Whenever you see a doctor for any problem you are likely to hear, "We need to do some tests." Telling a doctor that you have not been able to conceive should evoke that response.
Actually, tests are not the first step the doctor usually takes. The first step is usually a thorough medical history of the couple as well as an in-depth review of their reproductive history. If you go to see a doctor who, after hearing that you have difficulty getting pregnant, immediately suggests a laparoscopy to see if your tubes are open or hands you a prescription for Clomid, this is not the doctor for you. And, even worse, if he or she immediately recommends one of the assisted reproductive technology (ART) procedures at this point, head for the exit!
Most doctors have their own order for scheduling tests. The common thread through all their regimens will be that the less expensive and non-invasive tests should be done first. This reserves the more invasive, expensive, and risky tests for later. And later may never come. You may get pregnant before later arrives. The safest, simplest, and least expensive part of the evaluation will be the history - which is where all doctors should start.
Once the history has been obtained, the next safest and most cost-effective part of the workup is the physical examination. Although most of the time it is the female partner who comes in for the initial visit, we encourage the male partner to come in for that first visit, help provide the history, and be there to support his partner through these tests and procedures.
The physical exam is not unlike the complete physical you may get every year from your family doctor, internist, or gynecologist. There will be more emphasis on the pelvic examination, of course, and perhaps a vaginal ultrasound. The physician will be looking for signs of infection in the cervix that might give a clue to infection in the tubes, evidence of endometriosis, or any of the various problems that could affect fertility.
At this time, we would expect that the doctor would sit down with you in the consultation room and explain the series of tests. We like to think of these tests as being done in phases. Again, the tests with the least risk and cost will usually come first; if necessary, the more expensive and invasive tests will be done later. Since not all infertility specialists recommend the tests in exactly the same order, you can expect some variation. Just keep in mind that safer, simpler, less expensive ones should come first.
It is not possible for us to give specific and accurate estimates of costs for all these tests and procedures because there is tremendous regional variation; it would be best for you to determine average costs of key procedures when you make your initial search for a doctor.
In general, in patients without any significant history, our testing would be phased as follows:
Basal body temperature chart or ovulation detection kit
Tubal dye test (hysterosalpingogram-HSG)
Basal body temperature chart (BBT)
Most of the fertility tests will be timed to your menstrual cycle. In order to do this we have to monitor your cycle. One of the simplest ways is to utilize the basal body temperature chart (BBT). The basal temperature, the lowest temperature of the day, is fairly constant. Once you get up and engage in any activity, there will be a significant and variable increase in your body temperature. The BBT takes advantage of the principle that after ovulation the secretion of progesterone causes a half- to one-degree rise in your temperature, most evident in your basal temperature. Thus the BBT can estimate if and when you ovulated and the length of each phase of the cycle. All you need is a good-quality thermometer that you can read to a tenth of a degree (for example, 98.7°F). You can use a digital-readout thermometer if that is easier for you, but you do not need to invest in a special "basal thermometer."
You can make up a chart starting with the first day of your period as Day 1. You then take your temperature each morning, as soon as you wake up, before you get out of bed, when it reflects a true basal reading. Have the thermometer at the bedside, take your temperature immediately upon awaking, and record it on the chart in the column next to the appropriate date.
After you have done this for one or two months, the doctor can review the chart and probably tell if and when you ovulated, whether you had intercourse at the correct time of the cycle to maximize your chance of getting pregnant, and whether there was adequate time following ovulation for an embryo to implant in the endometrium before your period.
Some physicians do not use the BBT at all since they feel that the daily gathering and recording of this information may increase stress and that the information can be obtained in other ways. Others use it on a limited basis, for just a few months, and then discontinue its use once ovulation has been established and the patient has learned about the timing of her menstrual cycle. The big disadvantage is that the temperature shift does not predict ovulation as it occurs after ovulation has occurred. A better alternative to predict ovulation is to monitor the LH surge with an ovulation detection kit, which gives similar information as to timing, the consistency of ovulation, and the length of the luteal phase and it can more reliably be used to time intercourse.
Just as we need to learn that the woman is producing eggs, it is equally important to find out if the man is producing adequate sperm to achieve a pregnancy. To determine the man's status, a complete semen analysis will be obtained. If the doctor does not have his own reproductive laboratory, the male partner will usually be referred to a specific laboratory to have this done. At the lab or at home, he will masturbate a specimen into a special collection cup. It is best to have adequate sexual arousal before and during collection, otherwise a poor specimen could merely be an artifact of the collection procedure. The laboratory should provide reading materials or videos and an unhurried atmosphere. At home the wife may help with the collection.
It is advisable to abstain from ejaculation for two to three days before the test in order to get his best specimen. This is because with a shorter interval the sperm density may be lower. But more importantly, it will enable us to standardize the collection interval in order to compare results more accurately. With a longer period of abstinence the sperm may have lower motility. We usually recommend he give the specimen around the time of his wife's menstrual period since it is unlikely that she would get pregnant at that time.
We find that up to 40 percent of couples with an infertility problem have some male factor contributing to the couple's infertility. It does not make sense for the wife to go through tests that may involve some risk, discomfort, and expense if we don't at least find out if her partner's semen is adequate. In fact, physicians may obtain several samples since health and environmental factors such as fatigue, smoking, stress, and use of caffeine or drugs can affect the results. Variation is expected, and only with repeated specimens is a full evaluation obtained.
