Fertility Tests

Fertility tests determine that all the processes necessary for successful reproduction are occurring correctly. Normal reproduction requires the following steps (among others):

• The male must produce enough "quality" sperm capable of fertilizing an egg.
• These sperm must be successfully delivered to his partner's vagina.
• The sperm must travel through the vagina into the uterus to the end of the fallopian tube where fertilization occurs.
• The sperm must attach to and penetrate the egg's membrane (zona pellucida)
• The female must have eggs capable of development within her ovaries. These eggs must develop to maturity in the ovarian follicles under the influence of the hormone FSH.
• The eggs must be capable of successful fertilization and development.
• The eggs must travel from the ovaries through the fallopian tubes to the distal end where fertilization occurs.
• The fertilized egg (embryo) must implant in the lining of the uterus.
• The endometrium must support the embryo, providing nutrition, and the uterus must be free of large obstructions.
• The ovaries (corpus luteum) must produce progesterone to support the pregnancy. The placenta also produces progesterone.
• The female must be healthy and capable of carrying a baby to term.

Fertility tests examine each of these processes and often more than one cause of infertility is found. This is why a complete workup by an infertility specialist is warranted. The tests that we discuss are:

• Urinary LH Test Kits, Ultrasound, Progesterone Measurements- Is "quality" ovulation occurring regularly?
• Ovarian Reserve, Day 3 FSH Measurement, Anti-Mullerian Hormones (AMH), Clomid Challenge Test- Does the female produce quality eggs capable of fertilization?
• Post Coital Test- Does the cervical mucus support and facilitate the migration of sperm? Does the female produce antibodies to her partner's sperm?
• Hysterosalpingogram, Hysteroscopy, Ultrasound, Sonohysterogram- Are the tubes open and free of obstruction? Is the uterus normally shaped and free of polyps and fibroids?
• Laparoscopy- Are the reproductive organs free of endometriosis? Is the appearance of the organs normal and/or is scar tissue present? Can conditions, such as endometriosis, be treated during the diagnostic laparoscopy?
• Ultrasound, Progesterone, Estrogen Measurements- Are "quality" follicles developing that are capable of fertilization and is the endometrium thickening?
• Semen Analysis- Does the male produce a sufficient quantity of quality sperm and can they be ejaculated into the vagina?

Ovulation must occur regularly for successful reproduction. There are several tests to document ovulation including basal body temperature charts, urinary LH test kits and ultrasound.

The normal ovulatory cycle occurs under the influence of several hormones including follicle stimulating hormone, estrogen, luteinizing hormone and estrogen. These hormonal interactions are governed by the hypothalamus, a small gland located at the base of the brain. The hypothalamus monitors the levels of FSH, LH, and estrogen and adjusts their production by the pituitary gland.

The level of FSH increases at the beginning of the ovulatory cycle causing the ovaries to select follicles, each of which contains an egg. As healthy eggs develop, the follicles begin to produce estrogen and as estrogen levels rise the hypothalamus regulates the production of FSH. Once the eggs mature, the hypothalamus signals the pituitary to release a large quantity (spike) of leutinizing hormone ("LH surge"), which causes ovulation (release of the egg).

The BBT measures the slight rise in body temperature that occurs immediately prior to ovulation. The temperature is always taken in the morning before arising. Measurements are made over several cycles (the chart) until a pattern is established. The chart is used to predict the next ovulation and intercourse is planned around that time. Most physicians have abandoned BBT charting because it is inconvenient and much less accurate than urinary test kits.

Urinary test kits measure the level of luteinizing hormone (LH) and are very accurate. The level of LH begins to rise 36 hours prior to ovulation and intercourse is planned around that time. Their disadvantage is that they are more expensive but this is outweighed by their accuracy and convenience.

Ultrasound can be used to visualize the follicles as they develop and document that ovulation occurred. In general, ultrasound is not a good predictor of "ovulatory time" unless an injection of hCG is given based upon the ultrasound results and absence of the LH surge.

Progesterone levels rise after successful ovulation and embryo implantation. It is first produced by the follicular structure remaining after ovulation (corpus luteum) and later by the placenta. Progesterone must be present to support the endometrium for implantation and growth and development of the embryo.

Ovarian Reserve

Ovarian reserve can be thought of as "the quality and quantity " of eggs remaining for ovulation. Reduced ovarian reserve occurs as women age and eggs loose their ability to fertilize and develop. One measure of ovarian reserve is the day 3 FSH level which is a vital part of every fertility workup. FSH levels above 12 (opinions differ on the exact level) are often a sign of impending menopause.

There is a direct correlation between rising FSH levels and diminished egg quality and egg numbers. Women in their thirties who have an elevated day 3 FSH level should seek specialist care immediately. Elevated FSH levels can also occur in younger women and may signal perimenopause.

