You should have your fertility tested under the following conditions:
We also must be aggressive in evaluating and treatment of women 40 years and greater because of the increased potential for significant loss of ovarian reserve in this age group.
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 like IVF 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.
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.
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.
Improvements in diagnosis and treatment technology is changing the medical experience and your chance of success. The efficiency and accuracy of the infertility work up is a key factor in developing the appropriate treatment plan to achieve your ultimate goal, a healthy baby. Since many women are starting their families at later ages, the initial infertility evaluation in the female has evolved to focus more on ovarian function as an indicator of fertility potential. However, assessment of all the other factors are still important parts of the evaluation.
The initial tests used to assess the major causes of infertility are:
In the majority of cases this information is enough to indicate the appropriate initial treatment plan. Today laparoscopy is not routinely performed, because it has the risks of surgery and does not usually change the initial treatment plan. It may be recommended in specific cases if there is suspected endometriosis or tubal disease based on the history, physical findings, ultrasounds or if there are other specific gynecologic reasons to perform this procedure.
The FSH and estraduiol levels are drawn on the second or third day of full menstrual flow. The purpose is to evaluate ovarian reserve. Diminished ovarian reserve and egg quality may be suspected by elevation in either the FSH or the estradiol. An antral (early) follicle count and Anti-Mullerian Hormone (AMH) blood test can be used to further clarify your ovarian reserve in terms of number of eggs. The ovarian reserve essentially tells us whether it is reasonable to offer treatment using your own eggs.
The FSH levels will vary somewhat by the endocrine lab and the assay used. Unfortunately the prognosis is based on the highest, but not necessarily the most recent, FSH level.
The hysterosalpingogram (HSG) is still the best, and least invasive method of evaluating the inside of uterine cavity and patency of the fallopian tubes. In addition, a sonohysterogram (ultrasound after saline is placed in the uterus through a catheter) is a relatively non-invasive way of evaluating the uterine cavity alone if intrauterine pathology is suspected, but does not give you any information about tubal patency. Both tests can uncover uterine abnormalities such as intracavitary adhesions, fibroids or polyps. But, only the HSG can evaluate tubal abnormalities such as an occlusion or hydrosalpinges (fluid accumulation in the tubes). Abnormalities on an HSG or sonohysterogram may warrant further evaluation with laparoscopy and or hysteroscopy.
The proper development of your follicle, which contains the egg, and the timing of its release is critical to the evaluation of infertility. Ultrasound is a safe, painless and non-invasive way of evaluating this factor and timing subsequent tests.
Once the timing of ovulation is determined accurately, the next step is to assess if the sperm can penetrate the cervical mucus. When ultrasound and the urine LH kit pinpoint the timing, you will be instructed to have intercourse and come in the next morning, at which time a microscopic examination of the cervical mucus will show if there is adequate penetration of the sperm.
Menstrual cycle regularity and premenstrual symptoms are fairly reliable ways of determining the probability of ovulation. However, 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.
It is important to perform this test early in the infertility evaluation since in at least 40% of couples experiencing infertility the sperm quality will be a factor. The test will identify a potential male factor by checking the semen volume, sperm concentration, motility and morphology (appearance) in a semen sample.
With this streamlined work up, which can be completed within one menstrual cycle, you and your partner can be efficiently evaluated, specific major causes of infertility identified, and personalized treatment options considered. As with all medical testing, an infertility evaluation must be tailored to each patient's situation.