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The basic infertility workup 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 begins to develop 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.
1. The basal body temperature graph (BBT) detects ovulation by showing a rise in the temperature (usually to greater than 98 degrees). The temperature is taken orally for 3 minutes immediately upon awakening. Ovulation generally takes place within the 24 hours before the temperature elevation. The BBT is most useful for reviewing the timing of tests and intercourse/insemination, but does not predict ovulation.
2. Ovulation Predictor Kits (OPK) detect the LH hormone surge in the urine. LH is the hormone that triggers ovulation. These kits are the only method for predicting when ovulation will occur. For most kits, once a positive result is obtained ovulation will occur within 24 hours. OPKs are most useful for confirming that an LH surge has occurred, and for timing of tests and intercourse/insemination.
3. The serum progesterone test determines if the ovary is secreting sufficient hormone levels for optimal uterine preparation. The preferred progesterone level is 10 ng/ml or greater when measured 7-9 days after ovulation (as determined by BBT or urinary LH kit).
Abnormalities in the levels of other hormones can interfere with the normal process of growing and ovulating an egg. These hormones are routinely checked as part of the hormonal/ovulation evaluation and include TSH (thyroid) and Prolactin.
Evaluation of egg quality
In the beginning of the menstrual cycle (cycle days 1-5), the pituitary gland in the brain secretes Follicle Stimulating Hormone (FSH) to stimulate to ovaries to select and grow an egg for the cycle. Measuring the levels of FSH and Estradiol (estrogen) on cycle day 2 or 3 (first day of FLOW is cycle day 1) provides us with an assessment of the quality of the eggs. For some patients, we may request that you do a Clomid Challenge Test (CCT). This is a more extensive test for detecting egg quality issues.
Evaluation of fallopian tubes
A hysterosalpingogram (HSG) is an X-ray test that determines whether there is a blockage in the fallopian tubes, which would prevent the union of a sperm and egg. It may also be used to detect irregularity or scarring of the lining of the uterus. The HSG is performed in the 2nd week of the menstrual cycle (i.e. after menstrual bleeding has stopped but before ovulation).
The test involves lying on an X-ray table, in the same manner as for a routine pelvic examination. A speculum is placed in the vagina, as in taking a PAP smear. The vagina and cervix (opening to the uterus) is swabbed with an antiseptic solution, and a small catheter is placed snugly in 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.
Approximately 1/3 of an ounce of yellow dye is slowly injected into the uterus and tubes. You will be able to see the progress of the dye for yourself on the viewing monitor. The dye injection rarely takes more than 5 minutes. A few representative X-rays are taken for a permanent record and for later review. In some situations the radiologist may request a follow-up X-ray (without dye injection) 24 hours later to see that the dye has dispersed throughout the pelvis. Failure of the dye to disperse may indicate the presence of pelvic adhesions (scar tissue).
An HSG takes 5-10 minutes to perform and may have some cramping associated with it. However, most patients do not need to miss work, as these side effects tend to be minimal. You may take 2 Advil tablets an hour or two before the procedure if desired.
The risks of an HSG include an allergic reaction to iodine (rare) or a pelvic infection. The risk of infection is approximately 1% and is higher in women who have had infections of their fallopian tube and ovaries in the past. If you have had a pelvic infection, please report this to your ordering physician, since s/he may ask you to take antibiotics prior to the procedure.
Evaluation of sperm
The semen analysis is the measurement of 4 different properties of a single ejaculate:
1. Volume is the amount of the ejaculate measured in cc's
2. Count is the concentration of sperm, measured in million of sperm/cc
3. Motility is the percentage of sperm that are moving, i.e. living
4. Morphology is the percentage of sperm that are normal in shape
The "normal" values for these parameters are greater than 2cc in volume, 20 million/cc in concentration, 50% motility, and 50% normal morphology. The presence of white blood cells in the semen may indicate an infection of the prostate or urethra, even if no symptoms are present.
If the semen analysis is persistently abnormal, a urological exam, more specific sperm testing and hormonal testing are recommended. The urological examination will check for the presence of anatomical abnormalities (varicocele, congenital absence of the vas deferens). More specific sperm testing might include more stringent morphology testing (Kruger morphology), or testing for the presence of white blood cells or antibodies. Hormonal testing includes measurement of Prolactin, FSH and Testosterone.
Female pre-cycle screening checklist:
A. Cycle Day 3 Blood work
- FSH (Follicle Stimulating Hormone)
- Estradiol
- Prolactin
- TSH
B. Infectious disease panel
- Rubella Immunity
- Varicella Immunity
- Blood Group/type (ABO/Rh)
- HIV 1- Antibody
- Hep B- surface antigen
- Hep C-Antibody
- HTLV-1 Antibody
- RPR
C. A Mid-cycle (around cycle day 12) ultrasound will be required for all patients who will be doing IVF or entering the Egg Donor program. This test must be done in our center as part of the evaluation process.
Male pre-cycle screening checklist
A. Semen Analysis
B. Infectious diseases panel
1. HIV1 -Antibody
2. HTLV 1 Antibody
3. Hepatitis B-surface Antigen
4. Hepatitis C-Antibody
5. RPR
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