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Basic Infertility Evaluation
The basic infertility evaluation consists of a series of tests that evaluate the basic fertility factors: ovulation, egg quality, fallopian tubes, and sperm.
Evaluation Of Ovulation:
At the beginning of the menstrual cycle, an egg is developed in the ovary. After approximately two weeks of growth, the egg is released or ovulated. Following ovulation, the ovary produces the hormone progesterone to prepare the lining of the uterus for implantation of the embryo. There are three ways to evaluate the hormonal adequacy of the menstrual cycle:
- Basal body temperature graph (BBT) predicts ovulation by showing a raise in temperature. Temperature is taken orally for three minutes immediately upon awakening. Ovulation generally takes place within the 24 hours before temperature ovulation. The BBT is most useful for reviewing the timing of testing and intercourse/insemination but does not predict ovulation.
- Ovulation predictor kits (OPK) detect LH hormone surge in the urine. LH is the hormone that triggers ovulation. These kits are the only method of predicting when ovulation will occur. Once a positive result is obtained, ovulation will occur within 24 hours. OPKs are most useful for confirming when an LH surge has occured and for timing of tests and intercourse/insemination.
- Serum progesterone test determines if the ovary is secreting sufficient hormone levels for optimal uterine preparation. The preferred progesterone level is 10 nanograms/mL and is greater when measured seven to nine days after ovulation. However levels of greater than 4 nanograms/mL document ovulation.
Abnormalities in levels of other hormones can interfere with normal process of growth and ovulation of an egg. These hormones are routinely checked as part of the hormonal ovulation evaluation and include TSH and prolactin.
Evaluation Of Egg Quanity:
At the beginning of the menstrual cycle, the pituitary gland in the brain secretes follicle stimulating hormone (FSH) to stimulate the ovaries to select and grow an egg for the menstrual cycle. Measuring the level of FSH and estradiol (estrogen on days 2 through 4) (first day of flow is cycle day 1) provides an assessment of the quanity of eggs. In some patients, we may request that you do a Clomid challenge test (CCCT). This is a more extensive test for detecting egg quality issues. Ultrasound evaluation is also valuable to evaluate egg quantity.
Evaluation Of Fallopian Tubes
A hysterosalpingogram (HSG) is an x-ray test that determines whether there is blockage in the fallopian tubes that would prevent the union of egg and sperm. It may also be used to detect irregularities such as scarring of the lining of the uterus. HSG is performed the second week of the menstrual cycle.
The test involves lying on the x-ray table in the same manner for a routine pelvic examination. A speculum is placed in the vagina as in taking a Pap smear. The vagina and cervix (opening of the uterus) are swabbed with an aseptic solution, and a small catheter is placed through the cervix. The catheter is connected to a syringe that contains the HSG dye (HSG dye is made from poppy seed oil with a trace of iodine). It is this dye that shows up on the x-ray (you will be able to see the progress of the dye for yourself on the monitor). The dye injection rarely takes more than five minutes. A few representative x-rays are taken prior to instillation of the dye. The procedure takes five to ten minutes to perform and may create some cramping. You may take two Advil tablets an hour or two before the procedure. The risks of an HSG are allergic reaction to the iodine and pelvic infection. The risk is approximately 1% and is higher in women with past infection of the tubes and ovaries. If you have a history of pelvic infection, please report this to your physician since he or she may ask you to take antibiotics prior to the procedure.
Evaluation Of Sperm:
Semen analysis is the measure of four different properties of a single ejaculate:
- Volume is the amount of ejaculate measured in cubic centimeters (cc). Normal volume is 2-5 cc.
- Count is concentration of sperm measured in million of sperm per cubic centimeter. Normal is 20 million/cc or greater.
- Motility is the percentage of sperm that are moving. Greater than 40% motility is considered normal.
- Morphology is the percentage of sperm that are normal in shape. Using strict morphology, greater than 4% is considered normal.
If semen analysis is abnormal on two evaluations, a urological exam and more specific sperm testing and hormonal testing are recommended. The urological exam will check for the presence of anatomic abnormalities. More specific testing may become necessary. Hormonal testing may include the measurement of FSH, testosterone, estradiol, and prolactin.