Ovarian Reserve Testing
This is performed most commonly through a testing of the female hormone FSH. This blood test, along with the age of the woman, gives an important prognostic indication of the possible success of treatment for infertility. There are various tests that can be used to assess ovarian reserve. One of the most commonly used tests is with an FSH and estrogen blood level in the early part of the menstrual cycle. FSH and estradiol is often measured on the second to fourth day of the menstrual cycle. Adequate ovarian reserve is indicated when the FSH level is less than or equal to 10 mIU/mL. Pregnancy is very difficult to achieve when the FSH level is greater than 20. For levels between 10 and 20, it may be beneficial to do further evaluation with a clomiphene citrate challenge test.
Clomiphene Challenge Test
The clomiphene citrate challenge test (CCCT) is a sensitive test to further evaluate ovarian reserve. It is often considered when the FSH level is above 10 mIU/mL. It may be considered in women over the age of 38 or in women who do not have any other identifiable reason for their infertility (unexplained infertility) as approximately 30% will show abnormalities of their ovarian reserve that otherwise would not be detected with more simple testing.
It is important to evaluate if the fallopian tubes are open or not. If they are blocked, IVF is the best method to become pregnant. Women with blocked tubes often have a history of infections of the pelvis, a history of surgery to the tubes, or endometriosis. Evaluation is done via a hysterosalpingogram (HSG). This test is done at the hospital in the Outpatient Radiology Clinic. Dye is injected through the cervix, into the uterus and out through the fallopian tubes while taking an X-ray. It is best to perform this test in the early phase of the menstrual cycle. If a blockage is noted, the physician may recommend further evaluation through laparoscopy.
Some women may have a history of thyroid disease or prolactin problems. These hormones are released in the brain and most commonly influence menstrual cycle regularity and flow. TSH (thyroid stimulating hormone) and prolactin levels are evaluated in the blood.
Women with irregular cycles will have further evaluation of their hormones. This will include testosterone levels, glucose and insulin levels. Other more sophisticated testing will include a 17 alpha hydroxyprogesterone evaluation on the third day of the menstrual cycle.
This test is commonly done in women who have highly irregular cycles or too many periods. In these women, the lining of the uterus may become too thick and therefore require further evaluation. This test involves scraping and examining a sample of tissue from the lining of the uterus. This test may also be done in women with a history of recurrent miscarriage to look for infection of the lining.
Confirmation of Ovulation
Some women are not certain when they are ovulating in a menstrual cycle. There are several methods to use to evaluate the timing of ovulation. One method is to monitor the development and release of the maturing egg through ultrasound and hormone evaluation. Another method is to do a blood test for progesterone level on day 21 of the cycle.
During the initial evaluation of the female, a pelvic ultrasound will be performed. This ultrasound is done through the vagina and allows a close look at the physical appearance of the ovaries to evaluate for presence of cysts. Some cysts may indicate the possibility of endometriosis. This ultrasound also allows for evaluation of the presence of fibroids in the uterine cavity or wall. Some fibroids can affect the establishment of pregnancy and also increase the risk of miscarriage. Other abnormalities of the uterus may be seen with this test. Additionally, it is possible to evaluate the number of potential eggs at the start of a menstrual cycle through counting very small follicles that hold the future eggs. This particular assessment may also indicate the ovarian reserve.
This is an ultrasound that is done with water in the uterus. The purpose of the water is to push the wall apart to allow the ultrasound to display any abnormalities of the uterine cavity such as fibroids or polyps that may be diffucult to assess otherwise. This procedure is not painful and is done in the clinic.
The physician may recommend a diagnostic laparoscopy as part of the initial workup. It may be suggested in a woman who has had prolonged infertility and no other identifiable reason for her infertility or in which endometriosis is suspected. This is a surgical procedure done in the hospital where the physician can then look at the reproductive organs such as the tubes, ovary and uterus. The surgeon may then be able to make the diagnosis of endometriosis or tubal blockage directly. During this procedure, a small camera is placed through an incision made at the umbilicus (belly button). Small operative tools are then placed into the abdomen through other very small incisions. The abdomen has been inflated with gas in order to allow the organs to be viewed. Infertility specialists undergo special training in order to learn how to do this procedure.
Hysteroscopy is another surgical procedure that may be recommended as part of your initial workup or even later in treatment. During hysteroscopy, a camera is placed up through the cervix and the inside of the uterus is viewed. Diagnostic hysteroscopy is a good way to evaluate the uterus for fibroids or polyps or any other abnormality. Women who may have this procedure are ones in whom fibroids or polyps are suspected by ultrasound, women who have recurrent miscarriages or women with irregular heavy bleeding. Fluid is placed in the uterus to push the walls of the uterus apart to allow the surgeon to see inside the uterus. It is also possible to remove polyps, fibroids or other uterine abnormalities such as a uterine septum through this procedure.