Infertility

Diagnosis

Indications for Testing

  • Inability to achieve pregnancy within 12 months with regular, unprotected intercourse

Laboratory Testing and Clinical Assessment

  • Female
    • Full physical examination and complete medical history
    • Cervical cytology and screening for sexually transmitted infections
    • Document ovulation – midluteal progesterone level, urinary luteinizing hormone (LH)
      • Progesterone ≥5 ng/mL implies ovulation
    • Determine etiology if ovulatory dysfunction is suspected – follicle stimulating hormone (FSH), prolactin, thyroid stimulating hormone, 17-hydroxyprogesterone, testosterone
      • Elevated FSH drawn on day 3 of cycle is associated with infertility
      • If prolactin is elevated and CT/MRI of sella is negative, consider macroprolactin testing
    • Assess ovarian reserve – FSH and estradiol measures on day 3 of menstrual cycle; anti-Müllerian hormone; inhibin B
    • Assess anatomic dysfunction – transvaginal ultrasound, hysterosalpingography, laparoscopy
  • Male
    • Full physical exam and complete medical history
    • Assess spermatic function – semen analysis of at least 2 specimens (after 2-3 days of abstinence)
      • Up to 40% of subfertile men have normal sperm analysis 
      • Normal semen parameters (WHO 2010)

        Normal semen parameters*

        • Volume – ≥1.5 mL (1.4-1.7)
        • pH – ≥7.2
        • Sperm concentration – ≥15x106 spermatozoa/mL (12-16)
        • Total sperm count – ≥39x106/ejaculate (33-46)
        • Motility – within 60 min. of ejaculation
          • Total motility – ≥40% (38-42)
          • Progressive motility – ≥32% (31-34)
          • High viability with a low motility suggestive of structural defects (eg, primary ciliary dyskinesia)
        • Vitality – ≥58% live (55-63)
        • Morphology – ≥4% normal forms (3.0-4.0)
        *5th centiles and 95% confidence intervals
    • Assess androgen status using LH, FSH, testosterone
      • Most useful if oligospermia or azoospermia noted on semen analysis
    • Consider infectious evaluation – CBC, gonorrhea and chlamydia cultures, and urinalysis
    • Consider systemic disease – usually have low testosterone, FSH
    • Genetic testing
      • Warranted when sperm density <5x106/mL, nonobstructive azoospermia present, or clinical suspicion
      • Karyotyping
        • Klinefelter syndrome (XXY) is most common abnormality (see Hypogonadism, Clinical Background section)
          • Associated with normal semen volume but low sperm
          • Typically low testosterone with elevated FSH
      • Y chromosome microdeletion
        • Typically normal semen volume, low sperm count, normal or elevated FSH
        • Not detected with standard karyotyping
        • Deletion is in azoospermia factor (AZF) regions
        • Associated with successful assisted reproductive technology
      • CFTR gene analysis to exclude cystic fibrosis
        • When vas deferens absent
        • Typically low semen volume

Differential Diagnosis

  • Refer to etiology in Clinical Background

Clinical Background

Infertility is a common problem in the U.S. affecting millions of couples who incur significant expense for fertility treatments.

Epidemiology

  • Prevalence – 10-15% of couples in U.S. (~2 million couples)
  • Definition – inability to conceive after 12 months of regular, unprotected intercourse

Etiology

Clinical Presentation

Indications for Laboratory Testing

  • Tests generally appear in the order most useful for common clinical situations
  • Click on number for test-specific information in the ARUP Laboratory Test Directory
Test Name and Number Recommended Use Limitations Follow Up
Luteinizing Hormone and Follicle Stimulating Hormone 0070193
Method: Quantitative Electrochemiluminescent Immunoassay

Aids in determining etiology of ovulatory or androgen dysfunction

   
Progesterone Quantitative by HPLC-MS/MS, Serum or Plasma 2008509
Method: Quantitative High Performance Liquid Chromatography-Tandem Mass Spectrometry

