UNDERSTANDING INFERTILITY
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ulating hormone. If the patient was in prior relationships without
contraception and did not get pregnant, and those partners have
now fathered children, this can point to the patient being the is-
sue. In addition, there are a lot of men who now take testosterone
supplements including injections, patches or pills; all of them can
have a detrimental effect on sperm production. It might take up
to a year for the semen analysis to return to normal after stopping
these supplements. Low testosterone by itself will also lower sperm
production and can lead to decreased sexual frequency. The part-
ner should be referred to a urologist for possible clomid or HCG
treatment. Finally, the majority of over-the-counter lubricants are
spermicidal and should not be used near ovulation.
Bimanual examinations can elucidate a large fibroid uterus but
more subtle abnormalities cannot be palpated, especially in our
larger patients. If possible, a transvaginal pelvic ultrasound should
be done on all patients. Adenomyosis, polyps, fibroids and some
uterine anomalies can be seen on ultrasound. A 3D reconstruction
of the uterine cavity is just as good as an MRI for differentiating
a uterine septum from a bicornuate or didelphys uterus. The en-
dometrial stripe should be less than six mm during the menstrual
cycle and around seven to 12 mm near ovulation. A thinner than
expected endometrium could indicate synechiae or anovulation.
Conversely, a thicker endometrium could also indicate anovulation
and endometrial hyperplasia or an intracavitary lesion.
Fallopian tubes should never be seen on ultrasound, so if there
is an adnexal tubular structure then this raises a concern for hy-
drosalpinx. Repair of a hydrosalpinx is less likely to be successful
if it has been visualized on ultrasound, and the patient should be
appropriately counseled about this.
There are three tests for ovarian reserve, and the number of
antral follicles (less than 10 mm) seen on ultrasound is one of them.
Every time one of your patients has an ultrasound in your office, you
should make sure that the sonographer gets an antral follicle count
(AFC). Five to 12 follicles per ovary is normal. Obviously, it is easier
to get this count in the follicular phase when all follicles are small,
but it can be done regardless of where the patient is in her cycle.
Ovarian ultrasounds can confirm pre-ovulatory follicles or a corpus
luteum showing that the patient is ovulatory for at least that cycle.
There are new guidelines for the number of follicles seen in
polycystic ovarian syndrome (PCOS). Though controversy exists
as to the exact number, most physicians are using greater than or
equal to 20 per ovary and not the Rotterdam criteria of greater than
or equal to 12. This change is secondary to improved ultrasound
machines and thus better imaging. Approximately 30% of women
with endometriosis will have an endometrioma on ultrasound, so
any hemorrhagic cyst should have a follow-up ultrasound to see
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LOUISVILLE MEDICINE
if it has resolved.
About 10 years ago, an ultrasound based tubal test was developed
called hysterosalpingo-contrast sonography or HyCoSy. This used
air bubbles seen in the adnexae as indicating tubal patency. The ac-
curacy of this test is less than that seen with a hysterosalpingogram
(HSG), is very operator dependent, and the air can cause significant
pain in patients. It has fallen out of favor and is not recommended.
Though uncomfortable and with its own limitations, the HSG
is still best at determining tubal patency and the presence of hy-
drosalpinges, peritubular adhesions or salpingitis isthmica nodosa
(SIN). When a proximal block is seen, this is actually tubal spasm
in about 70% of patients. When both tubes have a proximal block,
this is a tubal spasm in 30% of patients. This false positive result can
be minimized by having the patient take 800 mg of ibuprofen 45
minutes prior to the test to help relax the tube and by injecting the
dye slowly. If a proximal block is still seen, the radiology technician
can place an IV and give one mg glucagon and the HSG is repeated
one minute later. This can relax the tube in the majority of patients.
This adds about 10 minutes to the procedure. A normal result will
eliminate the need for a laparoscopy to check for blocked fallopian
tubes. In addition, pushing the radiopaque dye so that it spills distally
from the tubal opening can help rule out peritubular adhesions.
Blood work mainly focuses on ovarian reserve and ovulation.
As mentioned earlier, there is no cure for women with decreased
ovarian reserve due to age. Ovarian reserve testing includes Antral
Follicle Count (AFC) on ultrasound, measurement of Anti-Mul-
lerian Hormone (AMH) and cycle day three follicle stimulating
hormone (FSH) and estradiol. Serum AMH, if lower than normal,
is an indicator of reduced ovarian production of follicles. It can be
done on any day of the menstrual cycle and should be greater than
one ng/ml. Day three testing can be done between cycle days two
to five and FSH should be less than 10 IU/L and estradiol less than
60-80 pg/ml. Abnormal testing needs to be evaluated in context
with the patient’s age. There is controversy as to whether abnormal
tests result in decreased pregnancy rates, as younger women with
values indicating diminished ovarian reserve have still been shown
to achieve pregnancy results similar to those with normal testing.
These tests appear to be more predictive of pregnancy rates in wom-
en older than 35. The tests also can determine response to fertility
drugs, and thus doses can be adjusted appropriately.
The ovulatory progesterone level in the luteal phase can confirm
ovulation if drawn on cycle day 21 or later. As long as the value is in
the luteal range for your assay, it is a positive test. LH is released in a
pulsatile fashion from the pituitary after ovulation, and progesterone
levels will vary due to LH level variation. A luteal phase defect is
diagnosed not by the absolute progesterone level, again as long as