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Infertility
Investigations
Investigations for Infertility
The basic requirements for normal fertility involve eggs, sperm and a pathway, which includes the vagina, cervix, uterus, tubes and ovaries.
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The normal medical approach to investigating these parameters follows certain principles:
Initial testing of the male (this should not be left to last or not at all!)
Repetition of certain tests of both male and female to establish baseline levels. Despite such tests having been performed previously, there may have been recent changes, the timing of the tests may be incorrect (wrong time of the month) or something significant may have been missed.
Those tests, which do not require anaesthesia should be, performed first, e g. blood tests and a hysterosalpingogram. Tests such as laparoscopy and hysteroscopy, which require general anaesthesia, may be performed at a later stage if needed at all.
Tests on the female require to be performed at appropriate times in the menstrual cycle.
Even if one problem is found, all the necessary tests for infertility must be completed as more than one cause of infertility exists in 15% of couples.
Semen analyses are preferably performed in a laboratory specialising in fertility, the results usually take up a foolscap page and not a few lines.
Let us review these tests in more detail:
Male
Female
- Tests of Ovulation
- Timing length of cycles
- Oestrogen Levels
- Progesterone Levels
- Ultrasound
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- Hormonal Trigger (LH surge)
- Other hormonal tests
Blood tests are used to investigate other hormones, which may have an effect on ovulation. These include: -
FSH (follicle stimulating hormone): indicates whether or not the ovary contains eggs, is capable of ovulating or has failed.
LH (luteinising hormone): used to diagnose ovulatory problems, eg. polycystic ovarian syndrome (PCOS) (a fairly common hormonal dysfunction characterised by irregular or absent ovulation in association with raised LH levels, and a specific ultrasound picture).
Serum testosterone and related hormones (sex hormone
binding globulin-SHBG, free androgen index FAI) used in assessing PCO and ovarian tumours.
Prolactin: Raised levels of this hormone can prevent or interfere with ovulation,
Thyroid: Thyroid stimulating hormone (TSH) and Free thyroxine (FT4). Abnormalities of thyroid hormone production, (either over or under) will influence ovulation and prolactin in certain circumstances.
Adrenal gland and related hormones, e.g. cortisol, DHEAS dehydroepiandrosterone sulphate: Abnormalities can affect ovulation.
Other hormonal tests: numerous tests exist but are rarely used.
2. Tests of the Fertility Pathway
2.1 CERVIX
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Sperm can only penetrate the cervical mucus in the time period preceding ovulation (1 - 2 days) so that testing of the cervical mucus can only be performed at this time.
2.1.1 Post Coital Test (PCT)
This test requires the couple to have intercourse 6 - 12 hours before the test is performed. Mucus is removed from the cervical canal - with no more discomfort than a Papanicolaou (PAP) smear.
This test is no longer considered of any value
2.1.2 High Vaginal Swab (HVS) and/or Endocervical Swab
This test is performed to exclude the presence of infection in the female reproductive tract. Although infection may not actually prevent conception, it is of value to eradicate it prior to repairing tubal anatomy to prevent further damage to the female reproductive tract and it may decrease results of ART. The presence of infection can cause sperm to stick together (agglutination), thus decreasing the number available for fertilisation.
One of these infections, which is difficult to detect but may interfere with tubal function, is Chlamydia trachomatis. Detection involves sophisticated genetic tests of urine called a Chlamydia PCR. Infection may also be inferred with a raised antibody level in the blood, a test called a Chlamydia antibody titre. Some doctors will treat this infection especially if tubal surgery or ART is planned. An elevated Chlamydia antibody titre (level) may indicate an increased risk of tubal dysfunction.
2.2 Uterus
2.2.1 Endometrial Biopsy
Examination of a specimen of the uterine lining (endometrium) taken on the first day of the menstrual cycle often provides useful data about the quality of ovulation. The procedure is usually performed in the doctor’s rooms. The specimen can also be sent for culture to exclude inflammation of the lining ie endometritis and infections, e.g.TB (Tuberculosis.) Please do not confuse the term endometritis with endometriosis.
2.2.2 Hysterosalpingogram (HSG)
Failure to adequately test the uterine cavity occurs commonly and patients often undergo a laparoscopy and Curettage and are incorrectly told that “their uterus is normal”, even though non of the following tests have been undertaken!
A HSG is an X-ray of the cervical canal, uterine cavity and interior of the tubes as well as a test (not absolute) of whether the tube(s) is open or not (tubal patency). It requires injection of a radio-opaque dye through the cervix, and is performed as an outpatient procedure. It does not require general anaesthesia. A great deal of useful data can be obtained with this test, provided it is performed by someone with a lot of expertise, and your own practitioner should discuss the results with you.
