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Fertility Tests

Several fertility tests will be conducted with both partners. Fertility tests document the physiologic processes that must take place in order for successful pregnancy to occur. First, the male must produce an adequate quantity and quality of sperm that can reach and fertilize the egg. These sperm must be deposited into his partner's vagina, and then, must be able to swim through the cervix (mouth of the uterus). Once inside the uterus, the sperm must then travel through the fallopian tubes to their ends where fertilization occurs.

The female must produce healthy eggs that can be fertilized. Once developed, the eggs are released from the ovary into a sticky substance on the surface of the ovary. The fallopian tubes then must pick up the egg (s) so they might be fertilized in the end of the fallopian tubes. The resultant embryos must then travel to the endometrial lining of the uterus where they implant and develop.

The corpus luteum is the structure formed by the follicle after ovulation. The cells within the corpus luteum produce progesterone to help stimulate the lining of the uterus (endometrium) to help support embryonic development. After approximately 9 weeks of gestation, progesterone is produced by the placenta. The uterus must be able to support the fetus as it develops to term and delivery.

Male Fertility Tests

The semen analysis is one of the most important fertility tests because approximately 50% of infertile couples have a male infertility component. The semen analysis documents the quantity and quality of sperm. Please read our "semen analysis" Web page for a complete discussion.

Semen Analysis with Strict Morphology

The male, after 48-60 hours of abstinence from sexual relations, produces a semen sample by masturbation into a clean labeled specimen cup for analysis of volume, absolute number of sperm, percentage that are motile, sperm morphology, and presence of white blood cells.

It is important to note that sperm within the uterus or fallopian tubes survives for a maximum of 72 hours while the female's egg survives a maximum of 24 hours once released at the time of ovulation. The Strict Morphology assay takes a critical look at the individual spermatozoa according to a strict set of criteria. A relatively low number of sperm are rated as "normal" or essentially near perfect during a typical Strict Morphology test, as compared to the estimated morphology done during a Complete Semen Analysis.

The result is an assay that can distinguish very fine differences in morphology from one specimen to the next, and yields a quantifiable result that is indicative and predictive of the entire sperm population's potential fertility function.

Female Fertility Tests

Successful pregnancy requires the recruitment, development and ovulation of eggs that can be fertilized. If a woman is not ovulating, she is said to be anovulatory. See our Web page on amenorrhea for more information.

Predicting and Documenting Ovulation

The first fertility tests seek to document that successful ovulation is occurring. The patient may be asked to use a basal body temperature thermometer or an ovulation predictor kit (OPK) to chart her temperature throughout her cycle. The body temperature is measured each morning before getting out of bed and noted on the BBT chart.

Prior to ovulation, there is a small temperature increase indicating imminent ovulation and intercourse is timed around this period. The BBT is charted for several months making it possible to predict the time of ovulation in subsequent cycles. Because BBT charting is less than 50% accurate in documenting adequate ovulation, Dr. Mac prefers his patients no longer use this technique.

Most specialists prefer to use the urinary ovulation predictor kits to document ovulation because they are more accurate. The urine is tested daily around the time that ovulation is expected. A sharp rise in luteinizing hormone (LH) indicates that ovulation is imminent within 36 hours.

Purpose of Fertility Tests

Endocrine Profile (CD=cycle days 3 - 5) (Checks brain - thyroid - adrenal - ovary axis). When grouped together these tests (FSH, LH, E2 (estradiol), Prl (prolactin), DHEA-S, Testosterone, TSH) are called an endocrine profile. They are all normally occurring hormones.

When the levels are out of the normal ranges, interference with ovulation can occur. Follicle stimulating hormone (FSH) is produced by the pituitary gland and stimulates the ovary to produce estrogen (E2). Luteinizing hormone (LH) is also produced by the pituitary gland and induces the ovary to ovulate.

Prolactin (Prl) is also produced by the pituitary gland and may interfere with the mid cycle LH surge if prolactin levels are higher than normal. Dehydroepiandrosterone sulfate (DHEA-S) is a hormone produced by the adrenal gland. Its level allows us to determine whether or not the adrenal gland may be acting to suppress the ovulatory process.

Testosterone is an androgen (male-like hormone) that is produced by both the ovaries and the adrenals. Its production, along with DHEA-S, allows us to better identify if the ovaries or adrenal glands are in a resistant (suppressive) state. Thyroid stimulating hormone (TSH), yet another hormone produced by the pituitary gland, may increase prolactin production to higher than normal levels that act to interfere with ovulation.

Inhibin B

Inhibin B serum concentration provides a new measure of ovarian reserve. Ovarian reserve describes the ovaries' capacity to respond to gonadotropin (FSH & LH) stimulation by producing a sufficient number of good quality eggs capable of generating normal embryos.

Inhibin B concentrations drawn on cycle days 3 to 5 have been shown to predict response of the ovaries to ovulation induction medications. In addition, these levels have been used to predict the chance of miscarriage after becoming pregnant. These levels are recommended in any woman where ovarian reserve may be suspected to be low, i.e. age > 35, previous ovarian surgery, when premature ovarian failure is considered, etc.

