Female Fertility Evaluation
The personal history form provides your physician with important information about your medical history and it helps determine whether your initial screening will include only the basic components or some additional testing. The questions relate to:
- Lifestyle, including smoking, alcohol and caffeine consumption, use of narcotics and stress
- Previous pregnancies and/or abortions
- Medical history, including rubella, sexually transmitted diseases, autoimmune disorders and other diseases
- History of pelvic infection or pain
- Exposure to DES during fetal development
The physical examination and medical screening help determine the size, structure and condition of your reproductive organs. It also will detect hormonal imbalances that affect your natural menstrual process and preclude normal development and fertilization of your eggs. You also will be screened for sexually transmitted diseases and, if indicated, for substances or conditions that could adversely affect sperm and/or keep your uterus from accepting and nurturing a fertilized egg. If you are a candidate for IVF, this work-up also will determine whether you are able to undergo folliclar stimulation and egg retrieval.
Routine Blood Tests
A series of routine blood tests check for various infections and collect other information related to your ability to undergo treatment and become pregnant. They include:
- Hepatitis B and C
- Human Immunodeficiency Virus (HIV)
- Sexually Transmitted Diseases
- Blood Group and Rh Typing
- Thyroid Function
- Anti-sperm Antibody (in all cases) and other Antibody Tests (if indicated)
In addition, baseline blood samples are taken at various points in your cycle to assess your hormone levels. Because even slight imbalances can disrupt reproduction, we make sure that the following hormones are released in sufficient amounts at the appropriate time in your cycle:
Follicle Stimulating Hormone (FSH) – develops the follicles and eggs
Lutenizing Hormone – stimulates development of the corpus luteum
Estradiol – promotes growth and maintenance of the reproductive system
Progesterone – prepares the uterus to accept and nurture and embryo
Androgen – stimulates the sex drive
Prolactin – induces lactation, the secretion of milk from the breast
Physical Examination and Cultures
The work-up includes a physical examination in our office. After a nurse has recorded your weight, height and routine vital signs, a physician will perform a pelvic examination – the type you receive during a routine gynecologic visit. As you lie on an examination table, your physician will insert a speculum into your vagina to help view the anatomy. He or she will use a swab to collect a sampling of cells for a:
Chlamydia Culture to indicate the absence of this sexually-transmitted disease
Mycoplasma/Ureaplasma Culture to identify harmful bacteria
Pap Smear to detect the presence of uterine cancer
Although your physician performs a manual examination of your vagina, uterus and abdomen, he or she also will order one or more advanced diagnostic procedures to get a more precise view of your reproductive organs.
Examination of the Uterus and Fallopian Tubes
Some women’s reproductive organs do not develop fully as a result of genetic defects or disease. For others, infertility is linked to infection or other problems that interfere with the development and fertilization of eggs, or the ability to sustain a pregnancy. Scar tissue or growths, such as polyps and fibroids, create blockages in the fallopian tubes and/or keep the fertilized eggs (embryos) from implanting in the uterus. The physical exam and a transvaginal ultrasound identify some of these problems. An even more precise picture is available from a type of ultrasound called a saline sonogram, or a radiological procedure called a hysterosalpingogram (HSG). Therefore, one or both may be included as part of your initial evaluation.
Ultrasound permits evaluation of the ovaries, the ovarian follicles, the uterus and the fallopian tubes. During the procedure, a probe is inserted about four inches deep into the vagina, providing a picture that appears on a monitor. Another probe is moved across the abdomen to enhance the picture. This allows your physician to evaluate and measure your reproductive organs, and to locate adhesions, scar tissue, polyps, fibroids or other foreign masses that may affect fertility.
Transvaginal ultrasound takes just a few minutes and is performed in our office. Although some patients experience minor discomfort, it helps to empty your bladder before the procedure. Otherwise, there are no significant risks or side effects associated with this procedure.
