At the initial visit to our fertility center, a complete reproductive gynecologic and medical history is obtained from the patient. A complete physical examination is performed, which includes a transvaginal ultrasound of the pelvis. Sometimes the OB/GYN will prescribe Clomid without a complete workup. Our infertility specialists will conduct a complete workup usually before providing any medical therapy. There is often more than one cause for infertility and they must be discovered before any therapy can be effective.
The two most important tests done on every patient include a hormonal evaluation on the third day of the menstrual cycle and a hysterosalpingogram to demonstrate normal endometrial and uterine anatomy and fallopian tube patency.
FSH is the hormone responsible for recruitment and development of the eggs within the ovarian follicles. If the FSH level is elevated on day three of the menstrual cycle, it could signal declining ovarian function, or in severe cases, ovarian failure. Ovarian failure means that the eggs are no longer viable and the treatment of choice will be IVF using a donor’s eggs. We have a very successful Donor Egg Center.
The ultrasound is often useful in identifying abnormalities within the reproductive tract. Polyps and fibroids can be elucidated by ultrasound often followed by additional tests such as the hysteroscopy. Ultrasound is used extensively during ovulation induction for ART procedures to monitor follicular development. The number and size of the follicles is documented. Also, conditions such as PCOS where multiple cysts are present on the ovaries, can be observed via ultrasound.
The hysterosalpingogram is performed by injecting radio opaque dye in the uterus and following its flow with x-rays back through the fallopian tubes. Collections of dye seen on x-ray can often identify tubal obstructions or uterine abnormalities. Tubal obstruction is often caused by endometriosis. In cases of moderate to severe tubal obstruction, in vitro fertilization is often the treatment of “first choice”.
Other tests may be performed where appropriate. These tests often include laparoscopic or hysteroscopic surgery for diagnostic and therapeutic purposes, post coital testing for evaluation ofcervical mucus receptivity and sexual function, and genetic studies.
Hysteroscopy involves viewing the interior of the uterus using a “telescope like” device. Polyps and fibroids are often diagnosed via hysteroscopy.
The laparoscope is one of the most important diagnostic/treatment tools. Many conditions, such as severe endometriosis, can be treated laparoscopically, often during the diagnostic laparoscopic procedure. This is why it is critical that a reproductive endocrinologist, infertility specialist (REI) perform the diagnostic laparoscopy for infertility. Physicians without advanced microsurgical experience will diagnose many conditions but will refer them to an REI for surgical treatment. When the REI performs the initial diagnostic procedure referral is not necessary.
Laparoscopic surgery is used to treat endometriosis, correct tubal abnormalities, and for many other conditions. Laparoscopic surgery has many advantages including; it is usually an outpatient procedure, pain is greatly reduced, less chance for scarring, external scars are usually barely noticeable, it is less expensive, and surgical risk is greatly reduced.
The post coital test is used to assess sperm characteristics after exposure to the cervical mucus. The couple has intercourse at home and the female comes to our office where we sample her cervical mucus. The presence of numerous dead or “non moving” sperm can indicate cervical mucus problems such as mucus that is too thick or in insufficient quantity or the presence of antisperm antibodies. The female’s immune system may produce antibodies to sperm which mistakenly identify sperm as invading pathogens and seek to destroy them. Intrauterine insemination (IUI) is often a treatment of first choice since the sperm are placed directly into the uterus thus avoiding exposure to the antibodies.
Use of basal-body temperature charting and urinary LH testing for ovulation monitoring is often helpful. These tests identify when ovulation is most likely to occur and allow the couple to time intercourse to coincide with the most fertile period. Basal body temperature charts are rarely used because of patient inconvenience and comparative inaccuracy. The only advantage of BBT charting is that it is less expensive. Urinary LH kits are much more accurate and convenient.