How do you know you are infertile? That’s a question that many of our patients ask themselves after they’ve been trying on their own without any success. The only surefire way to find out what’s causing you not to conceive (or stay pregnant), is to be tested.
Testing is simple and fast and often starts at your OB/GYN. If you choose to do testing at Shady Grove Fertility, our in-house testing allows for patients to have a diagnosis generally in less than 4-6 weeks, depending on where you are in your cycle. All of our blood work is completed on-site at our laboratory facilities and results are available within 24 hours. The results of other tests, like ultrasounds, are available right away.
Fortunately, insurance almost always covers the cost of a patient’s diagnostic screening tests, which can be a road block for many patients. We have found that 90% of our patients have insurance coverage for their initial fertility work-up, making treatment more accessible.
When to Seek Evaluation
Couples often wonder how long they should try on their own before seeking a professional evaluation. Patients under the age of 35 should be evaluated after one year of trying to conceive unsuccessfully while those over the age of 35 should be seen after six months. Patients over the age of 40 should see a fertility specialist to assist with conception as soon as possible. Additionally women with pre-existing conditions such as PCOS, irregular periods or multiple miscarriages may choose to seek an evaluation sooner.
The Basic Infertility Work-up
Today’s basic infertility work-up has been streamlined and only includes a few tests. Over the years, many tests have slowed the diagnostic process and have proven to be of little benefit for most couples. Eliminating these tests allows for a more rapid work-up. The following 4 factors may be helpful to your physician in determining the correct diagnosis and ultimately selecting an individualized treatment plan for you.
- A Detailed Patient History
- Ovarian Function Testing
- HSG
- Semen Analysis
Detailed Patient History
A Detailed patient history is one of the most important tools for diagnosing infertility. The age of the female patient is particularly important. Additional information gathered includes: how long the couple has been trying to conceive, the female’s menstrual history, any previous pregnancy losses, and history of any previous surgery on the ovaries or uterus.
Lifestyle factors such as weight and smoking are also considered. Extremes in weight, both overweight and underweight, can affect a woman’s reproductive function. Similarly, smoking has been shown to reduce pregnancy rates and increase miscarriage. Alcohol and substance abuse may also be discussed.
Ovarian Function
When considering ovarian function, your physician will evaluate ovarian reserve as well as ovulatory status. Ovarian reserve refers to the number and condition of the woman’s eggs in her ovaries. In most cases, the more eggs a woman has, the better her chances of success. Ovulation is the process whereby an egg matures and is released each month during a woman’s menstrual cycle. If a woman has an ovulatory disorder that prevents her from releasing an egg each month, her chances of pregnancy are significantly reduced.
A group of blood tests gives information about ovarian reserve. These tests are commonly called “Day 3 Blood Work” because they are drawn between the 2nd and 4th day of your cycle, usually on the 3rd day. Day 3 Blood Work provides measurements of the following 3 hormones:
FSH – Follicle Stimulating Hormone is a pituitary hormone that stimulates the growth of the ovarian follicle which contains the egg. Elevated FSH levels may indicate a decrease in egg quality or number or ovarian reserve.
E2 – Estradiol is a hormone made by the follicle which helps stimulate the lining of the uterus or endometium where the embryo implants. Estradiol production is higher during the reproductive years.
LH – Luteinizing Hormone helps cause the ovary to produce estrogen and to release a mature egg (ovulation).
TSH and Prolactin are often measured at the time of day 3 testing.
TSH- Thyroid Stimulating Hormone is a pituitary hormone which helps evaluate thyroid function to determine the presence of an over or underactive thyroid which can impact ovulation.
Prolactin- A hormone produced by the pituitary that plays an important role in preparing the breasts, during pregnancy, for nursing. An inappropriate elevation at times other than pregnancy may interfere with normal ovulation
Determining the levels of these hormones is a good first step in evaluating a woman’s ovarian function, but normal results do not always mean the patient has a good ovarian reserve. Therefore, an ultrasound is performed to provide what is called an “antral follicle count.” During the ultrasound, the eggs that are seen in the patient’s ovaries on that day can be visualized and counted. This provides a more concrete assessment of the woman’s ovarian reserve.