Aids in the workup of suspected infertility, detection of ovulation, and assessment of the luteal phase

   
Prolactin 0070115
Method: Quantitative Chemiluminescent Immunoassay

Screening for anterior pituitary tumor; determine if elevated prolactin is cause of infertility

   
Macroprolactin 0020765
Method: Quantitative Chemiluminescent Immunoassay

Exclude prolactinoma

   
17-Hydroxyprogesterone Quantitative by HPLC-MS/MS, Serum or Plasma 0092332
Method: Quantitative High Performance Liquid Chromatography-Tandem Mass Spectrometry

Assist in determining etiology of infertility

   
Thyroid Stimulating Hormone with reflex to Free Thyroxine 2006108
Method: Quantitative Electrochemiluminescent Immunoassay

Use to assess thyroid function

Reflex pattern – if the Thyroid Stimulating Hormone is outside the reference interval, then Thyroxine, Free (Free T4) testing will be added

   
Anti-Mullerian Hormone 2002656
Method: Quantitative Enzyme-Linked Immunosorbent Assay
Estimate ovarian reserve    
Estradiol, Adult Premenopausal Female, Serum or Plasma 0070045
Method: Quantitative Chemiluminescent Immunoassay

Suitable for measurement of estradiol in adult premenopausal women

In all other groups, the preferred test is estrogens, fractionated by tandem mass spectrometry (HPLC)

 
Semen Analysis % Abnormal

Determine if etiology of infertility is male-related

Cornerstone evaluation of male infertility

Time-sensitive test

Two semen samples should be evaluated (collected 7 days apart; 3 months after any febrile illness)

Samples are collected after a period of abstinence of >48 hours, but <7 days

Specimens should be analyzed within 1 hour of collection

 
Testosterone, Adult Male 0070130
Method: Quantitative Electrochemiluminescent Immunoassay

Aids in the evaluation of suspected hypogonadism in men

Use to monitor testosterone replacement therapy

Not recommended for use in women and children

 
Y Chromosome Microdeletion 2001778
Method: Polymerase Chain Reaction/Electrophoresis

Aids in determining  the cause of azoospermia or oligospermia and helps predict effectiveness of assisted reproductive technologies in men with Y chromosome microdeletions

Clinical sensitivity – ~5-10% for men with nonobstructive azoospermia or severe oligospermia

Analytical sensitivity/specificity – 99%

Breakpoints of identified microdeletions will not be determined

Mutations within individual genes included in the AZF regions will not be detected

Rare diagnostic errors may occur due to primer-site mutations

Male infertility due to causes other than the common Y chromosome microdeletions tested will not be detected

 
Chromosome Analysis, Peripheral Blood 2002289
Method: Giemsa Band

Detect chromosome rearrangements causing oligospermia or azoospermia

Clinical sensitivity – ~5-10% for men with nonobstructive azoospermia or severe oligospermia

Analytical sensitivity/specificity – 99%

Breakpoints of identified microdeletions will not be determined

Mutations within individual genes included in the AZF regions will not be detected

Rare diagnostic errors may occur due to primer-site mutations

Male infertility due to causes other than the common Y chromosome microdeletions tested will not be detected

 
Cystic Fibrosis (CFTR) Sequencing 0051110
Method: Polymerase Chain Reaction/Sequencing

For individuals suspected to be affected with CF but without 2 mutations detected by CF 32 mutation panel

Clinical sensitivity – 97%

Analytical sensitivity/specificity – 99%

Diagnostic errors can occur due to rare sequence variation

Breakpoints of large deletions/duplications and regulatory region and intronic mutations are not detected

CFTR gene sequencing may identify mutations of unknown clinical significance

 
CBC with Platelet Count and Automated Differential 0040003
Method: Automated Cell Count/Differential

Rule out infection

   
Unusual Organism Culture 0060714
Method: Culture

Order for unusual organism requests, including N. gonorrhoeae, S. moniliformis, and H. ducreyii, for which there is no stand-alone culture

