Incidence of Polycystic Ovarian Syndrome
The first office visit will usually consist of a history and physical. The doctor will ask questions regarding frequency of intercourse, regularity of periods and general health, as well as about any pelvic infections, endometriosis, surgeries, ectopic pregnancies, or social habits (such as smoking) that may negatively affect fertility. Assessment of reproductive function will include several tests. These tests will include, but are not limited to, hormone testing and evaluation of both the uterus and the Fallopian tubes. These tests are described below.
It is very important that the male partner be evaluated during the initial work up. A history of genital infections, trauma or environmental exposure to toxins can reduce male fertility. Disorders of the endocrine system (hypothalmus, pituitary), structural dysfunction (such as obstruction of the vas deferens), or numerous other conditions can cause male infertility. See treatment of male infertility.
Tests to Evaluate Infertility
>Ovulation must occur for an egg to be released. Ovulation will be documented during the early stages of the evaluation through the use of basal body temperature monitoring (BBT) or, in most cases, a urine ovulation detection kit (LH kit). The LH kit is far more accurate, and less intrusive, than the BBT.
Basal body temperature monitoring (BBT) is recommended by many gynecologists as a first step in the infertility workup. The purpose of the BBT is to monitor the early morning resting (basal) body temperature. Women experience a rise in body temperature after ovulation. Daily monitoring can be used to document that ovulation has occurred.
Estradiol is released by the developing follicle. Estrogen has many physiologic effects and is primarily responsible for stimulating the development of the endometrium. In general, as more follicles develop estradiol levels increase. Low levels of estradiol may indicate that the follicle does not contain a healthy egg.
Follicle-Stimulating Hormone (FSH) Assay
FSH is a hormone produced by the pituitary gland responsible for the development of the egg in the female and sperm in the male. FSH is measured in the female on day three of the menstrual cycle. An elevated FSH is associated with a low chance of pregnancy. A woman can have regular periods even if the FSH is elevated. Women with high day three FSH levels may be candidates for the Oocyte Donation and Embryo Donation program. FSH is the active ingredient in the injectable drugs used to stimulate ovulation.
Laparoscopy is a surgical outpatient procedure which allows the surgeon to diagnose and treat pelvic disorders. Small incisions are made in the abdomen, near the midline (belly button) and at the top of the pubic hairline. The laparoscope is inserted through one of the openings.
The laparoscope allows the reproductive surgeon to diagnose and treat diseases, such as endometriosis, at the time of the procedure. A laser is commonly used during this procedure. Laparoscopy often allows the surgeon to determine if the tubes are open, if scarring is present, or if there are uterine abnormalities.
Many patients have had a previous laparoscopy(s). Dependent on the disease, it may be repeated by your Mayo physician. The reproductive surgeon is highly trained in infertility treatment and advanced laparoscopic surgery.
Ovulation Prediction Kits
The kit measures the level of luteinizing hormone (LH). LH is the hormone that triggers the release of the egg from the follicle. The LH kit accurately documents that ovulation has occurred and can be used to time intercourse. It has largely replaced BBT monitoring.
Progesterone is a female hormone produced after ovulation. Levels of progesterone are measured to determine if ovulation has occurred. Blood is drawn four to nine days after predicted ovulation (or four to nine days after a positive LH surge). For women with a 28-day cycle this means blood progesterone should be drawn on day 20 or 21. Progesterone is usually administered for at least two weeks after an assisted reproduction cycle to help support the growth of the developing embryo.
The semen analysis will be one of the first tests ordered in the infertility evaluation. Male sperm abnormalities are implicated as a cause of infertility in more than 40 percent of patients and must be ruled out before extensive tests are done on the female.
The male produces an ejaculate through masturbation. A minimum of 48 hours, and a maximum of seven days, absence from sexual activity is required for this test. Care must be taken not to contaminate it with soap, lotion, or other agents and it must be kept at body temperature. Detailed instructions are provided with the specimen collection container.
An andrologist examines the sperm and determines the concentration (millions of sperm per milliliter of semen), the shape (head structure, tail, etc.), and their ability to swim in straight lines. These characteristics impact the sperm’s ability to fertilize the egg. Other, more specific tests, are ordered if necessary.
In rare instances (less than five percent) the female will produce antibodies to the male’s sperm. Her body may mistake the sperm for a hostile invader, such as a cold or virus, and produce defensive antibodies. These antibodies incapacitate the sperm before it can pass through the cervix and reach the egg. Treatment may consist of techniques such as intrauterine insemination or in vitro fertilization that bypass the cervical mucus.
Even after testing, in 10 percent of cases no cause for infertility can be found. Statistics demonstrate that well over 75 percent of patients who seek appropriate help will conceive. Regardless of the cause of infertility, a thorough evaluation by an experienced infertility specialist will yield the best chance for success.
Tests to Evaluate the Uterus
Sonohysterography is a valuable, safe, easy and cost-effective new technique for examining the inside lining of the uterus. Sonohysterography can be used to evaluate abnormal bleeding, infertility and recurrent pregnancy loss. It also can define abnormalities such as possible polyps and fibroids that are detected on X-ray hysterosalpingography and pelvic ultrasound.
Sonohysterography can distinguish between polyps and fibroids and clearly identifies their location and size. In the case of a normal sonohysterogram one might avoid unnecessary surgery. When an abnormality is found, it allows for proper surgical planning and perhaps avoidance of a purely diagnostic surgical procedure.
A probe is inserted into the vagina and sound waves are passed through the surrounding organ systems. These sound waves penetrate tissues of different density to different degrees, thus creating an impression similar to an X-ray. Unlike X-ray studies, ultrasound has no negative side effects. Vaginal probe ultrasonography is commonly used to monitor follicular development and visually confirm that the egg has been released from the follicle. Ultrasonography is also used to monitor the developing fetus and diagnose many other conditions.
In the endometrial biopsy, a small piece of uterine lining is removed for microscopic examination. The biopsy is done in the office and takes less than ten minutes. It is sometimes accompanied by intermittent cramping. The lining of the uterus responds to hormones produced during ovulation by thickening. The degree of endometrial thickening yields information about ovulation and the ability of the uterus to support a pregnancy.
A hysterosalpingogram (HSG) is an X-ray examination used to outline the inside of the uterus and the Fallopian tubes. The HSG is usually done to verify that the Fallopian tubes are open. The HSG is performed on days five to 12 of the menstrual cycle.
A hysteroscope is an instrument used to visualize the inside of the uterus. In hysteroscopy, a fiber optic tube is inserted through the cervix while the uterus is expanded using a gas or fluid. This is an outpatient test. Many surgical procedures are performed through the hysteroscope, such as removal of polyps and fibroids or resection of uterine septi.