Tubal and Uterine Anatomy
A Hysterosalpingogram or HSG is a quick test that uses x-ray technology to assess the health of the uterus and fallopian tubes, which are vital to achieving pregnancy. The HSG is the best, least-invasive test of its kind. The HSG procedure takes about 3 minutes start to finish to complete and most women equate the discomfort to menstrual cramps. Patients often fear this test because they have heard that it can be painful. However, our experienced clinicians perform over 2500 HSGs each year, and most patients find that it is over before they even know it started.
“I CRIED for days before the test, on the way to the test, and throughout the whole test because of the horrid things I heard about how painful it would be…. the Dr. probably thought I was crazy! I am such a wimp and I seriously felt NOTHING! 🙂 Thanks SG!” – Jackie
An HSG is usually scheduled between days 5 and 12 of a woman’s menstrual cycle. During the exam, a small, flexible catheter (much thinner than a coffee stirrer) is inserted through the opening of the cervix and into the uterine cavity. A small amount of dye, about three teaspoons, is passed through the catheter, slowly filling the patient’s uterine cavity and then filling the fallopian tubes.
The physician or physician assistant watches the fluid move from the uterus into the fallopian tubes and into the abdominal cavity using X-ray imaging. The dye reveals the shape and lining of the uterus and, if it passes freely into the abdominal cavity, it shows that the fallopian tubes are open. Usually, this process takes less than a minute. Many women have said they think the experience is somewhat similar to having a pap smear.
HSGs are performed in Shady Grove Fertility’s Rockville and Towson locations. The specialist performing the test reviews the resulting films with patients and lets them know right away whether the test is normal or abnormal. Results are also reviewed in more detail by the patient’s physician once the test is complete.
Semen Analysis
A semen analysis is a simple, low-cost test that should have a place in every couple’s fertility work-up. Couples are often surprised to hear that 40% of all infertility cases are caused by a male factor diagnosis.
There are several factors that are examined in a semen analysis. The first is the volume of the sample, which should be at least 2cc’s, which is just under half of a teaspoon. Besides sperm, semen contains amino acids, enzymes and several other secretions made by the male reproductive system. If the volume of ejaculate is low, that can mean the sample may be lacking in these important secretions that aid in the fertilization process. It could also signal a blockage or other issue in the semen’s pathway.
Next is the concentration of sperm, what people commonly call the “sperm count.” A low concentration can signal a problem with the testicles or male hormones that is preventing the testicles from making enough sperm.
The motility or movement of the sperm is another important factor. If it is low, that can affect the ability of the sperm to reach female reproductive tract and find the egg.
Finally, morphology is an important component of a semen analysis, especially when done for an infertility diagnosis. Morphology looks at the percentage of normally-shaped sperm in the sample. The head of the sperm is the part that penetrates and fertilizes the egg. If these are misshapen, it may mean they do not contain the proper enzymes or other materials that are necessary to complete fertilization.
The results of the semen analysis are most commonly graded on one of two scales – the World Health Organization (WHO) scale or what is called the “Kruger or Strict Morphology” scale. Shady Grove Fertility uses the Kruger Strict Morphology scale because it improves our ability to detect potential problems with fertilization of eggs. These criteria establish what is considered a healthy range and the sample is then compared against this range.
Our andrologists and embryologists work with samples every day doing fertility treatments like IVF. They know what to look for, not just related to the Kruger Strict scale, but in terms of all the other secretions and enzymes that make up a healthy sample.
Many patients find peace of mind in having a diagnosis from the results of their work up. All of our physicians work with their patients to review the results of their work-up and determine a unique individualized plan of treatment that the patients are comfortable, with, makes financial sense, and will yield the greatest possible success. Don’t let another month of the unknown go by again. Schedule an appointment and get your work-up started today!
