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Diagnostic Services
The complete fertility evaluation begins with a thorough personal
history, a physical examination, and Comprehensive Initial Infertility
evaluation.
SEMEN ANALYSIS
An evaluation of male infertility is performed early in your infertility
assessment.
A standard semen analysis usually includes several parameters. Some
of the parameters evaluated include:
- Semen volume ( normal semen volume is 2 - 5 mL)
- Concentration / Count ( 20 million/mL is the acceptable lower
threshold of normal fertility, but lower numbers do not rule
out a fertile male)
- Motility, or the ability of the sperm to swim (normal motility
is at least 50 percent) Morphology, or appearance of the sperm
(normal % morphology by strict criteria is >14 percent)
There are four categories of semen abnormalities that may be found
during the semen analysis: Azoospermia (a complete absence of sperm
seen in the ejaculate), Oligospermia (a low sperm count with concentrations
of less than 20 million/mL), Asthenospermia (a low motility with
less than 40 percent motile sperm/mL), and Teratospermia (a low
percentage of normal sperm forms).
SPERM ANTIBODY STUDIES
This test is not part of the basic infertility workup, but may be
requested by the physician when there is a normal sperm count, but
the number of motile sperm is low. Sometimes substances produced
by the body prevent the normal function of the sperm so they cannot
reach and penetrate the egg. There are a variety of antibody studies
performed. Blood from both the male and the female partner, cervical
mucus from the female, or seminal fluid from the male will be needed
for these studies.
POST-COITAL TEST (PCT)
The post-coital test (also known as a Huhner) is an excellent means
of assessing the interaction of the sperm and the cervical mucus.
In order to reach the fallopian tube and fertilize an egg therein,
the sperm must first migrate through the cervical mucus. There are
many factors which can impair the ability of the sperm to survive
and traverse the cervical mucus, including infection, prior surgery
on the cervix, and production of antibodies (substances that can
kill or immobilize the sperm).
During a normal menstrual cycle, there are only a couple of days
during which the sperm can survive in the cervical mucus. At other
times of the cycle, the mucus is a very effective barrier. Around
the time of ovulation, the cervical mucus becomes very thin and
watery and probably even somehow assists the sperm as they migrate
through to the uterus and into the fallopian tube. The quality of
the cervical mucus as well as the number of sperm present and their
motility will be assessed. The timing of this test is, therefore,
crucial and must be done within 12 hours after Intercourse.
Endocrine Studies to Evaluate
Hormonal Status in Female
- Hormonal
Assays
We offer various hormonal blood tests at our offices. The results
of these hormonal tests help determine the best course of treatment
for each individual patient. Most of the blood tests are time
sensitive in relation to the menstrual cycle. Our office staff
will help you schedule the tests at the appropriate time.
- Estrogen
Estrogen
is largely responsible for stimulating the development of the
lining of the uterus. For the embryo to implant, it is imperative
that the uterine lining develops adequately. Low levels of estradiol
may indicate that the follicles (small fluid filled sacs in
the ovaries that house the eggs) do not contain healthy eggs.
Because estrogen levels vary during the menstrual cycle, several
levels are usually measured over several days. Low estrogen
levels are supplemented when clinically indicated.
- Progesterone
Progesterone
is a hormone produced after ovulation that is critical to successful
implantation. The progesterone hormone test is performed 10
days after predicted ovulation or the LH surge to determine
if ovulation has occurred. Low levels of progesterone may suggest
a lack of ovulation or anovulation (the failure, termination,
or suppression of ovulation). Low levels of progesterone may
also be indicative of a luteal phase defect. Progesterone supplementation
may then be instituted.
- FSH
and LH Levels
Follicle
Stimulating Hormone (FSH) and Leutinizing Hormone (LH) control
ovarian function and ovulation. FSH levels are elevated in women
with diminished ovarian reserve.
- Testosterone
and Other Androgens
The
ovaries and adrenal glands usually produce small amounts of
androgens (male hormones), including testosterone. If androgens
are overproduced, normal ovulation can be affected. Indications
of excess androgen include oily skin, acne, and excessive hair
growth as seen in patients with polycystic ovarian disease.
- Thyroid
Tests
The
thyroid gland can affect fertility, the ability to become pregnant
and maintain a healthy pregnancy. The thyroid-stimulating hormone
(TSH) which is produced by the pituitary gland, is measured
first because it is a more sensitive indicator of thyroid function
than the thyroid hormone itself.
- Prolactin
The
prolactin hormone is produced at the base of the brain and is
responsible for stimulating milk formation during pregnancy.
Excess prolactin, a condition known as hyperprolactinemia, can
result in an assortment of reproductive dysfunctions, including
irregular ovulation and menstruation, absence of menstruation,
and galactorrhea (breast milk production by a woman who is not
nursing).
Tests to Document Evidence
of Ovulation
- UltraSound Exam
Ultrasounds
(sonograms) record information from sound waves passed into
the body and returned to recording surfaces. They produce images,
similar to X-Rays, but no radiation is involved. The ultrasonographer
and physician then interpret these images.
A vaginal ultrasound involves placing a probe into the vagina
and manipulating the probe to view the ovaries. It takes less
than 10 minutes to complete, and is painless. You should empty
your bladder prior to having a vaginal ultrasound.
An abdominal ultrasound is obtained by placing the sonogram
probe on the abdomen. It is recommended that your bladder be
full to prepare for an abdominal ultrasound. This type of sonogram
also takes approximately 10 minutes, and is painless.
Ultrasounds are used for a number of reasons, including: monitoring
for IVF cycles, medication cycles, and transvaginal guided egg
aspiration during IVF.
