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Have You Had a Fertility Workup?
a blog by David Kreiner, M.D., F.A.C.O.G.
I've received an enormous amount of email recently from patients asking me for information about how they should get started with their infertility workup. Apparently, they are women, men and couples who have experienced difficulty conceiving and now want some direction about how they should proceed. Building a family was something they had imagined their entire lives to be a natural progression -- from student to career, getting married then having a family -- and they’re frustrated that their difficulty conceiving has affected their lives. For many -- some of whom have never experienced a health problem -- it prevents them from appreciating or even doing anything else.
See an RE for a Fertility Workup
My response to these emails is that the patients seek assistance from an infertility specialist, a reproductive endocrinologist, whose specialty and experience is in helping infertility patients conceive. A reproductive endocrinologist has two to three years of additional specialty fellowship training in infertility after completing an OB/GYN residency.
The RE will conduct a history and physical examination during your initial consultation. This exam typically includes a pelvic ultrasound of a woman’s ovaries and uterus. He can tell if there are any uterine abnormalities that may affect implantation or pregnancy as well as assess ovarian activity and rule out cases of moderate or severe endometriosis.
Pelvic Inflammatory Disease
If he elicits a history of previous abdominal or pelvic surgery, a physician may suspect that scarring may have developed that typically interferes with fallopian tube transport of the egg to the sperm and the conceptus to the uterus. An infection that develops after a pregnancy may lead to pelvic adhesions affecting the tubes as well as scarring within the uterine cavity itself which can prevent implantation. Pelvic inflammatory disease, PID, can lead to tubal disease and may be associated with other sexually transmitted diseases including HPV, Herpes and especially Chlamydia.
The semen analysis is the simplest test to perform and will reveal a male factor in 50% of cases. A post coital test performed midcycle around the time of ovulation when the cervical mucus should be optimal can detect a male factor or cervical factor when few motile sperm are detected within hours of intercourse.
A hysterosalpingogram (HSG), is a radiograph x-ray of the uterus and fallopian tubes after radio opaque contrast is injected vaginally through the cervix directly into the uterus. It can detect uterine abnormalities that can affect implantation and pregnancy as well as tubal patency. Unfortunately, this exam may be painful and in some patients with PID can result in serious infection. Some physicians will administer antibiotics prophylactically for this reason.
A hydrosonogram is an ultrasound of the uterine cavity performed after injecting water vaginally through the cervix directly into the uterus. It can also detect uterine abnormalities and shares some of the risks seen with HSG but to a lesser extent and usually with less associated discomfort.
A hysteroscopy is a surgical procedure in which a telescope is placed vaginally through the cervix directly into the uterus. The physician can visually inspect the cavity to detect uterine abnormalities. The risks of pain and infection are also seen with hysteroscopy.
Blood tests may be run to identify if a patient is ovulating with adequate progesterone stimulation of the uterine lining. Day 3 E2, FSH and LH levels can give information regarding ovarian activity and ovulatory dysfunction. AntiMullerian Hormone (AMH) levels correlate with ovarian reserve. That is the number of eggs remaining in the ovaries. Hormones that can affect fertility such as thyroid and prolactin are also assessed to ensure that extraneous endocrine problems are not the cause of the infertility.
Laparoscopy is a surgical procedure in which a telescope is placed abdominally through the navel thereby allowing a physician to inspect the pelvic organs. He/she can identify endometriosis, cysts, adhesions, infection, fibroids etc. that may be causing the infertility. Unfortunately, only about 25% of cases in women who have a laparoscopy performed will conceive because of treatment performed at the time of the laparoscopy.
Workup Results and Treatment
Treatment can be directed at the cause such as surgery to correct adhesions or remove endometriosis, uterine polyps or fibroids. Treatment can also be independent of the cause but improve fertility nonetheless. Ovulation induction increases the number of eggs and therefore the likelihood that an egg will fertilize. Gonadotropin injections stimulate many more eggs to develop in a cycle than clomid fertility pills. IVF with minimal or full stimulation is the most successful treatment for any cause of infertility.
The decision as to what treatment to undertake will depend on numerous factors including your age, duration of infertility, cause of infertility, cost of treatment and success of treatment as well as your insurance coverage for the treatment and your motivation to conceive and willingness to accept the risks associated with the treatment. Today, there is a highly successful treatment available for nearly all women.