Infertility tests are designed to evaluate the organ systems involved in reproduction and conception, as several complex biological processes must occur for pregnancy to result. These tests are often categorized by the processes or organ systems effected. We list the organ systems below with links to the associated fertility tests.
Evaluation of male fertility:
- Semen analysis
- Practice prep
The Fallopian tubes, uterus, and endometrium:
- Laparoscopy
- Hysterosalpingogram (HSG)
- Hysteroscopy
- Ultrasound
- Progesterone levels
- Endometrial biopsy
- Sonohysterography
Ovulation, Ovarian Reserve, Hormonal Causes:
- Cycle day 3 FSH, LH, estrogen levels are assessed
- Androgen levels
- Thyroid hormones
- Clomid Challenge test
- Anti-mullerian hormone
- Progesterone hormone levels
- Prolactin hormone levels
- Predicting ovulation
Laparoscopy
Laparoscopy has revolutionized how many surgical procedures are performed. The physician makes two small holes: one at the pubic line and one at the navel. One opening is used to insert the laparoscope, which is a telescope-like device that allows the physician to view magnified organs and tissues. The other opening is used to insert and manipulate specially designed surgical tools.
The abdomen is filled with gas, allowing for a better view of the internal organs. A laparoscopy is performed under general anesthesia. There is usually little post-operative pain associated with the procedure. This contrasts to the long surgical incisions necessary in the past and dramatically shortens recovery time. Most laparoscopic procedures are performed on an outpatient basis whereas similar surgeries in the past required a week of recovery time in the hospital.
A laparoscope and a laser are often used to remove endometrial implants. It is essential that all endometrial tissue be removed, as even small amounts can setup an inflammatory environment in the abdominal cavity.
A laparoscopy performed for fertility testing should be done by a skilled reproductive endocrinologist or an Ob/Gyn with advanced surgical training. Specialist care improves success rates and helps prevent the scarring that can occur after surgery. If the diagnostic laparoscopy is being performed by a specialist, it is sometimes possible to treat the condition during the diagnostic procedure. If a condition such as severe endometriosis is discovered, the trained specialist can remove the implants, thus eliminating the need for a second treatment laparoscopy.
Hysterosalpingogram (HSG)
The eggs must pass from the ovaries through the Fallopian tubes, and undergo fertilization, and the resultant embryo must implant into the uterus. The hysterosalpingogram (HSG) is one of the most useful diagnostic tools to help determine if the tubes are open, partially or fully obstructed. It is also used to view the interior of the uterus and identify polyps and fibroids. The HSG involves inserting dye into the uterus and monitoring how the dye flows back through the fallopian tubes. As the dye passes through the Fallopian tubes, sequential X-rays are taken. Blockages or impediments show up as a collection of dye on the x-ray. If the tube is blocked, it is seen as a “white pool” at the point of the blockage. The HSG also helps determine the shape of the uterus.
IVF is usually the treatment of choice when bilateral tubal obstruction is present. This is because the egg and sperm are combined directly in IVF, which means the tubes are not necessary. Tubal surgery is sometimes possible, but the success rates are lower.
Hysteroscopy
A hysteroscopy allows the physician to examine the inside of the cervical canal and the uterus. The hysteroscope is a telescope-like device that is inserted through the vagina and cervical canal into the uterus. The uterus is usually filled during this procedure with either water or gas to make internal structures more visible. Operative hysteroscopy can often identify and remove fibroids and polyps before infertility treatment therapies begin.
The Endometrium
The endometrium (lining of the uterus) must thicken and become more vascular to support a developing embryo. After fertilization, the embryo moves from the end of the fallopian tube and embeds in the endometrium. Endometrial development is supported by the hormone progesterone, which is secreted by the corpus luteum (leftover follicle), and later by the placenta.
Sometimes an endometrial biopsy will be ordered to ensure the endometrium is developing properly, or in phase. A small sample of the endometrium is taken and examined under the microscope to evaluate cellular development. If the endometrium is not developing properly, progesterone will be administered to facilitate development. Some programs are using the biopsy on a very select basis as it is sometimes painful and the information is not always reliable.
A transvaginal ultrasound can also be used to measure the width of the endometrium, which an indicator of the endometrium’s development.
Ultrasound
An ultrasound is an extremely valuable diagnostic and monitoring tool. A transvaginal ultrasound is used routinely to monitor the progress of follicular development during assisted reproductive technology cycles. As the name implies, a transvaginal ultrasound involves inserting the ultrasound probe into/thru the vagina, allowing the specialist to view the uterus, ovaries, follicular development on the ovaries, the abdominal cavity, and more. IVF patients undergoing drug stimulation have routine transvaginal ultrasound examinations to follow follicular development. This information, along with estradiol measurements, is used to adjust the dosage of follicle stimulating hormone (FSH).
