Diagnostic Procedures
In order to determine the proper course
of treatment, we perform a number of diagnostics.
Click on the each of the tests below to learn more about how it is
performed and what it determines.
History and Physical Examination
A thorough history should include information about past surgical
history, medical history, exposures to tobacco, alcohol, environmental
toxins, a history of sexually transmitted diseases, a careful menstrual
history, a history of any past pregnancies, a thorough review of all
organ systems, and any other relevant information. In addition, an
equally thorough history of the patient's partner should be obtained.
The patient should then undergo a thorough physical exam to help
investigate and find a treatment
for infertility. Many times, transvaginal ultrasound will be performed at the
time of the initial examination to evaluate the uterus, tubes, and
ovaries. Only through an extensive evaluation of a patients history and
a thorough physical examination can an appropriate and directed
treatment plan be selected and implemented.
Preconceptual Counseling
It is important that preventative medicine begins before even trying
to get pregnant. The first "preconceptual counseling" appointment should
occur 4 months or so before attempting to conceive. Patients considering
pregnancy should be on a vitamin with 0.4mg of folic acid about 3 months
before pregnancy. (The spinal cord is developed by 1 month after
conception, so by the time a lot of women realize they are pregnant it
is perhaps too late to prevent spina bifida and anencephaly). Finally,
this consultation is a chance to discuss problems with previous
pregnancies, social issues, environmental exposures, and general health.
If not previously done, a hematocrit to check for anemia, a rubella
titer to check for immunity to rubella, and other blood tests can be
performed. A thorough family history and blood tests for genetic
diseases (Cystic Fibrosis, Tay Sachs, etc.) may be indicated.
Basic recommendations:
- Limit intake of alcohol, coffee, tea, soda, and other foods and
beverages containing caffeine
- Avoid use of recreational drugs (such as marijuana) and overuse
of prescription and over-the-counter drugs
- Avoid exposure to toxic substances such as industrial chemicals,
herbicides, and pesticides.
- Maintain good personal hygiene and health practices.
- Attempt to maintain a body weight within 15% of ideal body
weight for one's height and body frame.
Transvaginal Ultrasound
The transducer on a transvaginal ultrasound is a long probe that is
inserted into the vagina covered with lubricant and a condom. The
ultrasonographer will be able to see the uterus, ovaries, and sometimes
the fallopian tubes. The procedure is not painful, and many women prefer
it to an abdominal ultrasound for which the bladder must be full.
Semen Analysis
It is mandatory that the male partner in all infertile couples
undergo a formal semen analysis to assess whether there is adequate
sperm number and quality. The doctor may advise the man who is scheduled
for semen analysis to abstain from sex for two to four days beforehand.
The semen analysis should include basic parameters such as sperm number,
motility, and morphology (shape). In a normal ejaculation the total
volume of semen is between a half and a whole teaspoon. As part of the
semen analysis, the technician will determine the number of sperm
present in the ejaculate. A normal sperm concentration falls between 20
million/mL and 200 million/mL. The technician looks at how well the
sperm are moving and counts the total percentage of motile sperm by
figuring how many sperm per 100 are moving. At least 50% of any given
sperm population should be moving. Then the sperm movement is qualified.
A well developed sperm can propel itself up a woman's reproductive tract
at a rate of more than 2 inches an hour. Finally, the shape or
morphology of the sperm is determined. Sperm heads should be oval-shaped
without irregularities. In the event that the semen analysis is
abnormal, it should be repeated, and referral to a urologist who
specializes in male infertility should be considered. The evaluation of
the male involves a thorough physical examination and hormonal testing.
In the event that no sperm at all are found on a semen analysis, a
testicular biopsy may be indicated.
Hormonal Testing
By performing some basic blood tests, a physician can evaluate the
hormonal function of a woman trying to conceive. Tests that can be
performed at any time include prolactin and thyroid levels. Perhaps the
most important hormonal test that a woman should undergo is an FSH
(Follicle Stimulating Hormone) test. When performed on Day 3, this test
can provide information about the quality of a woman's eggs. An abnormal
or high FSH level can mean that it will be more difficult for the woman
to conceive, while a low or normal value is more reassuring. It is
important that this test be performed in conjunction with an Estradiol
to prove that it is a valid test.
Endometrial Biopsy
This procedure involves scraping a small amount of tissue from the
endometrium shortly before menstruation is due---between 11 and 13 days
following ovulation. It should ONLY be performed after a pregnancy test
reveals that the woman is not pregnant. This test is often used to
determine if a woman has a luteal phase defect- a hormonal imbalance
that may prevent a woman from sustaining a pregnancy because not enough
progesterone is produced. Due to inconsistencies in evaluating these
specimens and uncertainty over appropriate treatments, fewer infertility
specialists consider this an important test.
Post-coital Test
This test is a quick, painless procedure that can give information
how the cervical mucous and sperm interact. The test must be done within
one to two days before or after ovulation. Basal body temperature charts
or ovulation predicting kits are very helpful in determining the time of
ovulation. A couple should abstain from intercourse for 2 days before
ovulation, then have intercourse 2-8 hours prior to the office visit for
the post-coital test. A speculum is placed in the vagina, as it would be
for a pap smear. A syringe without a needle is then used to remove some
mucous from the cervical opening. The speculum is then removed and the
cervical mucous is evaluated. The specimen is then placed under a
microscope to look for the presence or absence of swimming sperm. There
have been many studies suggesting that the test is neither accurate nor
predictive of fertility. Many fertility specialists skip this step and
proceed directly to intrauterine insemination.
Hysterosalpingogram
This test is used to examine a woman's uterus and fallopian tubes. It is
essentially an x-ray procedure in which a dye is injected through the
cervix into the uterus and fallopian tubes. This "dye" appears white on
the x-ray, and allows the radiologist and your doctor to see if there
are any abnormalities, such as an unusually shaped uterus, tumors, scar
tissue or blockages in the fallopian tubes. If you are trying to get
pregnant in the same cycle as an HSG, make sure to schedule the test
PRIOR to ovulation so that there is no danger of "flushing out" a
released egg or developing embryo. Although most women report only minor
cramping and short-term discomfort during this procedure, some women,
especially those who have blocked tubes, report intense pain. Speak to
your doctor about taking a pain medication about 30 minutes prior to the
actual procedure.
Basal Body Temperature Charting
 For
women who are unsure of when they ovulate, keeping a basal body
temperature chart for several months may help to identify the time of
ovulation. Charting involves taking one's temperature every morning upon
waking up and recording the results. For optimal accuracy, this must be
performed before the woman drinks a cup of hot coffee or brushes her
teeth, as these events can interfere with the temperature reading. When
the temperature goes up 0.5 degrees, the woman is in the process of
ovulating. This is not recommended as a method to plan intercourse, as
the rise in temperature is caused by an increase in progesterone after
the follicle's release of the egg and the window of opportunity for
conception may be missed by the time the temperature rises.
Unfortunately, BBT charting is time consuming, frustrating, and is a
daily reminder to the patient that she is having difficulty conceiving.
Though it is a reasonable first step to attempting conception, if the
results are inconclusive after three months, it is recommended that the
couple move on to other methods to detect ovulation such as the urinary
LH detection kits.
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