An integrative approach to assessing fertility...
Your gynecologist may recommend a fertility evaluation after one year of regular unprotected intercourse in women under age 35 years, and after six months of unprotected intercourse in women age 35 years and older. However, the evaluation may be initiated sooner in women with irregular menstrual cycles or known risk factors for infertility. Your doctor may order many of these tests, or refer you to reproductive endocrinologist for advanced testing.
Basic Fertility Assessment...
The following tests are typically ran through a blood draw, unless otherwise noted.
Follicle Stimulating Hormone (FSH) stimulates the growth of ovarian follicles in the follicular phase, and influences estradiol production. This test is commonly used as a gauge of ovarian reserve. For this purpose, it is ideally ran on Day 3 of the menstrual cycle.
Estradiol (E2) levels, in combination with FSH, are helpful in establishing baseline ovarian reserve. For this purpose, E2 levels are ideally checked on Day 3 of the menstrual cycle.
Luteinizing Hormone (LH) triggers ovulation and the development of the corpus luteum. This test is typically ran on Day 3 of the menstrual cycle, and the results interpreted in conjunction with FSH and E2.
Anti-Mullerian Hormone (AMH) is a substance produced by granulosa cells in preantral and small antral ovarian follicles. It is valued as an important marker of ovarian reserve. This test may be ran on any day of the menstrual cycle.
Progesterone (P4) is a hormone produced by the corpus luteum that prepares the uterus for pregnancy. This test is typically ran in the mid-luteal phase, both to confirm ovulation and to ensure adequate progesterone production to support a potential pregnancy.
Prolactin (PRL) levels are best checked during the follicular phase, and a few hours after waking, as levels tend to be higher in the luteal phase and the early AM. High prolactin levels may contribute to ovulatory dysfunction and low estrogen levels.
Thyroid Stimulating Hormone (TSH) has a direct effect on our body’s metabolism. Suboptimal levels have been implicated cases of unexplained infertility, ovulatory disorders, irregular periods, preterm birth, and impaired fetal development. Ask your doctor to run a complete thyroid panel (TSH, Free T4, Free T3, Total T3) for a full assessment.
Other diagnostic blood/serum tests may be recommended based on your signs and symptoms. For example, if Polycystic Ovarian Syndrome (PCOS) is suspected, your doctor may additionally order lab tests for Total Testosterone (Total T), Free Testosterone (Free T), Dehydroepiandrosterone Sulfate (DHEAS), Sex Hormone Binding Globulin (SHBG), 17-hydroxyprogesterone (17-OHP), Cortisol, and Glucose tolerance testing.
Pelvic Ultrasound can be used to measure the size and shape of the uterus and ovaries, and to determine if there may be structural abnormalities such as fibroids or ovarian cysts. Pelvic ultrasound is also used to assess the thickness of the endometrium, the lining of the uterus.
Antral Follicle Count (AFC) is considered a major predictor of ovarian reserve. An AFC is performed via pelvic ultrasound, ideally between Days 2-5 of the menstrual cycle.
Semen Analysis (SA) is the most common test performed in the assessment of male fertility; a physical exam is also recommended. In heterosexual couples experiencing infertility, approximately 35% is attributed to male factors, 35% is attributed to female factors, 20% of cases have a combination of both male and female factors, and the last 10% are unexplained causes.
Advanced physical assessment...
The following tests are commonly ordered for advanced assessment of the fallopian tubes and uterus. Possible fallopian tube pathology noted on these tests include: scarring, swelling, and blockage. Possible uterine pathology noted include: structural abnormalities, and the presence of polyps, fibroids, or scar tissue.
Hysterosalpingogram (HSG) is a procedure that uses X-Ray and iodine to evaluate the fallopian tubes and uterus. It is typically done on Days 6-11 of the menstrual cycle. A thin tube called a cannula is inserted into the cervix and is used to gently fill your uterus with a liquid dye containing iodine; the iodine contrasts with your fallopian tubes and uterus on the X-rays. *HSG is considered the frontline test for tubal pathologies, but more sensitive tests should be performed if uterine pathologies are indeed suspected.
Saline Infusion Sonohysterography (SIS), aka Sonohysterogram (SHG), is a procedure that uses ultrasound and saline to evaluate the fallopian tubes and uterus. It is performed in a similar fashion to the HSG, also on Days 6-11 of the menstrual cycle. Doppler ultrasound, which provides information about blood flow, may be used to enhance the procedure. *SIS/SHG is considered a more sensitive test for uterine pathologies, but its assessment of tubal pathologies is limited.
Hysterosalpingo-Contrast-Sonography (Hy-Co-Sy) is a procedure that uses effervescent fluid and ultrasound to assess the fallopian tubes and uterus. One advantage of this test is that it does not require the use of X-ray (i.e., radiation exposure). While this test has not yet become the standard of care, Hy-Co-Sy appears to be the most comprehensive screening study in the evaluation of the infertility, allowing for adequate simultaneous evaluation of the fallopian tubes and uterus.