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
- Surgery
- History of pelvic infection or pain
- Medications
- Contraceptives
- 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:
- CBC
- CMV
- Hepatitis B and C
- Human Immunodeficiency Virus (HIV)
- Rubella
- Varicella
- Sexually Transmitted Diseases/VDRL
- Blood Group and Rh Typing
- Prolactin
- Thyroid Function
- Anti-sperm Antibody (in all cases) and
other Antibody Tests (if indicated)
Hormonal Analysis
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.
Transvaginal Ultrasound
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.
Saline Sonogram
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Normal Saline Sonogram (click
on each sonogram to view larger)
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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 severe 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.
Hysterosalpingogram (HSG)
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. When a blockage is present,
your physician may suggest surgery.
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 twelfth 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. 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:
Endometrial Biopsy
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.
Diagnostic
Laparoscopy
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.
Diagnostic
Hysteroscopy
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).
Psychological
screening and counseling to determine whether you fully
understand and are prepared to deal with the physical, emotional and legal
ramifications of infertility treatment.
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.
