocrine testing in an anovulatory female. In overview, abnormalities may be due to central defects in hypothalamic-pituitary function or due to defects within the testes. Most urologists will defer testing unless a sperm concentration is below 10 million/mL. Testing will include measurements of serum FSH and testosterone levels.

Low FSH and low testosterone levels are consistent with hypothalamic dysfunction, such as idiopathic hypogonadotropic hypogonadism or Kallman syndrome (Chap. 16). In these patients, sperm production may be achieved with gonadotropin treatment. Although such treatment is frequently successful, at least 6 months may be required for detection of sperm production.

Elevated FSH and low testosterone levels provide evidence of testicular failure, and most men with oligospermia fall into this category. In this patient group, it is important to determine, based on testosterone levels, whether testosterone replacement is indicated. Normal spermatogenesis requires high levels of intratesticular testosterone, which cannot be achieved with exogenous testosterone. Furthermore, many of these men will lack spermatogonial stem cells. Thus, testosterone replacement will not rescue sperm production. In fact, replacement will decrease gonadotropin stimulation of remaining testicular function through negative feedback at the hypothalamus and pituitary. Unless the couple has chosen to use donor sperm, androgen supplementation is deferred during fertility treatment. However, replacement will provide other benefits, such as improved libido and sexual function, maintenance of muscle mass and bone density, and a general sense of well-being.

Additional hormonal testing may be included as part of an evaluation of the infertile male. Elevated serum prolactin levels and thyroid dysfunction affect spermatogenesis and are the most likely endocrinopathies to be detected (Sharlip, 2002; Sigman, 1997).

Genetic Testing of the Male

Genetic abnormalities are a relatively common cause of abnormal semen characteristics (American Society for Reproductive Medicine, 2008a). Approximately 15 percent of azoospermic men and 5 percent of severely oligospermic men will have an abnormal karyotype. Although genetic abnormalities cannot be corrected, they may have implications for the health of the patient or their offspring. Therefore, karyotyping is pursued when indicated by poor semen analysis results. The lower limit in sperm concentration for such testing varies between practitioners but lies between 3 and 10 million sperm per milliliter.

Klinefelter syndrome (47,XXY) will be a frequent finding. Klinefelter syndrome is observed in approximately 1 in 500 men in the general population and accounts for 1 to 2 ­percent of male infertility cases. Classically, these men are tall, undervirilized, and have gynecomastia and small, firm testes (De Braekeleer, 1991). As the phenotype varies widely, lack of these characteristics does not preclude chromosomal evaluation. Conversely, a clinician may strongly consider obtaining karyotype testing in any male with these characteristics. Autosomal abnormalities will also be found in a subset of men with severe oligospermia.

A patient with severely decreased sperm counts and a normal karyotype is offered testing for microdeletion of the Y chromosome. Up to 15 percent of men with severe oligospermia or azoospermia will have small deletions in a region of the Y chromosome termed the azoospermia factor region (AZF). If the deletion is within the AZFa or AZFb subregions, then it is unlikely that viable sperm can be recovered for use in IVF. Most men with an AZFc deletion will have viable sperm at biopsy. However, these deletions should be presumed to be inherited by their offspring. The clinical significance of microdeletions in the recently identified AZFd region is unknown, as these patients have apparently normal spermatogenesis (Hopps, 2003; Kent-First, 1999; Pryor, 1997).

Obstructive azoospermia may be due to congenital bilateral absence of the vas deferens (CBAVD). Approximately 70 to 85 percent of men with CBAVD will have mutations found in the cystic fibrosis transmembrane conductance regulator gene (CFTR gene), although not all will have clinical cystic fibrosis (Oates, 1994; Ratbi, 2007). Conversely, essentially all men with clinical cystic fibrosis will have CBAVD. Fortunately, testicular function in these men is usually normal, and adequate sperm may be obtained by epididymal aspiration to achieve pregnancy through IVF. Careful genetic counseling and testing of the female partner for carrier status is critical in these situations.

Testicular Biopsy

Evaluation of a severely oligospermic or azoospermic male may include either open or percutaneous testicular biopsy to determine whether viable sperm are present in the seminiferous tubules (Sharlip, 2002). For example, even men with testicular failure diagnosed by elevated serum FSH levels may have adequate sperm on biopsy for use in intracytoplasmic sperm injection. The biopsy specimen can be cryopreserved for future extraction of sperm during an IVF cycle. However, freshly biopsied specimens are generally felt to provide higher success rates. Thus, the biopsy may have diagnostic, prognostic, and therapeutic value.

Figure 19-11 provides an algorithm for the evaluation of an infertile couple. Details will vary between practitioners and will be affected by patient presentation. In general, the female partner has some form of testing to confirm ovulation and undergoes HSG, whereas the male partner has semen analysis performed. In older women, evaluation of an early-follicular serum FSH level is essential to ensure adequate follicular reserves. A subset of couples will decline HSG and semen analysis if the woman has a clear ovulatory defect. These couples are reminded that there is a relatively high incidence of couples having two abnormalities, one of which would be missed by this approach. These patients may be treated, but are strongly encouraged to complete the evaluation if they do not conceive within a few months. Options for treatment are discussed in Chapter 20.