Another predictor of ovarian reserve, and suitability for IVF, is the Clomid challenge test (CCCT). The CCCT is performed by measuring the day 3 FSH and estradiol levels. One hundred milligrams of Clomid is administered on cycle days 5-9, and the FSH level is measured again on day 10. The test is abnormal if either the day 3 or day 10 FSH values are elevated or if the day 3 estradiol is greater than 80 pg/ml

Abnormal FSH levels and a failed CCCT usually mean that the patient will not achieve pregnancy using her own eggs. There are many other variables that influence this decision. Fortunately, successful donor egg programs provide an alternative for these couples.

Anti-Mullerian hormone levels are now available and are predictive of reduced ovarian reserve. They are much less sensitive to

Post Coital Test (After Intercourse)

Sperm must enter the vagina and travel through the cervix to the uterus. The female's cervical glands produce mucus (cervical mucus) that nourishes the sperm and provides a transport media. The post coital test examines the interaction between the sperm and the cervical mucus.

If the cervical mucus is too thick, the sperm may not be able to reach the uterus. Sometimes a women's body may produce antibodies to her partner's sperm. This is similar to how the immune system identifies and destroys invading bacteria and viruses.

The post coital (PCT) test requires that the couple have intercourse and that the female come to the office afterwards for examination. A sample of the cervical fluid is examined under the microscope. High numbers of "dead" or non-motile sperm may indicate a cervical mucus problem. This condition is often effectively treated using intrauterine insemination.

The PCT is often difficult to perform as vaginal secretions kill the sperm and only cervical mucus must be obtained for an accurate PCT.

Hysterosalpingogram (HSG), Hysteroscopy, Ultrasound

The tubes must be open and free of obstruction and the uterus must be normally shaped and void of large fibroids and polyps. The HSG is performed at the hospital as an outpatient procedure. A small tube is passed through the vagina and into the cervix and dye is introduced. The flow of the dye is monitored using sequential X-rays and blockages are clearly visible. The blockages usually show up as white spots where the dye has collected behind the obstruction.

Sometimes a catheter is placed within the uterus for the study, but it does hinder the evaluation of subtle changes within the uterus. This test is the most comprehensive test for evaluating the utero tubal status.

Hysteroscopy

The hysteroscopy is performed in our office allows visualization of the inside of the uterus. In this procedure, the uterus is "inflated" with saline solution causing it to expand. As the uterus expands, the physician can clearly view the internal contours of the uterus and obstructions such as polyps, adhesions and fibroids.

Sonohysterogram

The sonohysterogram is also used to evaluate the uterus. In this procedure, the uterus is filled with saline solution causing it to expand. A vaginal probe is inserted into the vagina and used to examine the uterus via ultrasound. The procedure is useful for examining the uterus and identifying polyps, fibroids, and adhesions.

Laparoscopy

The laparoscopy is an extremely important component of the infertility workup and should be performed by an infertility specialist. This is because a skilled microsurgeon can often correct abnormalities during the diagnostic laparoscopy, eliminating the need for a second procedure.

The laparoscopy is also preformed as an outpatient procedure under general anesthesia and is accompanied by minor discomfort. The surgeon makes two small incisions, one at the belly button and the other above the pubic bone (at the pubic hair line). A small telescope is inserted through one opening and microscopic tools are inserted through the other. The internal organs are clearly seen and any conditions, such as endometriosis, are treated.

Recovery from the laparoscopy is quick and many complicated surgeries are now done using the procedure.

Ultrasound

Ultrasound measurements are vital parts of the infertility workup. Vaginal probe ultrasound allows the physician to see the uterus, ovaries, follicles on the ovaries, and other internal organs. As the name implies, the vaginal probe ultrasound consists of placing the transmitter (probe) inside the vagina.

Ultrasound is very useful in visualizing follicular development, documenting ovulation, and measuring the width and character of the endometrium. The endometrium must thicken during the ovulatory cycle to support a developing embryo.

Semen Analysis

There is no test more important than the semen analysis given that approximately half of infertile couples have a male component. Certainly, no treatment of the female can be effective in the absence of healthy sperm.

The male comes to our office and produces a semen analysis, which is then examined by our andrologists (person specializing in semen analysis). The semen analysis examines many sperm parameters including the number (count), their shape (morphology), their ability to swim (motility), the viscosity of the semen, sperm survival, and others. Given the critical nature of the analysis, it should be performed by a reproductive laboratory. Our laboratory uses the WHO III criteria for semen analysis. These criteria are as follows;

• Volume of fluid in the ejaculate
• Number of sperm. Normal = 20 million per milliliter
• Motility (ability to move). Normal = 50%
• Shape and size of the sperm. Normal = 30% "highly normal forms"
• Presence of white blood cells that may indicate infection. Normal < 5 x 106/ml (~ < 3 white blood cells per microscopic field).
• Low sperm count, poor shapes, and limited motility are all cause of male infertility. Sometimes subtle changes can indicate a sperm problem. The sperm must travel though the male reproductive tract and be ejaculated into the vagina. We discuss this process and others in the male infertility section.

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