Fertility Testing. Diagnosing the Causes of Infertility

Once the physician completes the physical evaluation, she/he will order several fertility tests to assess the male and female reproductive systems.

Female Fertility Tests

The female must produce, and ovulate, eggs that can travel through the fallopian tubes, fertilize, develop into embryos and implant into the endometrium (lining of the uterus). Once implanted, the embryo must develop into a fetus and mature into a viable pregnancy and delivery. The aim of the tests is to find an interruption of the steps that go from ovulating an egg to the birth of a healthy baby.

The tests discussed below examine the various processes that must occur for a successful pregnancy.

Laparoscopy

The laparoscopy is an outpatient surgical procedure used to treat many conditions that cause infertility including endometriosis, tubal blockage, cysts, fibroids, and others. Advanced laparoscopy should be performed by a reproductive specialist properly trained. These specialists have extensive advanced training in laparoscopic surgery and can often treat conditions during the laparoscopic procedure.

Hysterosalpingogram (HSG)

The HSG is an x-ray evaluation performed at the outpatient surgery department of the hospital. In the HSG, a radio opaque dye is injected into the uterus and sequential x-rays are taken as the dye travels through the uterus and fallopian tubes. This test is typically performed between cycle days six and ten. If there is a blockage of the fallopian tubes, this test shows as a collection of the dye at the point of the obstruction. The dye also shows the size and shape of the uterus.

Ultrasound

Ultrasound is perhaps the most important tool for female fertility test and has numerous applications. Vaginal probe ultrasound involves inserting the probe directly into the vagina allowing visualization of the ovaries, uterus, and other structures. Contrast media may be added, as in the sonohysterogram, to increase the visibility of abnormal structures such as polyps and fibroids.

The ultrasound is an indispensable part of advanced reproductive technology cycles. It is used to monitor the development of the follicles on the ovaries and to measure the width of the endometrium. Data from ultrasound and estradiol measurements are used to adjust FSH doses for optimal follicular development and to reduce side effects. Ultrasound is also used to guide the aspiration needle in the egg retrieval.

Day 3 Hormonal Evaluation

Reproductive hormones such as FSH, LH, and estradiol are measured on day 3 of the menstrual cycle. An elevated FSH level (>10) may be indicative of impending ovarian failure or reduced ovarian reserve. The Ovarian reserve correlates with a woman's ability to develop eggs that will develop properly and is usually age related. Younger women, with premature ovarian failure, can also experience reduced ovarian reserve.

Estrogen levels increase as healthy follicles develop and are lower during the first part of the menstrual cycle. An abnormally elevated estrogen level on day three, or a high FSH/LH ratio, may also be indicative of reduced ovarian reserve.

Ovulation Prediction

In the past, the basal body temperature measurement (BBT) was used to predict ovulation. The BBT method has been abandoned in favor of urinary test kits which are much easier to use and more accurate. The urinary test kits measure the increase in the hormone LH (luteinizing hormone) that always occurs prior to successful ovulation. Unfortunately in women who have Polycystic Ovarian Syndrome and produce excess LH to begin with, may have up to 30% false positive results.

Clomiphene Citrate Challenge Test (C3T)

This fertility test is a good measure of ovarian reserve and pregnancy potential. Some programs will not offer in vitro fertilization to women who have a “poor” C3T response. To perform this fertility test, day 3 FSH and estradiol levels are measured and the patient takes 100 mg of Clomid on cycle days 5-9. The levels of FSH and estradiol are measured again on day 10 and if the FSH is elevated it is considered a “poor” response. Day 3 elevated FSH levels and an estradiol of over 80 pg/ml also indicates a “poor stimulation prognosis”.

Prolactin

Prolactin is the “breast milk” hormone responsible for stimulating milk production in pregnant women. An abnormally elevated level in non pregnant women is termed hyperprolactinemia and can lead to irregular or failed ovulation. Hyperprolactinemia is sometimes due to a small tumor on the pituitary that can be surgically treated. Fertility drugs, such as bromocriptine or dostinex are effective in lowering prolactin levels.

Androgens

Polycystic ovarian syndrome (PCOS) is a common cause of female infertility. One of the hallmark symptoms of PCOS is abnormally elevated androgens (male hormones) including testosterone. These patients are often overweight, have excess body hair (hirsuitism), are hyperinsulinemic, ovulate irregularly, or not at all, have a classic “pear shaped” body, ovaries contain small cysts (follicles where the eggs are housed), and are infertile. The incidence of miscarriage is also higher in this group of women. These patients are often treated with insulin sensitizing drugs, such as metformin as well as a nutrition program supervised by our nutritionist. Please see the section on Polycystic Ovarian Syndrome.

Thyroid hormones

Blood tests will be used to determine the levels of thyroid hormones. Abnormally high levels (hyperthyroidism) can lead to irregular ovulation, premature labor, and fetal abnormalities. Abnormally low levels (hypothyroidism) can lead to irregular, or no, ovulation and early pregnancy loss.

Infection

Cultures may be ordered to rule out infections usually caused by organisms such as Chlamydia. Untreated infections can lead to severe damage to the reproductive organs as in pelvic inflammatory disease. If infection is noted in the female or male, it will be treated with appropriate antibiotics.

Male Fertility Tests

See the Male Infertility section.