Fertility Evaluation for Women
We recommend a basic fertility evaluation of all couples. This usually occurs after seeing one of our specialists. The basic elements of an infertility evaluation target ovarian function, tubal and uterine anatomy, ability of the sperm to reach the fallopian tube and male factor. The efficiency and accuracy of the infertility work up is a key factor in developing the appropriate treatment plan to achieve the couple’s ultimate goal, a healthy baby.
Following a history and physical examination, the initial tests used to assess the major causes of infertility are:
- Ovarian reserve testing – Common tests include Day 2 or 3 FSH (Follicle Stimulating Hormone), estradiol (estrogen), and antral follicle count
- Hysterosalpinogram (tubal dye test that allows a study of your uterus and fallopian tubes)
- Ultrasound to document the time of ovulation
- Post coital test to see if sperm can penetrate the cervical mucous
- Mid-luteal phase progesterone level
- Prolactin, Thyroid stimulating hormone (TSH), and HIV
In the majority of cases this information is enough to indicate the appropriate initial treatment plan. A laparoscopy is not routinely conducted as it carries the risks of surgery and rarely changes the initial treatment plans. A laparoscopy is usually recommended in specific cases if there is suspected endometriosis or tubal disease.
When to Test for Infertility
It is our belief that anyone worried about their fertility should take immediate steps to have their situation assessed. Immediate evaluation and treatment of infertility is warranted in cases of known problems such as anovulation, tubal occlusion, or severe male factor infertility. Otherwise the standard guideline is that an evaluation of infertility is warranted for a couple when the female partner is older than 35 and has been trying to conceive for 6 months without success. It is also indicated if the female partner is 35 years of age or less after the couple has been trying to conceive for one year. We also must be aggressive in evaluating and treating women 40 years and greater because of the increased potential for significant loss of ovarian reserve in this age group.
Ovarian reserve testing
- Anti Mullerian Hormone (AMH) is increasingly used as the most useful marker of ovarian reserve. It reflects the number of eggs remaining and is unaffected by the time in the cycle or other hormone markers. It is used alongside the other tests mentioned below.
- Day 2 or 3 FSH (Follicle Stimulating Hormone) and estradiol (estrogen): One of the best ways to evaluate fertility potential is to measure the concentration of the follicle stimulating hormone (FSH) on the 2nd or 3rd day of the menstrual cycle. With age the number of eggs in the ovaries declines. As egg number or reserve declines the FSH level increases.
The results of the FSH tests provide a rough idea of the number of eggs in your ovaries at a given time. It helps predict how well you might respond to the fertility medications used in superovulation, IVF, and ICSI.
FSH levels may vary from cycle to cycle, it is the highest level of FSH on day 2 or 3 that is associated with the potential outcome of treatment. We may advise a woman not to proceed with assisted reproductive treatment if her FSH levels are very elevated. At Medfem Fertility Clinic we consider the upper limit of normal to be 10 U/L.
We will also use other estimates of ovarian or egg reserve such as an antral follicle count.
- Antral follicle count: An antral (early) follicle count can be used to further clarify a patient’s ovarian reserve. An antral follicle count (AFC) is a vaginal ultrasound examination of the ovaries used to determine the number of antral follicles in each ovary. An antral follicle is a tiny (2-10mm) fluid-filled structure that contains an immature egg. As a woman ages the number of eggs or follicles in each ovary declines.
Much like FSH testing, the AFC gives an estimate of the number of eggs in your ovaries at a given time. An AFC is done prior to IVF or ICSI to help predict how well you might respond to the fertility medications.
There is no specific number of antral follicles that is considered low or high – age and medical and fertility history are considered, along with AFC to estimate ovarian reserve. Typically, an AFC > 10 is reassuring, while an AFC < 5 is worrisome.
A hysterosalpingogram (HSG) is an X-ray test that looks at the inside of your 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
Abnormalities on an HSG may warrant further evaluation with laparoscopy and or hysteroscopy.
During a hysterosalpingogram, a radiologist injects a dye through a thin tube that is inserted through the vagina and into the cervix. The radiologist takes pictures using x-ray (fluoroscopy) as the dye flows through the uterus and into the fallopian tubes. If there is any blockage or problems with your uterus, this will show up on the x-ray.
The proper development of the follicle, which contains the egg, and the timing of its release is critical to the evaluation of infertility. An ultrasound is a safe, painless and non-invasive way of evaluating this factor and timing subsequent tests.
Post coital test
Once the timing of ovulation is determined accurately, the next step is to assess if the sperm can penetrate the cervical mucus. You will be instructed to have intercourse in the early morning followed by an appointment at the clinic, at which time a microscopic examination of the cervical mucus will show if there is adequate penetration of the sperm, and to see whether sperm are present and moving normally. The test is done 1 to 2 days before ovulation when the cervical mucus is thin and stretchy and sperm can easily move through it into the uterus.
Mid-luteal phase progesterone
Some women ovulate but fail to produce adequate quantities of progesterone (luteal phase deficiency) following ovulation. The clinical tests for ovulation (e.g. temperature chart, positive ovulation predictor kit) are not sufficient to diagnose luteal phase deficiency. We recommend obtaining a progesterone level approximately 8 days after detection of the LH surge.
A hysteroscopy is a procedure where the doctor passes a hysteroscope—a narrow, telescope-like instrument with a camera on the end—through your vagina and cervix and into the uterus to directly examine the interior of your uterus. This procedure is used to determine if you have any fibroid tumours, polyps, scar tissue, or other obstructions that could be affecting your fertility. During the procedure, the doctor inserts the hysteroscope into your uterus and may inflate the uterus with gas or saline liquid to get a better view of the uterine interior.
If the doctor finds anything abnormal, he or she may remove a small sample for further examination. You don’t need to have an incision with a hysteroscopy, and most women recover within an hour or two.
A laparoscopy is a surgical procedure that involves looking directly into your abdomen and pelvis using a small camera that is placed through an incision in your umbilicus. This allows us to evaluate and potentially treat gynaecological problems such as scar tissue (adhesions), endometriosis, and ovarian cysts that may affect fertility.
For this operation you will require a general anaesthetic (you will be asleep), but in most cases you will go home the same day.
Most women experience bloating, abdominal discomfort and/or back and shoulder tip pain for 24-48 hours after surgery. This is normal and is related to the gas used to distend your abdomen during the surgery. This pain should not be severe and should gradually improve over 24-48 hours.
Prolactin, Thyroid stimulating hormone (TSH), and HIV
At Medfem Fertility Clinic we routinely test all patients for Prolactin, Thyroid stimulating hormone (TSH), and HIV. A positive result for any of these tests will require intervention.