It should be noted that this is a test of the interior of the reproductive pathway, and as such is complemented by the following tests, which include fluid sonohysterography, hysteroscopy and laparoscopy.
The diagnosis of “blocked tubes” should never be made by hysterosalpingography alone, as they have a 10% false negative rate. The additional tests are mandatory.
2.2.3 Fluid Sonohysterogram
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This procedure involves viewing the cavity of the uterus and the walls of the uterus by ultrasound but the image is vastly improved by filling the cavity of the uterus with certain fluids which includes saline (a balanced salt solution) via a thin plastic tube placed in the cavity of the uterus. It is causes no more discomfort than a speculum examination of the cervix. Unfortunately this test does not provide sufficient information about the internal anatomy of the Fallopian tubes. A variant of this test is the HyCoSy, which may show if the tubes are open but gives no other information about the state of the tubes.
2.2.4 Hysteroscopy
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This is a surgical procedure which can be performed under local or more commonly general anaesthesia. A thin telescope is inserted through the vagina and cervical canal, which allows the interior of the cervical canal and uterine cavity to be examined under direct vision. The uterine cavity is expanded with either normal saline or carbon dioxide gas. Additional surgical procedures may be performed inside the uterus, using this instrument, e.g. cutting of adhesions (synechiae), biopsy of any suspicious area, and removal of polyps and fibroids.
Although not commonly used, direct visualisation of the tubal interior is possible using an extension of the hysteroscope, ie. a falloposcope.
2.2.5 Dilatation and Curettage (D&C)
This procedure has very limited place in the diagnosis of infertility if performed alone, but may be of value when combined with hysteroscopy.
2.3 Tubes
2.3.1 Hysterosalpingogram
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As previously mentioned, this procedure shows some of the internal anatomy of the tubes. If tubal surgery is planned it is an important additional test as grading of tubal pathology can give some prognostic information about the outcome of the surgery. Unfortunately, this test is rather crude and not very precise.
2.3.2 Laparoscopy
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Laparoscopy aids the diagnosis of uterine and tubal problems as it allows direct vision of the exterior of the uterus and tubes. Laparoscopy usually requires general anaesthesia and involves a minimum of two small cuts (approx 1 cm long) in the abdomen, usually one in the region of the navel (umbilicus) and the other in the pelvic region. This direct form of looking at the uterus and tubes is useful in the diagnosis of blocked or scarred tubes, and also in examining the relationship of the tube to the ovary. The injection of a coloured dye through the cervix and observing it filling and spilling from the Fallopian tubes is a good test of wether or not the tubes are blocked or not. The doctor can assess the state of health of the fingerlike processes at the end of the tube (fimbriae), which are vitally important for egg collection. Various degrees of corrective surgery can be performed at the same time and these involve making additional small holes in the abdomen. . Finally, the remainder of the pelvis may be examined to exclude conditions such as endometriosis, as well as other organs in the abdominal cavity. Laparoscopy normally requires a hospital stay of a few hours to one day.
2.3.3 Falloposcopy
This procedure is performed together with a hysteroscopy, during which a flexible scope is inserted via the uterus and passed through the opening of the Fallopian tube and the interior of the tube is visualised. This procedure is no longer performed as results were difficult to interpret.
2.4 Ovary
2.4.1 ULTRASOUND (see 2.4)
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Prior to any form of pelvic surgery it is essential to examine the ovaries with an ultrasound as it enables one to see the internal structure of the ovaries and helps to exclude ovarian cysts, tumours and endometriomas (cysts in the ovary filled with old blood and endometriosis- so called chocolate cysts.) Some of these cannot be seen with a laparoscope, as they occur within the substance of the ovary and the laparoscope only views the outside of the ovary.
2.4.2 Laparoscopy
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This type of surgery often called keyhole surgery, as it does not require a big cut in the abdomen, allows the specialist to view all the contents of the pelvis and abdomen. Therefore the uterus, tubes and ovaries can be clearly seen with magnification if necessary. Laparoscopic viewing of the ovary is of value in assessing its relationship to the tube. Also, it can show if any scar tissue (adhesions) is present which could prevent eggs from reaching the tubal openings. Biopsy of an ovary is rarely, if ever, needed, as all the data a biopsy could provide in terms of fertility can be obtained far more simply by blood tests. Furthermore, ovarian biopsy by means of a laparoscope often does not provide a representative specimen for the pathologist. Equally important, it can lead to scar tissue formation, which could affect ovarian function. Ovarian biopsy via laparoscopy is performed to save some ovarian tissue in an attempt to preserve fertility. This is offered to patients whose ovaries are at risk from damage either from radiotherapy or drugs used to certain cancers. Unfortunately this technology has not evolved to provide a useful treatment option.
Warning
It should be noted that a laparoscopy or a laparoscopy with a curettage as the ONLY test of the pelvis is inadequate.
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