Infertility Workup and Treatment

By Jamie A. Grifo, M.D., Ph.D., F.A.C.O.G.

Infertility is defined as the inability to conceive after one year of trying. It is surprising to discover that it takes 1OO% of fertile couples (around 25 years old) 13 months to conceive. We have not been conditioned to think how inefficient the process of conception is, and are constantly bombarded with the plight of couples facing unplanned or unwanted pregnancies. Most people spend years trying to avoid pregnancy only to find out how difficult the process really is. If it takes this long for fertile couples to conceive, then how long does it take couples with identifiable problems to conceive? The answers are unknown and relate to the individual couple. One must always be cognizant of the fact that population statistics only give a relative level of expectation. They do not predict outcome for the individual. With these facts in mind one must approach each infertile couple uniquely, yet there are basic principles to follow which are covered below.

When should the workup begin?

Textbooks say that the infertility workup should not begin until the couple has tried for one year. This would not be practical for many patients as some don't start trying until their late thirties/early forties where time is a critical factor. Ideally the workup should begin as soon as the couple becomes concerned that there may be a problem. However, for some couples who deny that infertility may exist, this is later than it should be. For the younger couple a one year trial is reasonable, however if the couple becomes anxious, the workup should begin sooner. Older couples should begin the workup much sooner, because some problems take a long time to find and to correct.

What should the workup consist of?

This question is one of the most difficult and controversial questions that the infertile couple and their caregivers face. The infertility literature is packed with contradictory and confusing studies. There are hundreds of tests that can be done, many expensive and many with marginal utility. Therefore, at least initially, the basic workup should include tests that will result in identifying correctable causes of infertility. These tests include: semen analysis, cervical cultures, thyroid function, prolactin, hysterosalpingogram, and for the older women some test of ovarian reserve, such as the day three FSH and estradiol or the clomiphene challenge test. Other tests such as the post coital test, endometrial biopsy, antisperm antibody test, karyotype, laparoscopy, immunologic tests (antinuclear antibodies, lupus anticoagulant), hamster test, etc. should be used sparingly and in an individualized way to alter the treatment plan.

When should treatment begin?

Most medical treatments are based in empiricism. Infertility is the result of many factors that occur in a process that is poorly understood. Therefore, treatments have evolved in an empirical way. Large groups of patients with similar classification have been studied in a randomized trial of differing treatment modalities, and through statistical analysis, treatment regimens have been defined which are more effective. Often this is done with no understanding of what the basic scientific mechanism is. The result is that patients get evaluated, categorized and a treatment regimen applied often without understanding why the couple is having difficult conceiving. This fact is frustrating to both patient and clinician, but we must accept the limitation of our knowledge.

When identifiable causes of infertility are found, they should be treated immediately, and a trial of conception begun. However, often no identifiable causes for the problem can be found, and empiric treatment begins. These treatments include artificial insemination, ovulation induction with fertility drugs (clomiphene citrate, human menopausal gonadotropins) and the assisted reproductive technologies such as in vitro fertilization and gamete intra fallopian transfer (GIFT).

When should the treatment progress to more invasive options?

A general principle of medical practice is to use the simplest, least invasive, least expensive option and then progress to more involved choice. But how many cycles of a given option should be tried before moving on? This is a difficult question as no magic number of cycles exist for any particular treatment. Clearly more than several attempts at a particular treatment are required to say that it has failed. However, the simpler options have lower chances of working on any given cycle, and in general will take more attempts to be successful. Therefore, a treatment plan must be individualized and must incorporate findings that are uncovered during the monitoring process. What must be absolutely clear is that the treatment actually should be considered a functional test that measures a couple's ability to conceive. Repeated cycle failure of a given treatment option suggests that a more invasive option may be required. However, we are all aware of the couple, after years of infertility treatment, who conceive spontaneously without even trying. This shows that we have a very rudimentary understanding of the components that contribute to infertility, and that more research needs to be done to refine our ability to diagnose the causes of infertility and find specific treatments. Some couples need more invasive treatments sooner, others may never want to proceed to the more involved options.

What should you do when the going gets rough?

Not every story has a happy ending. Some couples face a long and arduous battle with infertility and find that it severely compromises many aspects of their relationship and life. Clinical treatments do not, in general, deal very effectively with the emotional aspects of infertility. Often they actually make it worse. Therefore, it is important for all couples facing infertility to know about the resources available to make their journey a more palatable one. There are many support resources, such as the AIA, which serve an educational and emotional tool to aid you in the process. There are many psychological professionals and support groups available with specific expertise in this very emotionally charged area. Patients must seek out these options when, and maybe even before, problems arise. Fortunately, many couples achieve their goal with determination and persistence as their best ally. For some this may take months, and for many it may take years of frustration and battling. Unfortunately, not everyone gets duly rewarded for their efforts-no, infertility is not fair, nor is any medical condition for that matter. However, there are many resources available including donor options and adoption to help one resolve the battle that is infertility.

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