Infertility: What Are The Causes And Tests For It?

Infertility is a common problem in the world affecting approximately 10 to 15% of couples worldwide. Defined as failure to conceive after ≥12 months of trying, infertility is often a result of different factors and is rarely associated with only one single cause. Infertility can affect both men and women, with one-third of cases comprising male infertility. 

Causes of infertility

Successful conception is dependent on a healthy egg being fertilised by a healthy sperm, then subsequently being implanted in the woman’s womb. Infertility can be due to a problem with any of these factors. 

Male infertility happens when:

• There is a problem in the production of healthy sperms due to:
  • Low sperm count (number)
  • Sperms with low quality (low motility/ability to move or abnormal sperm structures)

AND/OR

•  The sperm cannot be delivered to the egg due to:
  • Erectile dysfunction i.e. issues with erection during sex
  • Blocks in the sperm ducts

Female infertility happens when: 

• There are problems in the production of a healthy egg: caused by hormonal imbalances – due to stress or medical conditions like polycystic ovary syndrome (PCOS)

AND/OR

• The egg cannot be properly transported from the ovaries to the womb due to: blockage of fallopian tubes e.g. in endometriosis, tissue similar to the endometrium (womb lining) grows in various places it should not; if it grows on fallopian tubes, excess tissue obstructs passage of fertilised egg to womb)

AND/OR

• The fertilised egg is unable to implant itself in the womb e.g. presence of fibroids, polyps or cysts on the endometrium reduces the surface area for the fertilised egg to latch itself onto

As conception takes two, fertility tests should be performed on both male and female partners.

What are fertility tests?

In determining the reason for, and extent of infertility, fertility tests involve detailed evaluation of medical and personal history (e.g. regularity of menstrual periods, sexual habits, lifestyle factors like presence of significant stressors), physical examination of reproductive organs with imaging techniques, along with blood tests to assess hormonal levels.. 

Fertility tests for women

Sometimes a simple pelvic examination may reveal enough information to pinpoint the cause of infertility. In other cases, invasive examinations may need to be performed. 

Examples of fertility tests usually performed for women are mentioned below:

Gynaecological Exam

This is often the first test performed by the gynaecologist-obstetrician for every woman with infertility. It can raise suspicion about any structural abnormalities that may be present. It is recommended that you do not engage in sexual intercourse or take birth control pills ≥48 hours prior to the pelvic exam so the results are not compromised. 

Sexually transmitted diseases (STD) Panel

During the pelvic exam, the physician may obtain a pap smear which is basically a smear of the cervix. Analysis of the Pap smear can alert the physician about the presence of cancer cells and certain STDs. STDs can cause infertility and need to be treated immediately. 

Blood tests

Blood tests help diagnose other medical conditions that may be affecting fertility or causing pregnancy complications and miscarriages e.g. autoimmune disorders. They also point towards hormonal imbalances. One of the hormones that is most commonly tested for is Anti-Mullerian Hormone or AMH. AMH is secreted by antral follicles which contain immature eggs that have the potential to mature and result in ovulation. Thus, the AMH is a fairly accurate indicator of a woman’s ovarian/egg reserve and fertility.

Ultrasonography (USG)

This imaging technique helps the gynaecologist visualise the ovaries, uterus, and any pathologies like cysts and fibroids, that may be present. These pathologies are common causes of infertility in women. 

Hysterosalpingogram (HSG)

HSG is performed with the purpose of assessing the fallopian tubes and the shape of the uterus. HSG can visualise fallopian tube blockage, which is another common cause of infertility. 

Hysteroscopy

If HSG examination shows diseased fallopian tubes or if the results of the exam are not clear, hysteroscopy can be performed. The exam is more invasive and performed by inserting a lighted tube through the cervix into the uterus. It allows the gynaecologist to view the uterus clearly and take a biopsy if needed.

Sonohysterogram

This fertility exam is performed to assess the uterine walls and their durability. For this exam, the uterus is filled with a sterile liquid and then, an ultrasound is performed. 

Diagnostic Laparoscopy

This is the most invasive fertility test and is not commonly performed. It is only performed when the infertility is either believed to be due to endometriosis or there is no other explainable cause of infertility. 

In most cases, AMH testing along with ultrasonography can give a lot more information about fertility and the other tests do not need to be performed.

Fertility Tests for Men

Men undergo some of the same fertility tests as women like blood tests, STD panel, and USG. The other fertility tests for men include:

Semen Analysis

This test includes laboratory evaluation of the male semen and is usually performed twice on two different days for a confirmed diagnosis. This test checks for sperm health i.e. sperm count, motility and morphology (structure). This test is usually the only test needed to assess male fertility. 

Specialised Semen Analysis

This test is similar to the semen analysis except that it includes genetic evaluation of the sperm and checks for the presence of any antibodies.  

Post-ejaculatory Urinalysis

This fertility test analyses the urine produced after ejaculation to check for retrograde ejaculation. In this condition, not enough sperm are being deposited into the birth canal for fertilisation and conception to occur.

Vasography

This test includes X-ray evaluation of male reproductive organs to see if there are any blockages in the tubes which can result in male infertility. This is the male counterpart of hysterosalpingogram. 

Other fertility tests available

Apart from the above-mentioned fertility tests for women and men, there are certain tests performed on the couple. These tests include genetic karyotyping and post-coital tests.

Genetic karyotyping is performed via a simple blood test and it checks if either one amongst the couple is a silent carrier of a genetic disease that can cause miscarriage or congenital health issues in children. It also checks if the couple suffers from a genetic disease that may be responsible for their infertility. 

Post-coital tests are no longer routinely done but they assess the cervical mucus of the female hours after the intercourse has taken place. It helps the physician analyse if the mucus is spermicidal, meaning that it is killing the sperm and not allowing them to reach the egg. 

All of these tests help evaluate the fertility of the couple, but it is important to note that there may be some cases of unexplained infertility. 

Conclusion

If you suspect you are suffering from infertility, it is best to seek help from a physician (gynaecologist or reproductive endocrinologist) so that appropriate tests can be done and treatment plans can be initiated to help with conception.