In any fertility work-up, both male and female partners are tested if pregnancy fails to occur after a year of regular unprotected sexual intercourse if the woman if younger than 35, or after six months if the woman is older than 35. Fertility testing is particularly important if a woman is over 35 years old or if either partner has known risk factors for infertility. An analysis of the man’s semen should be performed before the female partner undergoes any invasive testing.
The first step in any infertility work up is a complete medical history and physical examination. You will need to ask about the patient’s history of sexual activity, especially frequency and timing of intercourse. Menstrual history, lifestyle issues (smoking, drug and alcohol use, and caffeine consumption), any medications being taken, and a profile of the patient’s general medical and emotional health will help you decide on appropriate tests.
You will also need to know the history of previous pregnancies and their outcomes; pregnancy intervals; and detailed information about pregnancy loss, pregnancy duration, human chorionic gonadotropin (hCG) level, ultrasonographic data, and presence/absence of fetal heartbeat.
It is also important to know the family history, including family members with infertility, birth defects, genetic mutations, or mental retardation.
Several laboratory tests may be used to detect the cause of infertility and monitor treatments:
- Hormonal Levels. Blood and urine tests are taken to evaluate hormone levels. Hormonal tests for ovarian reserve (the number of follicles and quality of the eggs) are especially important for older women. Examples of possible results include:
- High follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels and low estrogen levels suggest premature ovarian failure.
- High LH and low FSH may suggest polycystic ovary syndrome or luteal phase defect.
- High FSH and high estrogen levels on the third day of the cycle predict poor success rates in older women trying fertility treatments.
- LH surges indicate ovulation.
- Blood tests for prolactin levels and thyroid function are also measured. These are hormones that may indirectly affect fertility.
If an initial fertility work-up does not reveal abnormalities, more extensive tests may help reveal abnormal tubal or uterine findings. The four major approaches for examining the uterus and fallopian tubes are:
- Ultrasound: Ultrasound is the standard imaging technique for evaluating the uterus and ovaries. It is also used for detecting fibroids, ovarian cysts and tumours, and obstructions in the urinary tract.
- Hysteroscopy: Hysteroscopy is a procedure that may be used to detect the presence of endometriosis, fibroids, polyps, pelvic scar tissue, and blockage at the ends of the fallopian tubes. Some of these conditions can be corrected during the procedure by cutting away any scar tissue that may be binding organs together or by destroying endometrial implants.
- Laparoscopy: A laparoscopy is a surgical procedure that involves looking directly into the abdomen and pelvis using a small camera that is placed through an incision in the umbilicus. This allows us to evaluate and potentially treat gynaecological problems such as scar tissue (adhesions), endometriosis, and ovarian cysts that may affect fertility.
- Hysterosalpingogram: A hysterosalpingogram (HSG) is an X-ray test that looks at the inside of the uterus and fallopian tubes. The HSG is the best and least invasive method of evaluating the inside of uterine cavity and patency of the fallopian tubes. HSG can uncover uterine abnormalities such as intracavitary adhesions, fibroids or polyps, and tubal abnormalities. The HSG test can also show:
- Blockages preventing the egg from moving through a fallopian tube to the uterus
- Blockages preventing the sperm from moving into a fallopian tube and fertilising the egg
- Problems on the inside of the uterus preventing a fertilised egg from attaching to the uterine wall
Female tests to be conducted include:
- Cycle day 2 or 3 FSH, LH, E2
- Insulin – Fasting
- Glucose – Fasting
- Thyroid Antibodies
- Growth Hormone
- Rub IGG + IGM
- Cardiolipin Antibodies
- Hep B – Surface Antigen
- Hep C – Antibodies
- Chlamydia swab