The Investigation of Infertility

Dr Carol Evans – Laboratory Director, Medical

Biochemistry & Immunology, University Hospital of
Wales, Cardiff

Defining infertility - NICE 2013

A woman of reproductive age who has not conceived after 1 year of
unprotected vaginal sexual intercourse, in the absence of any known
cause of infertility, should be offered further clinical assessment and
investigation along with her partner.

Offer earlier referral if

women is aged 36 or more
known clinical causes of infertility or relevant PMH

Defining infertility - NICE 2013

Primary infertility
couple have never conceived

Secondary infertility
Infertility after a previous pregnancy

Prevalence: 1 in 7 couples

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 Investigation of the Infertile Couple
Medical History

Physical exam

Diagnostic testing

Identify problem

Consider treatment options

Treat and monitor efficacy

Male factor infertility

Causes
• Pituitary/hypothalamic dysfunction
• Testicular dysfunction
• Obstruction to ducts
• Idiopathic

Investigation
• Semen analysis

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 Investigation of oligo-
/azoospermia
LH, FSH, testosterone

• All low suggest hypogonadotrophic hypogonadism:

check pituitary function

• High FSH, low T, ± small testicular size suggests

primary testicular failure
Trauma, infection, torsion, radiotherapy/chemotherapy
Kleinfelters syndrome (karyotype 47XXY), Unknown cause

• Normal LH, FSH, T suggests ductal obstruction or

idiopathic

Treatment of male infertility

• Hypogonadotrophic hypogonadism
• – hCG (homology with LH) & HMG (LH&FSH)
• – Pulsatile GnRH
• Obstructive azoospermia
• – surgery

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 Confirmation of ovulation

Plasma progesterone at mid-luteal phase (day 21 of a

28-day cycle or 7 days before expected period)

Prolonged cycles
7 days before expected menstruation e.g. day 28 of a
35-day cycle and repeated weekly until the next
menstrual cycle starts

Serum hormone concentrations during the menstrual cycle

Pre-ovulation Post-ovulation
Follicular phase Luteal phase

Menses

14 21
Days
progesterone Oestradiol
LH FSH

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 What concentration of progesterone is
consistent with ovulation?

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Conceptual Normal cycles As b timed to 7 days

cycles Ovulation likely before menses

In house RIA

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Luteal phase defined as 4-10 days post LH surge. (d 18-24 ?).

Confirmation of ovulation
• It is difficult to define the day 21 progesterone concentration
above which ovulation has occurred (Wood et al 1985).
• Ovulation is more likely with increasing progesterone
• Values range from 16 to 28 nmol/l as the lowest limit
indicative of ovulation (NICE 2004)
• Liverpool (Roche assay)
>25 nmol/l on day 21 sample is consistent with ovulation.
Traced back to Mike Divers paper taking successive
progesterone method changes into account

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 Anovular patients with irregular periods,
oligomenorrhea or ammenorhoea
Oligomenorrhea: infrequent periods (< 6 per year)

Ammenorhoea: absence of menstruation

primary - patient has never menstruated
secondary - previously established menstrual cycles
have stopped

Other laboratory investigations

• Prolactin
Evidence of anovulation
Ammenorhoea
+/- Galactorrhoea

• Gonadotrophins (LH & FSH)

Evidence of anovulation
Irregular periods, oligomenorrhea, ammenorhoea

• TFTs
Only if symptomatic

Other laboratory investigations

• Testosterone
Hirsutism
? PCOS

• Viral screening
Chlamydia

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 Ovulation disorders

WHO classification

Group 1: Hypogonadotrophic hypogonadism

Group 2: Hypothalamic-pituitary-ovarian
dysfunction (mainly PCOS)

Group 3: Ovarian failure

Hypogonadotrophic hypogonadism
• Causes
• Severe weight loss (eg anorexia nervosa)
• Intense athletic training
• Pituitary/hypothalamic lesions

Interventions
Weight gain (women with BMI <19 or reduce
exercise)

Hypothalamic-pituitary-ovarian
dysfunction (mainly PCOS)

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 Case 1 15 year old
HPC Menarche at age 11 years irregular periods /
oligomennorhea since then
acne & hirsutism
weight gain
US polcystic ovaries

Testoster + 2.2 (<1.7)

DHEAS 2.5 (1.7 – 13.4)
Androsten. 29.30 (1.75 – 12.9)

FSH 3.4
LH 5.2
Oestradiol 223

UFC within normal limits

Case 2 27 year old female

PMH PCOS
On OCP until 12/12
Irregular menses
BMI 21

Referred to IVF clinic for evaluation and management of primary

infertility

FSH 5.2
LH 14.7

Testoster 1.8 (<1.7)

AMH >142.8 pmol/L

LH : FSH Ratio

Abnormal LH:FSH (2:1 - 3:1) ratio can be seen in PCOS

Higher ratio’s tend to be seen in lean PCOS women

But LH & FSH

vary over the menstrual cycle
have pulsatile secretion
A single snapshop measurement can be unhelpful

Historical RIAs gave ratio’s >3 - modern immunometric assays

don’t always

Increased LH to FSH ratio is not needed to diagnose PCOS.

A normal ratio does not exclude PCOS

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 SHBG

Treatment of PCOS

Oral Contraceptives

Treatment of PCOS
Weight loss
Pharmacological reduction in insulin

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 Source of circulating androgens in
premenopausal women

Wallace & Sattar Clin Biochem Rev 2007, 28: 79-92.

Hyperandrogenism versus virlization

Hyperandrogenism
• Acne
• Hirsutism
• Male pattern balding

Virilization
• Acne
• Hirsutism
• Male pattern balding
• Increased muscle mass
• Deep voice
• Clitoromegaly
• Breast atrophy

Ovarian failure
• May present as premature menopause (<40 years)
• Autoimmune, commonly associated with other autoimmune
disorders
• Infective
• Radiation, chemotherapy, surgery
• Idiopathic

• Persistently high FSH

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 AMH
• Gylcosylated dimeric protein
• Produced in the somatic cells of the gonads
• Role in determining embryonic sex (female reproductive tract
develops in the absence of AMH)
• Main use -IVF
• Help predict stimulation of ovulation regimes (exogenous
gonadotrophins)
• Advantage - low variability over the menstrual cycle
AMH pmol/L

In females AMH reflects size and number of growing follicles

AMH
Adjunct to ultrasound in assessing ovarian reserve

<6 Maximum stimulation protocol

6 - 24 Safe responders

24 - 70 Reduced stimulation protocol

> 70 High risk of hyperstimulation

> 50 pmol/L Suggestive of PCOS

(High no of small antral follicles)

Women with high AMH / PCOS are potential over responders

- risk of developing ovarian hyperstimulation syndrome
- require reduced doses of FSH & monitoring

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Thank you

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