- Blood Progesterone
Levels
Progesterone is a hormone produced after ovulation that is critical
to successful implantation. The progesterone hormone test is
performed 10 days after predicted ovulation or the LH surge
to determine if ovulation has occurred. Low findings of progesterone
may suggest a lack of ovulation or anovulation (the failure,
termination, or suppression of ovulation). Low levels of progesterone
may also be indicative of a luteal phase defect. Progesterone
supplementation may then be instituted.
A Urine dip test is also used to determine if ovulation has
occurred
Ovarian Reserve Screening
Age has a significant impact on both the quality and quantity of
a woman's eggs. In fact, a female's fertility begins to decline
in her early 30s. Ovarian reserve screening is a method we can use
to predict your reproductive potential as well as the potential
of a healthy pregnancy. Ovarian reserve screening includes:-
- Estradiol (E2) and Follicle stimulating Hormone (FSH) testing.
- Inhibin B levels.
- Clomid Challenge test (CCT). The CCT is the most sensitive
method of determining ovarian reserve. To perform this test,
the ovulation inducing drug Clomiphene Citrate (Clomid) is utilized
to see how the ovaries respond to stimulation. Clomiphene Citrate
at a dose of 100mg is administered orally for five days (menstrual
cycle days 5-9). Blood FSH levels are obtained before (day 3)
and after (day 10) using Clomid. If either the day 3 or day
10 FSH level exceeds 10 mIU / Ml, the result is abnormal and
indicative of reduced ovarian reserve.
- Ultrasound for antral follicle count.
- Ovarian volume and blood flow evaluation.
TUBAL PATENCY
- Hysterosalpingogram
(HSG)
A hysterosalpingogram (HSG) is an x-ray of the uterus and fallopian
tubes that reveals abnormalities in the uterus or blockages
in the tubes. During the hysterosalpingogram, a radio-opaque
dye is injected into the uterine cavity that reveals the size,
shape, and symmetry of the uterus. If there is no blockage present
in the tubes, the dye will spill into the abdominal cavity.
Dye flowing into the abdominal cavity does not guarantee normal
function, but it is a positive sign.
Hysterosalpingograms can also determine where blockages are
located. In some cases, pushing dye through the fallopian tube
will remove any material that is causing a blockage. In fact,
some women have become pregnant following a hysterosalpingogram
without the use of further fertility treatments.
Other conditions that can be seen with a hysterosalpingogram
include endometrial polyps, fibroid tumors, scar tissue, and
defects within the fallopian tubes.
You may need to take anti-inflammatory medication, such as Motrin,
an hour before your exam to help alleviate cramping. Antibiotics
are also used prophylactically to prevent infection. You may
also experience a sensation of warmth during the hysterosalpingogram,
but most patients report minimal discomfort.
Saline Infusion Sonography (SIS)
Saline infusion sonography (SIS) can effectively diagnose and evaluate
abnormalities within the uterine cavity, including scarring of the
uterine lining, uterine fibroids, and endometrial polyps. It can
also be a valuable diagnostic tool for evaluating women who have
had recurrent miscarriages.
Normal saline is infused into the uterine cavity using a small bore
catheter. Following the infusion a sonogram is done to visualize
the uterine cavity. Most patients report very little discomfort
during the procedure.
Evaluation of Uterine Lining
- UltraSound
Exam
Ultrasounds (sonograms) record information from sound waves
passed into the body and returned to recording surfaces. They
produce images, similar to X-Rays, but no radiation is involved.
The ultrasonographer and physician then interpret these images.
A vaginal ultrasound involves placing a probe into the vagina
and manipulating the probe to view the ovaries. It takes less
than 10 minutes to complete, and is painless. You should empty
your bladder prior to having a vaginal ultrasound.
An abdominal ultrasound is obtained by placing the sonogram
probe on the abdomen. It is recommended that your bladder be
full to prepare for an abdominal ultrasound. This type of sonogram
also takes approximately 10 minutes, and is painless.
Ultrasounds are used for a number of reasons, including: estimation
of endometrial thickness, monitoring for IVF cycles, medication
cycles, and transvaginal guided egg aspiration during IVF.
For some couples, these basic tests will not clearly identify
a reason why conception has not occurred. Additional testing
may be necessary. Dr. Pinto will discuss this with you and some
additional investigations that may be requested are described
below.
Diagnostic Laparoscopy
During laparoscopy, a telescope-like instrument is inserted through
a small incision at the belly button into the abdomen. The abdomen
is then inflated with carbon dioxide to allow full visualization
of the pelvic organs. One or two small incisions are made along
the lower abdomen where graspers can be inserted to visualize the
entire abdominal cavity. Dye is then passed through the cervix and
uterus to evaluate function and patency, and the fallopian tubes
are inspected to ensure there are no blockages or abnormalities.
Video and photographs are taken during the procedure to record findings.
Once the procedure is complete, the abdomen is deflated and the
incisions are stitched closed. Recovery time for laparoscopy is
usually about one hour.
Diagnostic Hysteroscopy
Hysteroscopy is a minimally invasive surgical technique that allows
a virtual evaluation of the uterine cavity. This is important because
abnormalities of the uterine cavity may prevent fertility and can
even interfere with pregnancy.
Diagnostic hysteroscopy is performed when the results of a hysterosalpingogram
show a uterine abnormality, Women have repeated miscarriages or
a routine ultrasound shows evidence of a polyp or fibroid
Fertility-related diagnoses that can be made with hysteroscopy include:
Submucosal myomas, Uterine polyps, Scarring of the uterine lining
( Asherman's Syndrome), Presence of a uterine septum or bicornuate
formation and Congenital abnormalities of the uterus.
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