Fertility Process and Testing
To identify the causes of infertility and prescribe the best treatment options, a thorough infertility work-up is performed to determine the following:
- Ovulation
- Normal sperm
- Open fallopian tubes and normal uterine cavity
- Healthy eggs
Ovulation
Perhaps the most important female fertility factor is the egg factor, by the time a woman starts menstruating about age thirteen she has half a million egg follicles left in her ovaries. Now an egg follicle is a sac that holds one egg. Every month she is going to release a batch of these egg follicles […] only one of those egg follicles will ultimately grow each month and ovulate and the rest will die. But every month women lose eggs. And with time they run out of eggs and that’s called Menopause.By the time a woman is thirty she loses ninety percent of her eggs by the time she is forty she loses ninety-seven percent. One thing we test for is called Ovarian reserve, that is how many eggs are left and unfortunately patients and some doctors don’t really know what this means. Ovarian reserve is used by fertility doctors to determine if a woman has low ovarian reserve because those patients make less eggs, therefore they have a lower chance of pregnancy with fertility treatment…the ovarian reserve can be tested in a variety of ways. The best way is to perform an ultrasound when that woman is on her period and count the resting egg follicles in the ovaries.
Other tests for ovarian reserve include blood test for the hormone Anti-Mullerian hormone or AMH and follicle stimulating hormone that’s FSH and estradiol. Overall the key message for ovarian reserve is it’s needed by fertility doctors to counsel women on the chance of success for fertility treatment.
What’s really important is called egg quality that’s different than ovarian reserve. Egg quality basically means the following: the ability of an egg to create a chromosomally normal embryo. Poor eggs create embryos with abnormal chromosomal make up and good eggs create embryos with normal chromosomal makeup. Egg quality impacts the chance of a healthy baby and it is very much age dependent. Women who are in their forties especially have the lowest egg quality and actually by the age of forty-five its very rare to find any quality eggs and pregnancy rates essentially go to zero.
First recommendation I have to couples trying to conceive is to have sex at the right time of the month, the egg only lives one day so having intercourse for the one or two days before ovulation and the day of ovulation is critical for conception. To help women determine when they are ovulating we use ovulation detection kits. When we see women who don’t have regular menstrual cycles it means they are not ovulating […] and reasons for not ovulating could be things such as thyroid problems, excess production of a hormone called prolactin, a medical condition called polycystic ovarian syndrome or just stress weight changes, a lot travel.
We can obtain blood to test for some of these hormones and of course do an ultra sound to look at the ovaries for polycystic ovarian syndrome. So these are simple tests that should be done on women who are not having monthly periods. Sexually transmitted diseases such as Chlamydia and Gonorrhea but not HPV or herpes, can lead to fallopian tube damage and that can be a very significant form of infertility, that requires in-vitro fertilization or surgery to fix.
There are some other conditions that cause fallopian tube blockage, such as pelvic surgery and also endometriosis […] fallopian tube openness or patency can be determined by a test using dye in which we put dye through the uterus and fallopian tubes and take x-ray pictures. One of the most devastating conditions we see is recurrent pregnancy loss, that’s where women are able to conceive and carry the pregnancy until eight or ten weeks and then lose the pregnancy over and over again.bOne of the reasons for recurring pregnancy loss is uterine cavity abnormality such as fibroids, muscle tumors, polyps which are little growth, scar tissue or birth defects that that woman was born with in her uterus. Fortunately we can treat a lot of those uterine factors as it relates to recurrent pregnancy loss using surgical modalities.
One of the most frustrating diagnosis that we give to patients is something called unexplained infertility. This is a diagnosis that is assigned when the semen analysis is normal for the male partner, a woman is ovulating, her uterus and tubes are normal, she is at an age that should have quality eggs but yet they are unable to conceive. Oftentimes couples with unexplained infertility have to consider in-vitro fertilization which takes over each of nature’s steps and tries to fix them and augment the chance of success. Couples who fail to get pregnant sometimes think that they are allergic to each other, there is a mismatch. We don’t believe that actually exists and the reason for that is when we do in-vitro fertilization and put the sperm into the egg almost in all cases we get an embryos and in many cases we get pregnancies.
The release of the egg is a necessary component for pregnancy. In general, regular, predictable menses indicate that ovulation is occurring. The menstrual cycle is divided into two parts: the proliferative phase and the luteal phase. The luteal phase is the second half of the menstrual cycle following ovulation and typically lasts 13-14 days in most women. For example, if a woman has a 28-day cycle, she usually ovulates on day fourteen; a woman with a 32-day cycle would typically ovulate on day eighteen. Ovulation can also be presumed by testing the blood for progesterone level or if a monitor or kit indicates the presence of high levels of LH. There are many reasons for ovulatory disturbance including pituitary hormone imbalance, polycystic ovarian syndrome, stress and weight gain or loss. These issues can be overcome by using an oral medication called clomiphene citrate (Clomid), by injection of the hormone FSH, or by in vitro fertilization.
