Egg and Sperm
Bay IVF - Advanced Reproductive Care                                Palo Alto  650-322-0500

 

Infertility Tests

By Francis Polansky, M.D.

In a recent opinion, the American Society for Reproductive Medicine (ASRM) states that the following tests are not recommended as a part of the routine infertility evaluation without other clinical indication:

  • Laparoscopy
  • Endometrial biopsy
  • Immunologic testing
  • Postcoital testing
  • Karyotype
  • Prolactin level
  • Advanced sperm function testing
  • Thrombophilia testing

 

What are then the tests that a couple wishing to conceive should consider? And when should the investigation begin?

The majority of infertility causes will fall into one or more of the following three categories:

  • Male Factor Infertility: Sperm production and sperm quality
  • Ovulation and Hormonal Production: Egg production, egg quality, and preparation of the uterine lining for implantation
  • Passage: The joining of sperm and egg in the Fallopian tubes and transport of the fertilized egg to the uterus

 

Infertility is most often defined as 12 months of unprotected intercourse without achieving a pregnancy. There is no distinction between having unprotected intercourse and "trying" to conceive. They both represent "exposure" to conception.

The following table illustrates the recommended length of "exposure," as it relates to the female partner’s age, before starting an infertility investigation.

Length of "exposure" before consulting an infertility specialist
Age No
Exposure
1 to 3 months 4 to 6 months 7 to 9 months 10 to 12 months 13 or more months
35
or
Less
Begin sexual activity Continue sexual activity Continue sexual activity Continue sexual activity Continue sexual activity Consult
Specialist
36-37 Begin sexual activity Continue sexual activity Continue sexual activity Continue sexual activity Consult
Specialist
 
38-39 Begin sexual activity Continue sexual activity Continue sexual activity Consult
Specialist
   
40-41 Begin sexual activity Continue sexual activity Consult
Specialist
     

42-44
 
Consult
Specialist
         

 

Your reproductive history, together with the result of your testing, will determine which treatment will most likely and inexpensively result in pregnancy.

The following are the most commonly performed reproductive tests:

  • Semen analysis

    A significant portion of all infertility is due to male factor infertility, and the presence of male infertility has a major impact on the direction of fertility testing and treatment.

    Unless semen evaluation results are highly abnormal (i.e., a concentration less than 3 million, total motility less than 3%, and normal morphology less than 3%), the test results cannot be reliably used to know the male fertility potential.

  • Ovarian reserve testing (egg quality tests)

    Ovaries not only produce eggs, but they also secrete the female reproductive hormones estrogen and progesterone. The production of these female hormones is dependent on the biological health of one's eggs. Normal egg quality equates to normal levels of estrogen and progesterone.

    Egg quality is the most important factor in determining female fertility potential.

    At birth, a newborn girl has approximately two million eggs within her ovaries. By the time she starts ovulating, she has about 400,000 eggs remaining. From that point on, the ovaries lose approximately 1,000 eggs a month. When only approximately 100,000 to 150,000 eggs are remaining around the age of 40, the biologically "perfect" eggs have already been depleted. This is why successful conceptions end years before menopause.

    A combination of transvaginal ultrasound examination of the ovaries and an assessment of reproductive hormone levels will determine the most appropriate treatment for you.

    Ultrasound examination of the ovaries will assess the number of antral follicles (seen as small dark circles) within each ovary. Their number is related to the quality of the eggs. Ideally, there should be approximately a total of 20 antral follicles in both ovaries combined. Too few or too many antral follicles mean that normal quality eggs may be infrequent or even absent within the ovaries. The majority of women will have 12 to 24 antral follicles.

    Follicle Stimulating Hormone (FSH), estradiol (estrogen, E2), and Anti-Mullerian Hormone (AMH) blood levels relate to the egg quality.

    FSH stimulates the ovaries to produce eggs. If the ovaries cannot produce normal quality eggs, the FSH level is increased. Estradiol production by the ovaries influences FSH secretion and is also directly related to egg quality. FSH should ideally be less than 7.0 and estradiol less than 30 in a blood sample drawn during a menstrual period.

    AMH level also reflects the quality of eggs, and the result should ideally be 2 to 3. Lower or substantially higher levels signify less than optimal egg quality.

    Most women will have normal ovarian testing results. An abnormal result does not necessarily mean that one cannot get pregnant. If the test results are abnormal, they should be repeated.

  • Evaluation of the uterus and the Fallopian tubes

    The endometrial cavity must be free of polyps, scarring, and myomas (fibroids) before any treatment can be initiated. The presence of any of these structures inside the uterus could significantly compromise the likelihood of embryo implantation.

    Saline ultrasound can be used to assess the endometrial cavity. A thin, soft catheter is passed through the cervix into the uterus, and a small amount of sterile saline solution is gently instilled. A transvaginal ultrasound is used to confirm the absence of polyps, scarring, or fibroids inside the uterus.

    Patency of the Fallopian tubes is commonly evaluated by an x-ray of the uterus and the Fallopian tubes, a hysterosalpingogram (HSG) performed by a radiologist. The HSG is not necessary if your infertility investigation concludes that In Vitro Fertilization is the most appropriate treatment. IVF bypasses the function of the Fallopian tubes.

Lifestyle and Reproductive Health:

Your physical condition can play an enormous role in achieving a birth. Optimizing your fertility potential could have a considerable impact on the probability of a successful outcome.

 

March 2021

 

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