Normal Saline Sonogram
Like the transvaginal ultrasound, the saline sonogram is used to evaluate your reproductive organs and identify growths or abnormalities contributing to infertility. To prepare for the procedure, which is performed in the office, a speculum is inserted into the vagina. The cervix is swabbed with an antiseptic to help avoid infection that can be caused by insertion of a small, balloon-tipped catheter through the cervix. The speculum is removed and a transvaginal ultrasound probe is inserted into the uterus, providing a picture on a monitor. A warm saline solution is injected through the catheter, expanding the fallopian tubes to allow for better visualization.
Saline sonograms are more comfortable when your bladder is empty. Although you may experience mild to moderate cramping, it subsides quickly upon completion removal of the probe. Although other side effects may include infection, perforation of the uterus, cervical bleeding, abdominal pain and/or fever, they occur in fewer than 1% of cases.
The HSG is a diagnostic procedure performed by a radiologist in an outpatient setting. To prepare for the procedure, a speculum is used so the cervix and vagina can be swabbed with an antiseptic to help avoid infection that may occur from insertion of a thin tube. A dye is injected through the tube, outlining your uterine cavity and fallopian tubes. The fluid’s progress is viewed on a monitor and a series of x-rays record its flow, identifying any tubal obstructions or other structural problems. In some cases, in vitro fertilization (IVF) is recommended because it involves harvesting eggs directly from the follicles before they are released into the fallopian tubes where they can be fertilized.
Depending on the length of your menstrual cycle, an HSG is scheduled between the fifth and tenth day – or between the time of bleeding and ovulation. You should eat a light breakfast or lunch before the procedure and take 400 milligrams of Ibuprofen about one hour before to minimize cramping. Antibiotics or other premedications may be required depending on your individual situation. The procedure lasts only about 15 minutes, but many women experience mild to severe cramping as the dye is injected, depending on the condition of the tubes and the extent of blockage. Although these cramps usually subside within five minutes, they may continue and/or be accompanied by light bleeding and discharge.
Adverse symptoms can be minimized by limiting activity on the day of your procedure. Also, because there is a small risk of pelvic infection after an HSG, especially in cases where the tubes are blocked, your physician may order an antibiotic. If you experience fever or pain, you should call the office to speak with a nurse.
Examination of the Uterus and Fallopian Tubes – Additional Screening, if Indicated
As a result of your medical history or the results of preliminary tests, your physician may require additional information to identify the cause and best course of treatment for your infertility. In this case, he or she may order:
During each menstrual cycle, secretions of estrogen and progesterone promote the thickening of the inside wall of the uterus (the endometrium) in preparation for receipt of a fertilized egg. If an embryo implants, the prepared lining provides nutrients and support during development. If fertilization does not take place, the lining breaks down. The blood and tissue are discharged during a menstrual period.
Without the required levels of estrogen or progesterone, the lining will not develop properly and implantation either will not occur or it will not be sustained, resulting in spontaneous abortion or miscarriage. A sample of the tissue, collected during endometrial biopsy, is analyzed to determine whether it has the qualities required to sustain pregnancy. If not, your doctor may prescribe estrogen and/or progesterone to supplement your natural levels.
The actual biopsy takes just a few seconds and is performed in the office at a point in your cycle when the endometrium is thick. In preparation, the doctor will place a speculum into your vagina to allow insertion of a small catheter through the cervix and into the uterus. You may feel a quick pinch as the tissue sample is collected. You also may experience cramping, which will subside when the procedure ends.
Laparoscopy is performed on an outpatient basis because it requires general anesthesia. It is scheduled after menstrual bleeding, when your uterine cavity can best be examined and to minimize the chance that you are pregnant.
The procedure relies on a small, lighted telescopic device, a laparoscope, to view the ovaries, fallopian tubes and the outer wall of the uterus. To best explore these organs, a needle is inserted through your navel and into the abdomen. Carbon dioxide gas is pumped in, moving the organs away from the abdominal wall. This helps avoid puncture by the laparoscope as it is inserted through the same incision.