Normal sperm
A semen analysis is performed to evaluate semen volume, sperm count, percentage of normal motility and percentage of normally shaped sperm. Male factors account for twenty-five percent of all infertility and may be due either to malignancies or to genetic, hormonal or environmental issues. There are several treatments used to improve sperm function. Among these are artificial insemination, in which the sperm are washed and the healthiest are introduced into the uterus with a catheter; and IVF using intracytoplasmic sperm injection (ICSI), the injection of a single sperm into an egg. For men who do not ejaculate sperm, vasectomy reversal or harvesting procedures such as MESA, or TESE can be performed.
Open fallopian tubes and normal uterine cavity
In order for the egg and sperm to meet and for the embryo to be transported to the uterus, the fallopian tubes must be open. Once the embryo reaches the uterus, it must be able to implant in the uterine cavity. If the tubes are scarred and blocked as a consequence of prior pelvic surgery, sexually transmitted disease or a condition called endometriosis; or if polyps, tumors or scar tissue are present in the uterus, implantation may not occur. A hysterosalpingogram (HSG) is a test to assure that the tubes are open and that the uterine cavity is normal. Radiologists conduct the HSG on an outpatient basis. In this test, a small balloon is placed in the cervix and dye is introduced into the uterus and tubes with a syringe. The dye makes it possible to see the fallopian tubes and the contour of the uterine cavity by x-ray. Alternatively, a hydrosonography can be performed. This test utilizes saline rather than dye and makes the uterus (and to some extent, the fallopian tubes) visible via ultrasound. If the tubes are blocked they may need to be opened or removed prior to fertility therapy.
Healthy eggs
The quantity and quality of a woman’s eggs decline with age. Typically, by age 35 less than 10% of the lifetime egg supply remains. There are several tests that can be used to determine if a woman has fewer eggs than expected for her age (diminished ovarian reserve). Tests used to determine ovarian reserve include day 3 FSH and Estradiol, Anti-Mullerian Hormone and Antral Follicle Count. For an egg to be fertilized and develop into a genetically normal embryo, it must be of good quality. Egg quality cannot be determined with fertility testing, but it is strongly correlated with age. As the egg ages it is more likely to give rise to a genetically abnormal embryo. Usually, such embryos will not give rise to a pregnancy or are miscarried during the first trimester. Thus, as a woman ages, she experiences more infertility or miscarriage. In such cases, egg donation may be considered, as the function of the uterus does not decrease with age and an older woman can successfully carry a pregnancy to term using donor eggs.
Unexplained infertility
Occasionally, a couple may be unable to conceive, yet their infertility tests yield normal results. This condition is called unexplained infertility and is usually caused by sperm-egg interactions and factors related to the female reproductive tract. Fertility treatments can be very effective in treating this condition.
Recurrent miscarriage
An investigation for recurrent miscarriage is warranted when two or more pregnancies are spontaneously lost. Though recurrent miscarriage can be caused by inherited chromosomal or genetic abnormalities from one or both parents, these are seen less frequently. Instead, most miscarriages are the result of chromosomal and genetic abnormalities that arise during embryo development. These losses frequently correlate with the age of the female partner. Other causes for recurrent miscarriage relate to anatomical distortion of the uterine cavity caused by birth defects, fibroids or scar tissue, and to autoimmune conditions of pregnancy that give rise to blood clots in the developing placenta. The work-up for recurrent miscarriage can include testing the blood for diabetes, thyroid problems, autoimmune antibodies, and parental chromosomes (karyotype). An HSG can also be performed to determine the configuration of the uterine cavity. There are proven treatments for most causes of recurrent pregnancy loss.
Other tests that often accompany the infertility evaluation
Male Tests
- Infectious diseases tests: These tests are required by law and include Hepatitis B and C, syphilis, HIV and HTLV 1.
- Semen culture: A test to diagnose bacterial contamination of the semen.
Female Tests
- Prolactin: Prolactin is a hormone produced by the pituitary gland that stimulates the production of breast milk. Prolactin is a common cause of ovulatory disturbance.
- Thyroid stimulation hormone (TSH): A test to detect problems affecting thyroid gland function.
- Testosterone/DHEAS: A test for male hormones (androgens). Presence of testosterone or DHEAS can cause ovulatory disturbance and may be a sign of polycystic ovarian syndrome.
- Fasting insulin/glucose ratio: This test can diagnose diabetes and polycystic ovarian syndrome.
- Anti-cardiolipin antibody: A test to detect a type of antibody associated with recurrent pregnancy loss.
- Lupus anticoagulant: A test to detect a type of antibody associated with recurrent pregnancy loss.
- Prenatal screening tests: CBC, chemistry panel, Rubella titer, fasting glucose, lipid profile, blood type and screen, PT/PTT, TSH, HIV, Hepatitis B and C, syphilis, PAP smear and possibly mammogram.
- Genetic screening tests: Cystic fibrosis and other specific tests based on ethnic background: Jewish (Tay Sachs, Familial Dysautonomia, Canavans); African American (Sickle Cell); Mediterranean (Thalassemia).
At Santa Monica Fertility, we coordinate and interpret all of these factors in order to determine the best course of treatment.