Sonohysterography
Sometimes media is added to the uterus (i.e. water) to make large polyps, fibroids and congenital abnormalities visible. There is not usually any significant pain associated with an ultrasound examination.
FSH, LH, Estrogen, Progesterone, Androgens, Other Hormones
Ovulation must occur regularly each month for an egg to be released and fertilized. Failed ovulation can be evidenced by absent or irregular menstrual cycles, abnormal progesterone levels after ovulation, and/or altered levels of FSH, LH, and estradiol. Increased androgen levels (male hormones) and irregular or absent ovulation may indicate the presence of polycystic ovarian syndrome (PCOS).
A woman is born with a lifetime’s supply of eggs in her ovaries. As a woman ages, so do her eggs, until they can no longer be fertilized or develop into a healthy embryo. Sometimes the eggs age faster than normal, leading to failed fertilization, increased miscarriage, and infertility. The FSH level is a good predictor of ovarian reserve, which is the ability of eggs to fertilize and develop normally.
FSH, LH, and estradiol levels are measured on day 3 of the menstrual cycle. Ovarian function is normal when the FSH is <10 mIU/mL and the estradiol is <65 pg/mL. If the FSH is >20 mIU/mL, the patient will usually require egg donation or turn to adoption. When the FSH level is above 12 mIU/mL, the pregnancy success rates using the patient’s eggs are very poor. Fortunately, at Baystate we have a very active, successful donor egg program.
When the FSH level is elevated, we often order the Clomid Challenge test to further assess ovarian function. In this test, 100 mg of Clomid is taken in the morning on cycle days 5-9, and on cycle day 10 the FSH level is assayed. An elevated level is a very poor prognosis for a successful ovarian stimulation cycle.
Another test useful for evaluating ovarian reserve is the Anti-mullerian hormone (AMH), or mullerian inhibiting substance (MIS), blood test. As ovarian reserve declines, so does the AMH/MIS result. This is consistent with a rise in FSH levels.
Progesterone
The most important function of progesterone is to prepare the endometrium to receive a developing embryo. The endometrium must thicken and become more vascular. Failed endometrial development is sometimes caused by a luteal phase defect. Progesterone is initially produced by the corpus luteum, and later the placenta. The corpus luteum is the follicular structure remaining after the eggs have been ovulated. When a luteal phase defect is present, it is effectively treated with progesterone supplementation.
Androgens
Androgens are male hormones, such as testosterone. Abnormally elevated androgen levels can lead to irregular or absent ovulation, increased body hair, lowering of the voice, acne, and other symptoms. These patients are usually hyperinsulenemic, meaning more glucose is required than normal. One treatment of PCOS, metformin, is a drug that lowers insulin levels, thus allowing ovulation to resume.
Thyroid Hormones
Thyroid hormones are produced by the thyroid gland and are measured by blood tests. Elevated (hyperthyroidism) or depressed (hypothyroidism) thyroid hormones can lead to ovulatory disorders, premature labor, and an increase rate of miscarriage. When thyroid hormones are an issue, they are usually elevated.
Prolactin
The level of prolactin normally rises in pregnant women because it is the hormone responsible for breast milk production. When prolactin is elevated in non pregnant women it can lead to failed ovulation. Excess prolactin is often caused by a small noncancerous tumor on the pituitary gland. Treatment involves removing the tumor or treating with the fertility drug Parlodel (bromocriptine).
The Male Semen Analysis
Some degree of male sub fertility is present in up to half of infertile couples, making the semen analysis one of the most important tests. No treatment of the female should ensue before a semen analysis has been performed.
Our reproductive laboratory uses the Kruger Strict Criteria for semen analysis testing, which is more rigid than some standards. Our laboratory also specializes in reproductive medicine and our andrologists and technicians have years of combined expertise. Using the Kruger criteria the following sperm/semen characteristics are evaluated:
- Volume is the milliliters (ml) of fluid that comprise the sample.
- Sperm count (technically it is the concentration) is the number of sperm in a standard given volume (ml) and 20 million/ml is considered normal.
- Motility is the percent of sperm that are moving in the sample. Above 50 percent is considered normal. The percent of sperm swimming forward in straight lines (progressive motility) is also determined.
- Viability is the percent of sperm that are alive. This test using special stains is completed if the percent of sperm that are motile is very low.
- Sperm morphology (shape) using Kruger strict criteria. Greater than 14 percent normal forms usually predicts excellent fertilization capability in vitro (>60-70 percent) if the other test parameters are normal.
- Less than five round cells (may be white blood cells which can indicate an infection) per high power field (or 3 million/ml).
Sometimes managed care companies will dictate that patients have their analyses done at a particular corporate laboratory. Given the extreme importance of this test we strongly recommend patients have it performed at a reproductive medicine facility. Sometimes mild degrees of sperm impairment can be very difficult to identify and a specialist is invaluable. Even if a patient has to pay for the test, the cost is much less than the wasted female treatments if some degree of male infertility is present.
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