As an OB/GYN, you are usually the first healthcare practitioner a patient will see for a fertility exam. Although you may need to refer the patient to a fertility specialist, there are many things you can do during an initial exam that will streamline the process and make sure you get the most accurate and complete information possible.
An initial fertility exam usually involves laboratory tests, including bloodwork for hormone levels, thyroid function and ovarian reserve testing. It also involves imaging diagnostics, including ultrasound, and possibly procedures such as hysterosalpingography and sonohysterography.
Because male factors are responsible for about half of all infertility cases, it is important for any male partners to have a comprehensive assessment as well.
Sometimes, these tests are ordered by different physicians, which can lead to confusion and extra time and stress for patients. Prospective parents typically prefer to have the process streamlined as much as possible, with one physician who can advise them on all of the results.
Using Ultrasound to Detect Causes of Infertility
Ultrasound is one of the most useful diagnostic tools employed in the initial fertility evaluation. Transvaginal ultrasound can detect some of the uterine disorders and abnormalities that can lead to infertility. Clinicians should consider using ultrasound to diagnose several common causes of infertility in the initial exam.
Polyps, for instance, are usually asymptomatic but can cause infertility and abnormal vaginal bleeding. Polypectomy via hysteroscopy is the gold standard for both diagnosis and treatment of polyps, especially in cases of infertility. Transvaginal ultrasound is the most effective diagnosis tool for polyps, and it is best performed before day 10 of the menstrual cycle, according to research published in Sage Open Medicine.
Fibromas, or benign uterine tumors, typically originate from smooth muscle. They are found in as much as 70 percent of women of reproductive age, according to a systematic review published in BJOG. Fibromas tend to be hormone-related, responding to levels of both estrogen and progesterone. Although they are benign in and of themselves, some research has indicated that fibromas increase the risk of pregnancy loss. Identifying and treating fibromas prior to infertility treatment is crucial to maximize the chances of a successful pregnancy. Transvaginal ultrasound and transabdominal ultrasound are both imaging methods of choice in evaluating myomas.
Endometrial hyperplasia results in a thickened endometrium and is more likely to occur in patients with polycystic ovarian syndrome (PCOS), due to higher circulating estrogen levels. In women with PCOS, transabdominal or transvaginal ultrasound can be used to take careful measurements of endometrial thickness. Clinical signs of endometrial hyperplasia include heavy, prolonged, irregular and frequent uterine bleeding.
Intrauterine adhesions (IUA), fibrotic tissue present within the endometrial cavity, is caused by trauma to the basal layer of the endometrium, typically after infection or curettage. IUA can be detected by transvaginal ultrasound, when the endometrium is irregular and thin, but hysterosonography may be necessary to confirm the diagnosis.
Adenomyosis occurs when the ectopic endometrial glands grow into the uterine myometrium. It typically occurs in multiparous patients. Transvaginal ultrasound is the first-line imaging modality for evaluating suspected adenomyosis, though depending on the skill of the sonographer, an MRI may be required to confirm the diagnosis.
Congenital uterine malformations can also be detected by transvaginal ultrasound, particularly with 3D techniques, allowing the investigation of the coronal view of the uterus, which looks at both the endometrium and the myometrium together for a more accurate diagnosis.
Referring Patients to a Fertility Specialist
When the initial evaluation is complete, including the imaging, bloodwork and clinical history, you may still need to refer your patient to a specialist for further testing, or for in vitro fertilization or other assisted reproductive technologies (ART). If your patient's results indicate they are going to require ART, this would be the time for a referral. However, you may be able to treat certain conditions yourself. Taking the time to perform a high-quality, thorough ultrasound will minimize the need for specialist referrals and provide both you and your patients with the information you need to treat their infertility.
