Your Fertility Work-Up (The Basics)
You have been trying for a baby but unfortunately it's not happening. When should you start to consider a trip to your doctor and a fertility work-up?
If you are under 35 it is advised to seek help after 12 months of trying. If you're over 35 a quicker evaluation is recommended, so that would be after 6 months of failed attempts, and in women older than 40, a more immediate evaluation and treatment is advised.
Once you get to the clinic, your doctor will begin a fertility work-up to better understand your fertility and overall health. Tests for women will mostly focus on ovarian reserve (egg reserve), ovulatory function and the reproductive organs. For men, the initial focus is on reproductive history and semen parameters.
What you can expect.........
History and Physical
A full medical, surgical and sexual history from both you and your partner. This is very important as certain medical conditions, previous surgical procedures or sexually transmitted diseases could be impacting your fertility in different ways. It is always advised to be as open and honest as possible with your physician when it comes to discussing your past medical history. "Nothing to hide here".
A physical exam should also be performed with a focus on vital signs (blood pressure and pulse), your thyroid, breasts, and a pelvic examination. Your doctor should check your weight, body mass index and any signs of androgen excess.
Menstrual Cycles
You will be asked about the frequency and regularity of your menstrual cycles. Knowing precisely when you are ovulating each month is an important piece of information. When it comes to menstrual cycles there is a wide range of normal. Some women have short cycles (23 days or so) and others have longer cycles (35 days). It is important to have this information in order to better understand when ovulation is happening. Using applications such as 'Flo' can be useful as they keep track for you.
Ultrasound
A "transvaginal" ultrasound scan, meaning "through the vagina". Not as bad as you may think. Your fertility specialist will be able to visualise your reproductive anatomy better using this specific ultrasound approach. If you are uncomfortable or do not want to have a scan in this way, discuss this with your doctor as an abdominal approach may be an option. The physician will look at the anatomy of the uterus, ovaries, fallopian tubes, cervix and vagina and may also check the blood supply to these organs. Ovarian volume declines with age and so is a good potential indicator of ovarian reserve. As well as looking at the anatomy, your physician will also do an antral follicle count or 'AFC' to check the activity and number of antral follicles seen in both of the ovaries (best done on day 2-3 of the menstrual cycle). The number of AFC's correlates with the remaining follicular pool.
'AFC' Antral Follicle Count: counting the number of antral follicles in the ovaries that are 2-10 mm in diameter
Hormonal Blood Tests
Depending on your specific case, your physician may order some of the below blood tests to better understand what is going on.
Some tests are better drawn on cycle day 2-3 of your cycle and some can be done at any time.
Anti Mullerian Hormone
AMH is a hormone secreted by the granulosa cells of each dormant and growing follicle (egg), and a very good indicator of a woman's ovarian reserve. Serum AMH levels reflect the overall follicular pool and with very little variation throughout a woman's cycle, can be done at any time. Levels are low in women with diminished ovarian reserve and are high in women with Polycystic Ovary Syndrome (PCOS). AMH is useful in Assisted Reproductive Technology (IVF) as it can be predictive of ovarian response to hormonal stimulation in women doing IVF.
Follicle Stimulating Hormone - FSH
FSH stimulates the growth of ovarian follicles in the ovary and is produced by the pituitary gland in the brain. This test is best done between cycle day 2-3 and can fluctuate from month to month. High serum FSH concentrations in the early part of the menstrual cycle are a well-known predictor of reproductive ageing; therefore, physicians for many years have used FSH testing as a component of ovarian reserve testing. To determine ovarian reserve, your specialist will measure your FSH value early in the follicular phase, cycle days 2–3. While FSH is strongly associated with reproductive age, it also varies during your lifetime, as well as throughout a typical menstrual cycle. Given this large amount of variation, many studies have demonstrated that maternal age, rather than FSH value alone, may be more predictive of fertility potential.
Estradiol - E2
Estradiol hormone is a form of Estrogen and the primary female sex hormone. Best done between day 2-3 of the cycle, this hormone acts as a growth hormone for tissue of the reproductive organs, supporting the lining of the vagina, the cervical glands, the endometrium and the lining of the fallopian tubes. It's also crucial for egg growth and ovulation. Your physician will measure E2 levels as part of ovarian reserve testing but the results should not be used alone to detect diminished ovarian reserve. Levels of this hormone in reproductive age women fluctuate depending on timing of the menstrual cycle.