Phase 2 (about one month later)
Postcoital test (PCT)
We now move on to slightly more sophisticated tests. The postcoital test involves the examination of cervical mucus under the microscope for the presence of moving sperm after the couple has had intercourse just before or at the time of ovulation. The timing of this test is most crucial to its accurate determination of the quality of the sperm-mucus interaction.
Since proper timing is so vital, in addition to the BBT we often have the patient use a urine test to determine the LH surge as the means for assuring precise scheduling of this test. Otherwise repeated visits may be necessary, since often a poor test is simply due to poor timing. The LH surge will occur the day before ovulation, when the cervical mucus should be most favorable for sperm transit.
The couple would generally have intercourse late in the evening of or in the morning following the detection of the surge and then the woman will come into the office for an examination of the cervical mucus for the presence of sperm. This test can be helpful because it shows whether there is enough mucus, the quality of the mucus, and if her spouse's sperm can get into and survive in the cervical mucus. Some experts have questioned the accuracy and therefore the usefulness of this test, but since it is simple and inexpensive, we feel it is worthwhile.
Many couples ask if they should have intercourse any special way in order to have a better result on their PCT. The answer is no, because we want to be able to tell whether there are enough motile sperm in the cervical mucus based on their usual coital technique.
Some doctors obtain a blood level of the hormone progesterone to make sure that there is adequate progesterone to stimulate the lining of the uterus to prepare itself properly to allow an embryo to implant.
Tubal dye test (hysterosalpingogram or HSG)
We usually obtain a tubal dye test (hysterosalpingogram) just after a menstrual period is over. You may be referred to a radiologist since this test involves X-rays, although some doctors, including Reproductive Partners do their own HSGs.
This test involves a pelvic examination similar to a Pap smear. But this time a small instrument is placed through the cervix into the lower part of the uterus and some dye is injected. The doctor will follow the dye with a fluoroscope and take pictures as he or she sees the dye go through and out the end of the tubes. This will allow visualization of the contours of the endometrial cavity to determine if there might be an abnormally shaped uterus, polyps, or fibroids. We can see not only if the tubes are open and look healthy but also if the pattern of the spill indicates there may be adhesions in the pelvis.
Cramping is fairly common with the injection of the dye, but you can be premedicated with a mild tranquilizer and given a prophylactic dose of a pain medication to help prevent or minimize the pain. It is our routine to recommend the antibiotic as a prophylactic so that even rare infections in women with normal tubes will usually be prevented.
Phase 3 (four to six months later)
This phase consists of a thorough look at the woman's reproductive organs by means of an operative procedure called laparoscopy. Before going on to this procedure, we usually wait four to six months after the HSG to allow for its therapeutic effect by reducing the activity of pelvic scavenger cells in patients with unexplained infertility and endometriosis. The current trend seems to be that unless there is suspicion of significant endometriosis or adhesions in the previous tests, many fertility specialists are bypassing this surgically invasive procedure and moving more quickly to treatments designed to overcome mild endometriosis and other factors in unexplained infertility.
The woman is usually admitted to an outpatient surgical center or the outpatient surgery department of a hospital. The procedure is usually done under general anesthesia but can also be performed with a spinal, epidural, or even local anesthetic. A small incision is made in the navel and a telescopic device is placed through this incision to look at all the internal reproductive organs. A small cut is made in the pubic hairline to insert another instrument to move the organs around so all aspects can be visualized. A dilute solution of dye will be flushed through the fallopian tubes by means of a small tube placed into the uterus through the cervix. This way the doctor can see not only if dye comes through the tubes but also that there is no scar tissue around the ovaries and tubes. With the anesthetic there is no pain felt during the operation, but there may be some minor discomfort afterward. Carbon dioxide gas is used to expand the abdomen to enable visualization of the organs. Although as much CO2 as possible is removed, a small amount may remain and cause a bloated feeling and shoulder pain for a few days.
Although the HSG evaluates the inside of the tubes, there are other conditions that may be preventing pregnancy, such as adhesions or endometriosis, conditions which we have no way of finding except by looking directly in the pelvis. The tubes can be open and yet adhesions around the ovary can block the egg from getting to the tube. Also, if adhesions or endometriosis are found at laparoscopy, there is a good chance that they can be corrected through laparoscopic surgery at the same time. As in any operation, there are rare surgical risks, such as bleeding or injury to bowel or bladder as the instruments are inserted and the organs manipulated. But the risk is small and the recovery period usually only a few days. It is often recommended that the laparoscopy be performed before going on to even more sophisticated tests or treatments.
Some doctors now combine the laparoscopy with hysteroscopy. That is, at the same time they insert a telescope into the uterus through the cervix to make sure there are no congenital abnormalities, polyps, fibroids pushing on the cavity, or scarring. There is controversy over whether this adds any information to a normal HSG.
Laparoscopy is one of the most common operations performed by gynecologists. Many insurance plans will cover the procedure even if it is done to evaluate infertility. But be careful; some insurance policies specifically exclude procedures done to evaluate or treat infertility. If an insurance policy does exclude infertility but some other condition such as endometriosis or pelvic adhesions are discovered, the insurance may cover the procedure on that basis. Nowadays many plans require precertification, or even a second opinion, and may even provide higher benefits in a particular hospital or surgical center. We recommend that patients contact their insurance company before having the operation to make sure they are eligible for the best benefits.
Based on your age and the results of all these tests you doctor will offer you your treatment options. They may vary from another few months of trying if you are young and everything is normal to an assisted reproductive technology procedure such as in vitro fertilization if some significant problems are found.