The scope allows the doctor to examine your reproductive anatomy for adhesions (scar tissue), fibroids, endometriosis and other structures that may cause blockage contributing to infertility. To assist in this exploration, a probe is inserted through a second incision in your lower abdomen, above the pubic area. It is used to move your reproductive organs to view different angles or uncover hidden problems. In some cases, your physician may inject a blue dye into the area to help further visualize growths and obstructions. If they exist, he or she may be able to remove them at the same time.
An average laparoscopy takes about two hours, but the time varies significantly, especially when the diagnostic procedure becomes operative laparoscopy to remove growths or adhesions. You may experience some discomfort after the procedure and be precluded from normal activities for a day or two. Laparoscopy can cause tenderness and bruising of the abdomen and naval area, and you may feel pain in your shoulders and abdomen associated with the gas.
Although there are risks associated with laparoscopy, they are rare and affect only 1 to 2% of every 100 women who have the procedure. Even in these cases, complications usually are not serious but they may include pelvic or abdominal infections, blood clots in the abdomen, allergic reactions, skin infections near the incision, nerve damage, bladder infection or complications from anesthesia. The greatest risk associated with laparoscopy is puncture of the bowel, bladder, blood vessels and other organs. Although occurring rarely, a puncture requires surgery to repair the damaged area.
When an HSG, an endometrial biopsy or a diagnostic laparoscopy indicates structural problems, your physician may also require a diagnostic hysteroscopy. This procedure uses a lighted telescoping device, called a hysteroscope. The procedure can be performed on an outpatient basis, as it requires either general or local anesthesia. However, hysteroscopy often is performed in the office, using a smaller scope that requires either local or no anesthesia. Unlike laparoscopy, which allows for examination of the outer wall of the uterus, hysteroscopy provides a view of fibroids, scar tissue, polyps and anatomical defects inside the uterine cavity.
During the outpatient procedure, the cervix is dilated to allow the hysteroscope – which is similar to but smaller than the laparoscope – to be inserted into the uterus. Dilation is not required for the office-based procedure. Gas or fluid is injected through the scope, enlarging the cavity and washing away blood and other debris from the uterine wall. This allows your physician to get a clear picture of any structural defects, scar tissue, fibroids or polyps. The procedure usually lasts for an hour to 90 minutes, but the length of time varies. In some cases, after diagnosing a blockage or other problems, the diagnostic procedure becomes an operative hysteroscope as your physician removes them.
Following a hysteroscopy, you should rest for a day or two. During that time, you may experience cramping or discharge, but serious complications from hysteroscopy occur in fewer than 1 to 2% of cases. The greatest risk is perforation of the uterine lining, which heals by itself in most cases. Patients also may have trouble breathing from fluid in their lungs if a liquid is used to distend the uterus, or they may experience an allergic reaction, blood clots or hemorrhage.
Additional Testing and Screening
As your physician reviews the findings of your personal history, the basic screening tests and other diagnostic procedures, he or she may order additional testing to assist in your diagnosis. These may include:
Post coital testing to identify incompatibilities between the mucus, discharged around the time of ovulation, and your partner’s sperm. Problems with the consistency of the mucus can hinder sperm from swimming up through the cervix. Bacteria or other substances can destroy them. If this test is ordered, you will be instructed to have intercourse at the time of ovulation. (An ovulation predictor kit may be needed to help you pinpoint this point in your cycle). A sample of your mucus is collected in our office the next day. It will be examined, along with the condition of the sperm included in the specimen.
Genetic screening and chromosomal analysis to identify hereditary diseases. Some genetic testing is done through analysis of blood samples. Genetic defects also can be identified through examination of embryos as part of an IVF cycle, a procedure called preimplantation genetic diagnosis (PGD).
Mammogram to rule out breast cancer in women over age 35 or with a family history of the disease. You will be referred to a radiologist for this procedure.
Additional Physical Examination if you have certain medical conditions such as heart disease or cancer, you may be referred to an internist or other appropriate medical specialist for a physical examination and testing.