Evaluation
Female Infertility
The Diagnostic Cycle
Our program offers an efficient diagnostic pathway to determine the cause of infertility. Both partners are evaluated concurrently since male factors are involved in half of the cases. In most cases, the cause of infertility can be found within 1 to 2 cycles. The diagnostic cycle can be summarized as followed:
Day 2 or 3: Baseline sonogram, serum FSH or AMH level to check the ovaries.
Day 7 to 10: HSG to check the tubes and the uterus.
Day 13: Sonogram to check follicular growth.
Day 15: Coitus or Intrauterine Insemination (IUI).
Day 21: Serum progesterone to confirm ovulation.
Follicle Stimulating Hormone (FSH) is secreted from the pituitary and acts on the ovaries to recruit eggs. When the egg reserve declines with age, the pituitary compensates by producing a higher level of FSH to make eggs available for the cycle. A high FSH level at the beginning of the cycle therefore reflects a diminishing egg supply. FSH level should be less than 10 mIU/ml on cycle day 2 or 3. A baseline FSH level higher than 15 mIU/ml is rarely associated with pregnancy even with aggressive treatment.
Antimullerian Hormone (AMH) is secreted from the antral follicles of the ovaries and has been shown to correlate very well with the egg reserve. Women with higher AMH values tend to have more eggs and thus respond better to ovarian stimulation. Unlike FSH which has to be drawn at the beginning of the cycle, AMH level can be checked at any time of the cycle. An AMH level of 1.0 ng/ml or higher is considered to be normal. For women with very low egg reserve (AMH <0.5 ng/ml and <5 antral follicles) the high cost of medications and low chance of success would make IVF very cost ineffective. Their treatment should be limited to ovulation induction or donor egg IVF.
History and Physical Exam
A careful history can often suggest the cause of infertility:
1. Irregular periods can indicate problem with ovulation. Short cycles (<25 days) are especially worrisome since they can be early signs of diminished ovarian reserve (aging ovaries). Long cycles (>35 days) are usually caused by emotional or physical stress and are easier to treat with medications.
2. Excessive facial or body hair, weight gain, or milky breast discharge can indicate hormonal imbalances that can impair ovulation. These symptoms are often found in polycystic ovary syndrome and thyroid conditions.
3. Prior STD treatment for chlamydia, condyloma (HPV), herpes, or syphilis can suggest tubal damage and pelvic adhesions.
4. Prior abnormal Pap smear with treatment to the cervix such as conization, cryosurgery, or LEEP can result in cervical stenosis or constriction of the cervix that can impede the movement of sperm into the uterus, where they can survive for several days.
5. Pain during menstruation or intercourse can indicate endometriosis, a condition in which menstrual implants colonize the pelvis outside of the uterus. These implants can lead to scarring of the pelvic structures thus impairing the ability of the tubes to pick up the egg.
6. Heavy menstrual flow (with clots) can indicate abnormalities within the uterine cavity such as fibroid tumors or polyps. These lesions can prevent embryo implantation through their destabilizing effect on the endometrium.
7. Recurrent miscarriages can indicate multiple problems and will require extensive testing.
8. Prior abdominal operations such as appendectomy, myomectomy, or tubal surgery can suggest pelvic adhesions and tubal problems.
Hormonal Evaluation – is conducted to assess ovarian function:
1. Day 3 FSH can provide information on the ovarian egg reserve. The pituitary constantly secretes FSH to recruit eggs. When the egg supply is exhausted, the pituitary will compensate by overproducing FSH in an attempt to provide eggs for the cycle. A baseline FSH level of 10 mIU/ml or higher is abnormal, suggesting low egg reserve. A FSH level of ?15 is rarely associated with pregnancy even with IVF treatment. Donor egg IVF may be required.
2. Day 10 FSH is measured after a 5 days course of clomiphene to allow detection of patients with borderline egg reserve who may have normal baseline FSH level. The clomiphene challenge test can give a better assessment of the ovarian reserve than a single baseline FSH. Passing the test requires that both FSH levels on day 3 and 10 be less than 10 mIU/ml.
3. Estradiol is produced by a growing follicle to promote egg development, increase production of cervical mucus, and thicken the endometrial lining.
4. Progesterone is produced by the same dominant follicle after ovulation. Progesterone transforms the endometrium to prepare it for embryo implantation. Progesterone level is usually measured a week after ovulation (i.e.. day 20-22), and a level of ?12 ng/ml is desirable.
5. Thyroid Stimulating Hormone (TSH) reflects the function of the thyroid gland. Abnormal thyroid activity can interfere with egg development.
6. Prolactin Overproduction of this hormone can lead to undesired milk production and impairment of egg recruitment and development.
7. Androgens are male hormones that are normally produced by women in small amounts. Excess production of these hormones can impair egg development.
Hysterosalpingogram
The HSG is performed to assess the internal anatomy of the tubes and the uterus. A special dye that glows under X-Ray is injected into the cervix while the pelvis is being X-rayed. The dye outlines the contour of the uterine cavity and will show abnormalities within the uterus. The dye then follows the tubes and spills into the pelvic cavity if the tubes are open. The test can sometime cause cramping that can close the tubes at their insertion into the uterus, leading to a false impression of tubal occlusion. Because it outlines only the internal surfaces of the uterus and tubes, the HSG cannot diagnose external pelvic abnormalities such as endometriosis and adhesions. The test is usually performed after the cessation of menses (on day 7-10). An antibiotic (Doxycycline) is taken 1-2 days prior the HSG to prevent infection.
Sonograms
A lot of information on egg development can be obtained by performing vaginal ultrasound at different parts of the cycle. A sonogram done at the beginning of the cycle (day 2-3) can give an indication of the egg reserve. A normal ovary should have at least 5 immature (antral) follicles at baseline. Finding of small ovaries with few antral follicles indicates low egg reserve. In addition, exhausted ovaries also tend to have cysts, probably due to the stimulatory effect of high baseline FSH level. A sonogram performed at midcyle (day 13-14) can assess the growth of the follicle and the endometrium. The average diameter of the follicle should be at least 18 mm, and the uterine lining should be at least 7 mm at this time. Smaller follicle means suboptimal egg development and indicates a need for medications.
Hysteroscopy
In this procedure a small camera attached to a thin scope is introduced into the cervix to inspect the uterine cavity. The examination can be performed easily in the office taking only 10 minutes. It is performed to confirm suspicious findings by the HSG.
Laparoscopy
Laparoscopy is usually deferred as the last step in the infertility investigation due to the risks associated with surgery and anesthesia. Under general anesthesia, a fiberoptic scope is inserted into the abdominal cavity via small incisions to allow examination of the pelvic and abdominal organs. Laparoscopy is used to diagnose endometriosis and pelvic adhesions, findings not detectable by the HSG. Often abnormalities found can be corrected in the same setting.
