As we welcome you to Virginia Fertility Associates, we begin with an initial consultation. Your medical and gynecologic history will be reviewed as we search for any clues to help uncover problems. If you have had any previous tests, x-rays, or treatments, we would appreciate having those records available at your visit or sent in advance. We understand the confidentiality and very personal nature of these inquiries, but we do need to know menstrual history, marital history, and many lifestyle issues.
When you first meet your physician, he will thoroughly evaluate you and your partner’s medical history and make recommendations about what tests should be performed to evaluate possible causes of infertility. The following is an overview of different tests that may be performed, but not every couple will undergo every test.
Approximately 15% of couples will experience infertility due to ovulation dysfunction – the woman not consistently releasing an egg each month. Many tests can be used to document ovulation.
Menstrual History – Menstrual history alone can often determine whether a woman is ovulating. Women who ovulate generally have regular cycles with consistent amounts of blood flow each month. A woman who has irregular bleeding, frequent bleeding, wide variation in the amount of bleeding, or long episodes without any bleeding at all is likely to have an ovulation disorder.
Progesterone level – Progesterone is a hormone that the ovary produces after a woman ovulates. A blood progesterone level greater than 3 ng/ml is a very accurate indicator that a woman has ovulated that cycle.
Basal Body Temperature Charting (BBT) – Your physician may ask you to keep a BBT chart to determine if you are ovulating. Generally, after a woman ovulates the release of progesterone causes a mid-cycle temperature rise of ½ to 1 degree Fahrenheit. Thus, a woman who is ovulating will have a biphasic temperature chart – lower temperatures before she ovulates and a rise in temperature after she ovulates. The rise in temperature only occurs after ovulation, so a temperature chart cannot be used to time intercourse for conception. Some women may be ovulating even though the temperature chart is unclear, and factors such as a cold or the timing of taking one’s temperature can affect the accuracy of this testing.
Ovulation predictor kits – Many over-the-counter ovulation predictor kits can be used to determine if a woman is ovulating. These urine kits detect the surge of luteinizing hormone (LH) that occurs just before a woman ovulates. We highly recommend the use of these kits since many procedures we perform require accurate timing, and these kits are one way to detect the day of ovulation.
Ultrasound – Your physician may elect to perform an ultrasound examination to look for developing egg follicles on your ovaries, which may be an indication of impending ovulation. If a follicle on the ovary appears collapsed, this may be an indication the ovulation has occurred. Ultrasound has evolved into the most important modality to monitor one’s ovulary process.
Abnormalities of the Uterus and Fallopian Tubes
Hysterosalpingogram (HSG) – This is an X-ray procedure done by your doctor, generally during the first half of your menstrual cycle. It involves placing dye into your uterus that will show up on X-rays. The dye outlines the inside of the uterus and fallopian tubes. If the fallopian tubes are open, the dye passes into the surrounding pelvic cavity and is reabsorbed by your body. You may experience some cramping with this test which generally disappears quickly. You will be instructed to take over-the-counter pain medication (acetaminophen, ibuprofen) before the test to help with cramping. You will also be given antibiotics to take prior to the procedure.
Sonohysterogram – This test involves performing a transvaginal ultrasound during the introduction of sterile saline solution into the uterus through the cervix. This test will help define the shape of the uterine cavity and can identify uterine abnormalities. It generally cannot be used to identify problems with the fallopian tubes.
Abnormal Sperm/Mucus Interaction
Post-Coital Test – This test is performed around the time of your expected day of ovulation, usually determined by the ovulation predictor kit. You will be asked to have intercourse with your partner (without lubricants) the night before or the day of your appointment. You may shower but should not tub bathe or douche. Your doctor will take a small sample of mucus from your cervix (no different from a Pap smear) to be examined for the presence of motile sperm. A transvaginal ultrasound will be done at the time of the post-coital test.
There are many opinions regarding the interpretation and usefulness of this test. The most common reason for a poor post-coital test is timing, as the test generally will only be good around the time of ovulation. Furthermore, many fertile couples do have persistently poor post-coital tests. However some factors such as infections, a history of cervical injury, treatment with drugs such as clomiphene (Clomid), sperm issues, poor coital technique, and failed ejaculation may cause a poor post-coital-test.
Semen Analysis – Up to 50% of couples experiencing infertility will have a male factor present; therefore, a semen analysis is an extremely important part of the fertility evaluation. Your partner will be asked to collect a specimen which should be obtained 2 – 4 days after his last ejaculation. He will be asked to collect a sample by masturbation into a clean container at home or in an examination room at our andrology center. You may accompany him if desired. If the specimen is to be brought to the laboratory, it should be received within one hour of collection. The basic semen analysis will evaluate the semen for sperm volume, concentration, motility, morphology (shape), and the presence of infection. If indicated, more advance sperm tests may be performed.
Evaluation of the Pelvic Structures
Laparoscopy – Under general anesthesia, a telescope-like instrument (laparoscope) will be placed through a small incision in the navel. The entire pelvis, including the uterus, fallopian tubes, and ovaries can be looked at directly, and abnormalities associated with infertility can be identified. With the use of a laser and other modalities, the procedure is often sufficient to treat problems such as endometriosis, pelvic adhesions or scarring and tubal obstruction. Generally, you will be able to return home a few hours after the laparoscopy has been completed.
Hysteroscopy – Usually under general anesthesia, the hysteroscope will be placed through the cervix and into the uterus to directly visualize the uterine cavity. Often this procedure is combined with laparoscopy. This test is the definitive test to identify abnormalities in the uterine cavity, and can often be used to remove polyps, fibroids and intrauterine adhesions and to correct some congenital uterine anomalies.
Obviously these are not all of the tests, and all may not be necessary. But often with these basics we can pinpoint the problem and begin the path to treatments.