   
Chlamydia trachomatis Culture 0060850
Method: Cell Culture/Immunofluorescence

Not recommended for routine detection of Chlamydia trachomatis (CT)

Use to detect CT in medicolegal settings and to assess suspected treatment failure

May be considered for anatomic locations for which amplified testing has not been validated

   
Urinalysis, Complete 0020350
Method: Reflectance Spectrophotometry/Microscopy

Screen for various metabolic and kidney disorders

   
Additional Tests Available
 
Click the plus sign to expand the table of additional tests.
Test Name and NumberComments
Thyroid Stimulating Hormone 0070145
Method: Quantitative Chemiluminescent Immunoassay

Preferred test for screening and monitoring of thyroid function

Testosterone Free, Females or Children 0081059
Method: Quantitative High Performance Liquid Chromatography-Tandem Mass Spectrometry/Electrochemiluminescent Immunoassay
Total Testosterone and SHBG are measured and free testosterone is estimated from these measurements.

Most sensitive test for detection of hyperandrogenemia in women and children

Acceptable test for androgen deficiency in men

Suggested for women and children due to an improved sensitivity of testosterone by LC-MS/MS

Testosterone, Females or Children 0081058
Method: Quantitative High Performance Liquid Chromatography-Tandem Mass Spectrometry

Use in conjunction with free testosterone in the evaluation of suspected hyperandrogenemia in women and children

Testosterone, Bioavailable and Sex Hormone Binding Globulin (Includes Total Testosterone), Females or Children 0081057
Method: Quantitative High Performance Liquid Chromatography-Tandem Mass Spectrometry/Electrochemiluminescent Immunoassay
The concentrations of free and bioavailable testosterone are derived from mathematical expressions based on constants for the binding of testosterone to albumin and/or sex hormone binding globulin.

Acceptable test in the evaluation of suspected hyperandrogenemia in women and children

Acceptable test for evaluating androgen deficiency in men

Testosterone Free, Adult Male 0070111
Method: Quantitative Electrochemiluminescent Immunoassay
Total Testosterone and SHBG are measured and free testosterone is estimated from these measurements.

Aids in the evaluation of suspected hypogonadism in men with a total testosterone level at the lower limit of the normal range

Not recommended for females or children

Testosterone, Bioavailable and Sex Hormone Binding Globulin (Includes Total Testosterone), Adult Male 0070102
Method: Quantitative Electrochemiluminescent Immunoassay
The concentrations of free and bioavailable testosterone are derived from mathematical expressions based on constants for the binding of testosterone to albumin and/or sex hormone binding globulin.

Acceptable test for the evaluation of suspected hypogonadism in men

Not recommended for females or children

Testosterone, Free and Total (Includes Sex Hormone Binding Globulin), Adult Male 0070109
Method: Quantitative Electrochemiluminescent Immunoassay
The concentration of free testosterone is derived from a mathematical expression based on the constant for the binding of testosterone to sex hormone binding globulin. 

Aids in the evaluation of suspected hypogonadism in men with a total testosterone level at the lower limit of the normal range

Not recommended for females or children

Inhibin B 0070413
Method: Quantitative Enzyme-Linked Immunosorbent Assay

May be used for infertility evaluation

Use to differentiate ovarian tumor with normal CA-125 from stromal or mucinous epithelial tumor

May be used for monitoring recurrence of stromal ovarian tumors

Follicle Stimulating Hormone, Serum 0070055
Method: Quantitative Electrochemiluminescent Immunoassay
Estriol, Serum 0070051
Method: Quantitative Chemiluminescent Immunoassay

Screening test for fetal aneuploidy in conjunction with other biomarkers and ultrasonography

Indicator of fetal well-being and placental function

Free Estradiol by ED/LC-MS/MS 2006160
Method: Quantitative Equilibrium Dialysis/High Performance Liquid Chromatography-Tandem Mass Spectrometry

Direct measure of free estradiol in serum

Most accurate measure of bioactive estradiol