After 1 year of unsuccessfully trying to have a baby, it is time to have a basic infertility evaluation. And the urgency increases the older the woman is.
A: Preparatory Tests done on the woman:
- Tests for Ovarian Reserve: On the third day of spontaneous or progesterone withdrawal menstruation, blood is drawn to test for ovarian reserve. This requires testing for blood concentrations of estradiol (E2), follicle stimulating hormone (FSH), luteinizing hormone (LH) and for anti-Mullerian hormone (AMH).
- A hysterosalpingogram (HSG): This is performed within a week of the cessation of menstruation. This out-patient procedure involves injection of a radio-opaque dye which outlines the fallopian tubes allowing the diagnosis of tubal blockage. To a lesser degree, it permits the detection of surface lesions inside the uterine cavity.
- Hysterosonogram (HSN) : When IVF is planned this procedure is done early in the menstrual cycle. It involves instilling a sterile saline solution into th uterus, followed by a pelvic ultrasound to map the contour of the uterine cavity.
- Laparoscopy: This is a procedure that is sometimes needed. It is usually performed under general anesthesia in an ambulatory surgical center. Here, a telescope like instrument is passed into the abdominal cavity to allow thorough inspection of pelvic structures. It is usually confined to cases where symptoms and signs backed up by pelvic ultrasound findings, suggest significant underlying organic pelvic pathology (e.g. advanced endometriosis/fibroids, tubal disease and pelvic adhesions
- Hysteroscopy: Women suspected on the basis of symptoms and/or signs, (usually following ultrasound assessment or HSN) of having intrauterine pathology (fibroids/polyps/scar tissue) that might interfere with embryo implantation are sometimes required to undergo a hysteroscopy. This involves introducing a thin telescope-like instrument via the vagina and cervix into the uterus in order to allow visualization of the uterine cavity and surgical repair. It can be performed under local anesthesia with sedation in an ambulatory center orin-office. In some cases general anesthesia is needed.
- Testing the urine LH surge…for impending ovulation: Commencing at least 17 days before the expected menstrual period (i.e.; usually about 10 days following the initiation of menstruation), urine should be collected twice daily and tested for the onset of the spontaneous luteinizing hormone (LH) surge. The initiation of the LH surge usually precedes ovulation by 8 to 36 hours. In order to detect the onset of the LH surge accurately, an early morning urine specimen is needed. Ideally, the bladder should be emptied first thing in the morning, upon awakening. About one half-hour later urine is collected (only a very small amount is required) and tested using an over-the-counter LH – kit (obtainable over the counter, at a drug store). At the earliest sign of a color change the woman should present at her treating physician’s office for:
The 1st In-Office Assessment where the following is carried out::
- A pelvic ultrasound examination to assess for a dominant follicle or for evidence of recent ovulation and for the thickness and pattern of her uterine lining to be assessed (ideally it should measure >8mm with a triple “line” (trilaminar) appearance
- Blood should be tested for measurement of estradiol (E2) l level.
A 2nd In-Office Assessment is arranged for three (3) days after the first office assessment. At this visit, a vaginal ultrasound exam is performed to check (or to confirm) that ovulation has occurred (i.e. whether the egg has been released). The presence of small amount of fluid collecting in the lowermost region of the pelvis, or a change in the shape of the follicle is suggestive of ovulation.
A 3rd In-Office Assessment takes place five (5) days after the 2nd visit. At this visit, blood is drawn for the measurement of progesterone (P4) and estradiol (E2)
- Assessment for an Immunologic Implantation Dysfunction (IID) This is selectively done at one of about six Reproductive Immunology Reference Laboratories in the United States (I preferentially use Reproductive Immunology Associates [RIA] in Van Nuys, CA). Testing is indicated when:
- Autoimmune assessment; In my opinion, this is indicated when here is a personal or family history of autoimmune diseases (e.g. Lupus Erythematosus, Hypothyroidism, Rheumatoid Arthritis etc.), symptoms or signs of endometriosis (e.g. prior surgical visualization of lesions in the pelvis, heavy painful periods and pain during intercourse and/or ovulation) which is associated with immunologic implantation dysfunction (IID) in about 1/3 of cases. Also, when there is a past history of repeated “unexplained” IVF failure. Here, blood is drawn (at any time) from the female partner and sent to a reliable Reproductive Immunology Reference Laboratory for testing of antiphospholipid antibodies (APA), antithyroid antibodies (ATA) and the K-562 Target cell test, otherwise known as a natural killer cell activity test (NKa) test. In some cases, a uterine biopsy is done to test for endometrial cytokines.
- Alloimmune assessment: In select cases (especially where there is a history of Recurrent Pregnancy Loss (RPL), or “unexplained” secondary infertility or where Natural Killer cell activation (NKa) is diagnosed without there being an underlying autoimmune cause, both partners should be tested for alloimmune genetic similarities (DQ alpha and HLA genetic matching).
- A semen analysis is required for accurate measurement of sperm motility and count. Sperm morphology is assessed employing “strict (Kruger) criteria.”
- Sperm Antibody Test: Selectively we also test the man and/or the woman’s blood for anti-sperm antibodies (ASA) using the indirect Immunobead test (IBT). This is particularly important in cases of “unexplained” infertility (where the blood of both partners should ideally be tested) in men when there is a history of a prior vasectomy or sperm microscopy reveals significant sperm-to-sperm attachment (agglutination).
- Sperm Chromatin Structure Assay (SCSA): In selected cases, semen should also be sent for a Sperm Chromatin Structure Assay (SCSA) to assess the DNA Fragmentation Index (DFI) which ideally should be <15%, but 15%-30%
- Hormonal assessment of the man: in an ambulatory surgical center, performed In men where a semen analysis reveals a low count/motility/morphology, blood id collected from the man for FSH, LH, TSH, testosterone and prolactin measurement
- Male Urology Visit: In selected cases (the man is referred to an Urologist for further testing or testicular biopsy.