Clomiphene challenge fertility test (CCT)

The clomiphene challenge test is a sensitive way to measure a woman's "ovarian reserve," or relatively speaking, whether she has fertilizable eggs left in her ovaries. It appears to be more sensitive than an endocrine profile since some women with normal profiles on day 2 or 3 may have an abnormal clomiphene challenge fertility test. It is most often used in women over the age of 35 to assure the patient that ovulation induction is worthwhile. Results of this test will help you and your physician evaluate your ovarian reserve and how aggressive you may need to be with regard to treatment.

Hysterosalpingogram (HSG)

Hysterosalpingogram is an x-ray of the uterus and tubes. It is an outpatient procedure that takes less than 30 minutes performed in the radiology department. A catheter is threaded through the cervix into the uterus and dye is injected to determine whether the fallopian tubes are open and to see if the shape of the uterine cavity is normal. This procedure causes moderate menstrual cramps and ibuprofen is recommended 1 hour prior to the procedure. Antibiotics are also recommended to decrease any risks of developing a uterine infection.

Urine LH "Ovulation Predictor" Kits

This pituitary hormone that triggers ovulation suddenly rises about 36 hours before ovulation and is easily measured in the urine. One can predict ovulation and plan intercourse, insemination, or post coital test based on this test.

Follicular Ultrasound

Follicles develop in a characteristic fashion prior to ovulation. After ovulation, the ruptured (ovulated) follicle becomes the corpus luteum that produces progesterone. The endometrial lining also develops gradually throughout the cycle. Watching the development and changes via ultrasound is a safe and simple method of determining ovulation and appropriate growth of the endometrial lining.

Ultrasound Fertility Tests

The pelvic ultrasound has many uses including assessing follicular development, measuring endometrial thickness, and diagnosing other abnormalities such as large uterine fibroids. Please see our Web page on "Ultrasound" for more information.

Cervical Mucus

The cervical mucus changes from scant, thick, sticky, and cloudy early in the cycle to plentiful, thin, clear, and stretchable just before and during ovulation. As estrogen levels increase mid cycle, the mucus changes. This allows for sperm to be easily transported to the fallopian tubes where fertilization takes place.

Post coital Test (PCT)

The PCT or "post-intercourse test" is done from 2 to 12 hours after intercourse within 2 days of predicted ovulation. Evaluation is made of both the mucus and the number of sperm that show progressive forward movement, thus examining simultaneously both female and male factors.

The post coital test (PCT) is a test performed on the cervical mucus after intercourse looking for sperm. In the post coital test, the couple has intercourse and the female then comes to the office within 2 to 12 hours. At the office, a speculum exam is performed where a sample of her vaginal and cervical fluid is examined.

The fluid will be analyzed and the quantity and quality of sperm will be determined. If numerous dead or nonmoving sperm are seen, it may be indicative of the presence of antisperm antibodies. The cervical mucus may also be too thick or there may not be enough mucus to transport sperm into the uterus.

This type of infertility is known as "cervical factor infertility" and is often treated using intrauterine insemination (IUI), which places sperm directly into the uterus.

Estradiol (E2)

Estradiol is an ovarian hormone secreted by the cells that surround the egg. This hormone helps develop the uterine lining during the first half of the cycle. It is also used to monitor the development and health of the developing egg (s).

Progesterone (P4)

Progesterone is an ovarian hormone secreted by the corpus luteum after ovulation. This hormone helps maintain the endometrial lining which is crucial for implantation of the embryo. Furthermore, it is vital in sustaining the early pregnancy for the first 7-9 weeks of gestation.

Endometrial Biopsy

The endometrial lining changes throughout the cycle from "proliferative" before ovulation to "secretory" after ovulation. This is necessary to allow implantation by the embryo. A biopsy allows one to assess if the proper amount of hormone (E2 and P4) was received by the lining by a certain day of the cycle. The physician may want to document that the endometrium is properly prepared to accept the developing embryo by ordering an endometrial biopsy. In this procedure, a small sample of the endometrium is taken and examined under a microscope. The depth of the endometrium can also be determined using transvaginal ultrasound. Progesterone levels are often measured before an endometrial biopsy to insure that successful ovulation has occurred.

Endometrial function test (EFT)

A family of cell-surface protein receptors appears on the endometrial lining of the uterus during "the window of implantation." This window often exists 8-10 days after a woman's urinary LH peak. The absence of certain proteins leads to poor implantation or lack of implantation in many cases. It is now been proven that implantation markers are necessary for proper development of the endometrial lining during a woman's menstrual cycle and for implantation.

Recently, many women with "unexplained infertility," "luteal phase defect," "endometriosis," or "hydrosalpinx (swollen tubes)" have been shown to have alterations in their endometrial lining function at the time of implantation. The lack of these implantation markers has been associated with each of these disease states. Biopsies of the uterine lining at appropriate times in the cycle can identify this type of abnormality. These biopsies collectively are termed the endometrial function tests.

Laparoscopy

The laparoscopy is a cornerstone infertility test where the physician can visually examine the internal "pelvic" organs. It is an outpatient surgical procedure performed to inspect the female for such infertility factors as endometriosis or pelvic scarring. Please see our page on "Laparoscopy" for an extensive discussion of this procedure.

Hysteroscopy

Hysteroscopy is a procedure in which a small camera is inserted through the vagina into the uterus. The structures such as fibroids can be seen. Please see our discussion on the hysteroscopy for more information.
Many other tests that may be ordered based upon each couples individual condition.