Preliminary Fertility Evaluation & Testing

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.

Normal Saline Sonogram

Saline sonograms are more comfortable when your bladder is empty. Although you may experience mild to moderate cramping, it subsides quickly upon completion and removal of the probe.

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 pre-medications 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.

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. 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 your IRMS physician 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, she may be able to remove them at the same time.

An average laparoscopy takes about 90 minutes but the time can vary significantly especially when the diagnostic procedure becomes an 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. A laparoscopy can cause tenderness and bruising of the abdomen and navel area, and you may feel pain in your shoulders associated with the gas blown into the abdominal cavity for the procedure.

Although there are risks associated with laparoscopic surgery they are quite rare. Complications are usually not serious in nature.

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 less 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.