Infertility may have one or more causes. A complete medical history and physical exam is the first step in evaluation and may reveal issues related to menstrual irregularities and ovulation, pelvic surgery, or illnesses, infection or cancer treatments that can cause fertility problems. However, some causes can only be detected through special tests. Complete evaluation and fertility testing for every possible cause is required in order to ensure appropriate and successful treatment.
Fertility testing is performed to identify problems in the following areas:
Because fertility depends on the release of an egg which can then be fertilized, the first step in determining a cause for infertility is to confirm that ovulation (release of an egg) is occurring. Irregular menstruation can suggest a problem with ovulation, but a small percentage of women with regular periods will also be diagnosed with ovulatory disorders. Home ovulation kits can be used to detect the Luteinizing Hormone (LH) surge, a rise in the hormone that immediately precedes ovulation. This provides presumptive evidence of ovulation. A progesterone level may also be checked one week after presumed ovulation if more definitive evidence of ovulation is needed. A level of 3 ng/mL is evidence of ovulation, however levels under 10 may be deemed “inadequate” as peak levels between 10-20 ng/mL are ideal, and adequate levels are needed to help prepare the uterine lining for implantation. If a patient is found to be anovulatory, lab tests will be performed to determine the cause of anovulation. At the very least, thyroid stimulating hormone (TSH), prolactin, and testosterone will be checked to rule out thyroid disease, hyperprolactinemia and polycystic ovary syndrome.
Ovarian reserve is determined by performing several direct and indirect assessments of egg quantity and quality. A pelvic ultrasound can determine the antral follicle count; the doctor counts the number of small growing follicles seen in each ovary, and a higher number correlates with a more robust response to fertility medications. Young women typically have high follicle counts and with age these diminish, but the rate of decline may be varied so that the antral follicle count in women over 30 and especially over 40 is variable.
The brain and the ovary communicate with each other via several hormones, and Follicle Stimulating Hormone (FSH) is produced by the brain in order to drive the follicles in the ovary to produce an egg (or oocyte) that can be released and fertilized. As the ovary ages, the pituitary gland in the brain notices subtle changes and responds, producing increasing amounts of FSH in order to get the ovary to respond. This is a reflection of both a decrease in the quantity and quality of the eggs. The level of FSH is typically measured together with LH and estradiol on day 3 of a woman’s menstrual cycle and is elevated when a woman’s supply of eggs is decreased and when those eggs are of lesser quality. Abnormal levels suggest the ovary has reached a critical point in aging. A level >10mIU/mL is an indication of decreased ovarian reserve and implies poor egg quality and number, while a level greater than 20mIU/mL is evidence of impending ovulatory failure and predicts poor response in assisted reproduction cycles.
Fertilization of an ovulated oocyte necessarily depends on a woman having open fallopian tubes that allow for the sperm and egg to meet. Prior pelvic surgeries or infections from STDs or appendicitis can block the tubes, thereby preventing fertilization and pregnancy from occurring. A study called a hysterosalpingogram (HSG) is performed, either with fluorescent dye and an X-ray or with a mixture of air/saline using a pelvic ultrasound machine (FemVue HSG) to determine if the tubes are open.
Recently, a new imaging procedure called FemVue has made it possible to evaluate the fallopian tubes without using any radiation. The FemVue infuses a mixture of saline and air bubbles into the uterus and allows us to visualize the bubbles flow out of the tubes using ultrasound. At the same time, the ultrasound enables us to clearly see the contour of the uterine cavity, an essential component of the fertility evaluation. Dr. Koopersmith and Dr. Landay are the only physicians in Los Angeles and the San Fernando Valley who perform this procedure in their office.
We encourage you to look into having the FemVue performed as part of your fertility work-up and to discuss it with your doctor.
Successful implantation is also dependent on having normal uterine cavity, and uterine abnormalities can be the cause of infertility and should be evaluated. Developmental anomalies and acquired anatomic abnormalities such as endometrial polyps, uterine fibroids and intracavitary scarring should be ruled out if suspected. A basic pelvic ultrasound can often identify if any of these are present . An HSG performed to evaluate the tubes can also tell us whether or not there are abnormalities of the uterus or in the uterine cavity. However it is frequently also necessary to perform a special ultrasound called a saline hydrosonogram which can provide better visualization of the uterine cavity. Occasionally, it is also necessary to perform minimally invasive surgical procedures to directly look inside the uterus (hysteroscopy) and/or the pelvis (laparoscopy), especially if clinically significant fibroids or endometriosis is suspected.
Close to half of all cases of infertility can be attributed at least in part to the male partner, and therefore a semen analysis is always performed. Semen analysis will identify problems with the number of sperm present, their motility and forward progression (ability to swim well and in a forward direction), and the morphology (shape) of the sperm. The semen specimen is obtained after 2 – 5 days of abstinence and is brought to a lab that specializes in microscopic examination of the sperm. If there are any significantly abnormal results on the semen analysis, especially if no sperm are seen (azospermia), referral to an urologist and genetic testing may be recommended.
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