Serum Progesterone
A blood test to measure serum progesterone in the mid-luteal phase of your cycle (day 21 of a 28‑day cycle) to confirm ovulation. Advised even if you have regular menstrual cycles. Depending upon the timing of your menstrual periods, this test may need to be conducted later in the cycle (for example day 28 of a 35‑day cycle) and repeated weekly thereafter until the next menstrual cycle starts. Progesterone levels remain low during the follicular phase (<1 ng/mL), rise on the day luteinizing hormone (LH) surges (1–2 ng/mL), and increase steadily until they peak approximately 1 week after ovulation. A progesterone level <3 ng/mL will imply anovulation (no ovulation), except when assessed immediately after a woman ovulates or prior to menses when progesterone levels are at a physiological low.
Thyroid Stimulating Hormone - TSH
Thyroid disease can cause ovulatory dysfunction, ranging from an inadequate luteal phase to oligo-ovulation (infrequent menstrual periods) or amenorrhea (no ovulation). Serum thyrotropin may be be measured if you are experiencing ovulatory dysfunction or have signs of thyroid disease.
Prolactin
Hyperprolactinemia can also cause ovulatory dysfunction. Serum prolactin might be measured if you are experiencing certain signs and symptoms (infertility, changes in menstrual flow, loss of libido, lactation (galactorrhea) or pain in breasts).
Clomiphene Citrate Challenge Test (CCCT)
This test measures FSH blood levels on day 3 and day 10 of the menstrual cycle. Clomiphene Citrate is given orally from days 5-9 (100 mg daily). Rising inhibin B and estradiol levels produced from a growing pool of follicles will suppress FSH in women with responsive ovaries (normal negative feedback mechanism). It differs however in women with poor ovarian reserve as a lower ovarian reserve will generate less inhibin B and estradiol, resulting in decreased negative feedback and therefore more FSH to be produced. An elevated FSH after a CCCT test can indicate a diminished ovarian reserve however this test adds limited additional value to a baseline FSH test (mentioned above) and should not be used as a sole predictor for pregnancy or IVF outcome.
Tubal Patency Tests
Hysterosalpingography - HSG
Women who are not known to have comorbidities (such as pelvic inflammatory disease, previous ectopic pregnancy or endometriosis) should be offered hysterosalpingography (HSG). HSG is an X-ray procedure that is used to view the inside of the uterus and fallopian tubes by injecting radiopaque contrast through the cervix. It often is used to see if the fallopian tubes are partly or fully blocked. It also can show if the inside of the uterus is of a normal size and shape. This is a reliable test for ruling out tubal occlusion, and it is less invasive and makes more efficient use of resources than laparoscopy. Your doctor will more than likely presribe you antibiotics (Azithromycin 1 g stat) just before a HSG/HYCOSY/HYFOSY.
Inside scoop: It's not painful if done correctly. It may be uncomfortable, often described as 'tolerable'. Ask your doctor for some pre-test Ibuprofen
Hysterosalpingo-contrast-ultrasonography - HYCOSY/HYFOSY
Where appropriate expertise is available, screening for tubal occlusion using hysterosalpingo-contrast-ultrasonography should be considered because it is an effective alternative to hysterosalpingography for women who are not known to have comorbidities. It uses a contract or foam with the use of an ultrasound to visualize any tubal occlusions, without the need for an X-ray and can be done in the doctors office.
Laparoscopy & Dye
If comorbidities are present, a laparoscopy and dye test may be offered so that tubal and other pelvic pathology can be assessed at the same time. The laparoscopy will help find out if you have endometriosis, pelvic infection, adhesions, ovarian cysts or fibroids. This procedure uses a camera with a thin light source that is inserted through the abdomen.
For him
History
A full history covering past medical conditions if any, surgical procedures and sexual history is required. Coital frequency (how often you are having sex), evidence of any sexual dysfunction (ejaculation or erectile issues) as well as any previous childhood issues will be assessed (cryptorchidism/undescended testicles). It's important to also disclose any medications you are taking, such as anabolic steroids or supplements (testosterone) as these can affect fertility.
Semen Analysis
If you are having difficulty conceiving your physician will request a basic semen analysis to assess the vitality, count (number), morphology (shape), motility and several other parameters that are important for sperm function. A semen analysis can assess these parameters to determine if everything is normal or detect any abnormalities.
A semen analysis is a simple test that can be done at your local fertility clinic and it is relatively quick and easy. Results are usually available the next day. Depending on the semen analysis results, further investigations may be required. These may include FSH, LH and Testosterone. To read more about preparing for your semen analysis test, check out the 'Your Swimmers' article.
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