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Fertility Tests

 Fertility tests will be ordered by your infertility specialistafter a complete physical exam and thorough review of your history.  This fertility testing is usually much more extensive than fertility tests ordered by the general OB/GYN.

 

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Even if one cause of infertility is known, infertility specialists will often order the full range of fertility tests. This is because there is often more than one cause of a couple’s infertility.  In fact, some degree of male factor infertility is present in up to half of infertile couples necessitating male fertility tests. It is a waste of time and money to treat only one condition, such as ovulatory dysfunction, when male factor infertility, or another condition, is also present. Thorough fertility testing is one reason why pregnancy outcomes are higher in couples who seek care from an infertility specialist.

 

Fertility 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 fertility tests are often categorized by the processes, or organ systems, affected by infertility. We list the organ systems below with links to the associated fertility tests.

 

Fertility Tests for the Evaluation of Male Fertility

Fertility Tests to Evaluate the Fallopian Tubes, Uterus, and Endometrium

Fertility Tests to Evaluate Ovulation, Ovarian Reserve, Hormonal Causes

 Laparoscopy- A Diagnostic Fertility Test that is also an Effective Treatment

Laparoscopy has revolutionized how many surgical procedures are performed. The physician makes two or three small holes: one or two just above the pubic hair 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 carbon dioxide gas, allowing for a better view of the internal organs. A laparoscopy is performed under general anesthesia.  There is usually little post-operative pain. 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 several days of recovery time in the hospital.

 

A laparoscope allows visualization of small implants of endometriosis, which can be removed with instruments such as the harmonic scalpel.  This has been shown to increase fertility in the months following the procedure, possibly by removing implants that contribute to inflammation 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. Infertility specialist care improves success rates and helps prevent the scarring that can occur after surgery. If the diagnostic laparoscopy is performed by an infertility 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 endometriotic cyst walls, separate pelvic organs, and sometimes eliminate the need for a second treatment laparoscopy.

 

 Hysterosalpingogram (HSG)

The HSG fertility test determines the status of the fallopian tubes and uterus. The eggs must pass from the ovaries through the Fallopian tubes, undergo fertilization, and the resultant embryo must implant in the uterus. The hysterosalpingogram (HSG) is one of the most useful fertility tests to help determine if the tubes are open, or partially/fully obstructed.

 

The HSG 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 fertility test 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- Fertility test to Evaluate the Uterus.

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 with either water or gas to make the internal structures more visible.  Operative hysteroscopy can identify fibroids and polyps, which can then be removed often at the time of this fertility test.

 

 The Endometrium

The endometrium (lining of the uterus) must thicken and become more vascular to support a developing embryo.  After fertilization, the pre-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 the endometrial biopsy fertility test will be ordered to ensure the endometrium is developing properly. A small sample of the endometrium is taken, stained by a pathologist, and examined under the microscope to evaluate cellular development. If the endometrium is not developing properly, progesterone may be administered to facilitate development.  Some programs are using the biopsy on a select basis as this fertility test is sometimes painful and the information is not always reliable.  We rarely do endometrial biopsies in the context of infertility.

 

A transvaginal ultrasound can also be used to measure the width of the endometrium, which an indicator of the endometrium’s development.

 

 Ultrasound

The ultrasound is an extremely valuable diagnostic fertility testing 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 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 usually very little pain associated with this ultrasound examination.

 

 FSH, LH, Estrogen, Progesterone, Androgens, Other Hormones- Fertility Tests, Hormone Evaluation

Ovulation must occur regularly each month for an egg to be 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. Specific fertility tests are used to measure levels of these hormones.  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 and 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.

 

Fertility tests to measure FSH, LH, and estradiol levels are conducted on day 3 of the menstrual cycle.  Ovarian function is normal when the FSH is <10 mIU/mL and the estradiol level is <65 pg/mL. If the FSH level is >20 mIU/mL, the patient will require egg donation or adoption. When the FSH level is above 12 mIU/mL, the pregnancy success rates using the patient’s eggs are 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 fertility test to further assess ovarian function. In this fertility 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 predicts a poor prognosis for a successful ovarian stimulation cycle.

 

  Anti-mullerian Hormone

Another fertility test useful for evaluating ovarian reserve is the Anti-mullerian hormone (AMH), or mullerian inhibiting substance (MIS), blood fertility test. As ovarian reserve declines, so does the AMH/MIS value. 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 and support a developing fetus. The endometrium must thicken and become more vascular. 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. Poor endometrial development can often be treated effectively with progesterone supplementation.

 

 Androgens

Androgens are male hormones, such as testosterone. Abnormally elevated androgen levels can be associated with irregular or absent ovulation, increased body hair, lowering of the voice, acne, and

other symptoms seen in polycystic ovary syndrome (PCOS).  These patients are usually hyperinsulinemic, related to resistance of the tissue to glucose uptake.  One treatment for PCOS is metformin, a drug that makes cells more sensitive to insulin and reduces circulating 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.  Abnormal thyroid function can be treated, and often leads to increases in the chance for live birth.

 

 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 drugs Parlodel (bromocriptine) or Cabergoline.

 

 The Male Semen Analysis- An Essential Fertility Test

The male must always undergo fertility testing, primarily the 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 fertility 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. The laboratory also specializes in reproductive medicine fertility tests and our andrologists and technicians have years of combined expertise. Using the Kruger criteria the following sperm/semen characteristics are evaluated in this fertility test:

  1. Volume is the milliliters (ml) of fluid that comprise the sample.
  2. 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.
  3. 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.
  4. 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.
  5. Sperm morphology (shape) using Kruger strict criteria. Greater than 4 percent normal forms usually predicts good fertilization capability in vitro. 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 dictate that patients have fertility tests done at a particular corporate laboratory.  Given the extreme importance of the semen analysis, we strongly recommend patients have it done by a reproductive medicine facility. Sometimes mild degrees of sperm impairment can be difficult to identify if the laboratory technician does not have extensive experience.  Even if a patient has to pay for this fertility test, the cost is much less than the wasted female treatments if male infertility is present.