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| INFERTILITY WORK-UP |
The physical causes of infertility are numerous and can occur in the female, the male, or a combination of both. Although some of the basic components of the infertility work-up may be accomplished at the Obstetrician-Gynecologist or Family Practice physician level, the detailed investigation of the infertile couple is a complex matter and will include evaluation of both partners. Sperm function, ovarian function, and the condition of the female's fallopian tubes and uterus are just some of the preliminary tests. Laboratory Studies
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A Pap smear and cervical cultures for bacteria, Chlamydia, and Mycoplasma/Ureaplasma are routinely done to identify abnormalities in the cervical cells to rule out cervical cancer, and to identify cervical or vaginal infections. Blood tests are obtained for a complete blood count, blood typing, hepatitis, and HIV. There may be immunological causes of infertility resulting in early spontaneous pregnancy loss or failure of implantation, which are thought to be due to abnormalities in antibody or immune system responses. Diagnostic blood tests may be done for detecting lupus anticoagulants, antiphospholipid antibodies, anticardiolipin antibodies, leukocyte antibodies, embryo toxicity, and reproductive immunophenotype. The basal body temperature is taken every day. It is the process of taking your temperature every morning before getting out of bed. The daily temperatures are then plotted on a special temperature graph. This serves as a tool to assess the length of the follicular phase (where the follicles are being matured), the approximate time of ovulation for timed intercourse, and the length of the luteal phase. It is important to bring your basal body temperature graph to every appointment. --->Download BBT chart A post-coital test is performed around the time of ovulation. When the ovulation predictor kit becomes positive or there is a rise in the basal body temperature, an office visit should be scheduled for the following morning. Intercourse should take place 2-12 hours prior to your appointment. A speculum is placed and a sample of the cervical mucus is obtained. The mucus is placed on a glass slide and studied under a microscope. The receptability of the mucus to the sperm and the ability of the sperm to survive in the cervical mucus is assessed. Luteinized Unruptured Follicle Test (LUF) Luteinized Unruptured Follicle Syndrome is present when there are clinical indications that ovulation has occurred (blood hormone changes, temperature rise on the BBT chart, or a positive ovulation predictor kit), but the egg is not released from the ovary. The follicle sac is unruptured and the egg is trapped. Three specifically timed ultrasound examinations are done to confirm ovulation. The first ultrasound is done prior to ovulation, the second around the time of ovulation, and the third is done after ovulation. The ultrasounds are compared to verify that the follicle ruptured. This test helps determine whether ovulation is occuring. The Ovarian Reserve Test evaluates the function of the ovary. The test is started on day 2 or day 3 of the menstrual cycle. A baseline ultrasound and blood work is obtained. Clomid (serophene) is given days 5-9. Blood work and another ultrasound is done on day 10. Even though this is a test cycle, couples may be able to try for pregnancy. Female hormones such as Estradiol, Follicle Stimulating Hormone (FSH), and Luteinizing Hormone (LH) are assessed. Values will be assessed by the physician upon completion of the test. The endometrium is the lining of the uterus. After ovulation, the ruptured follicle on the surface of the ovary becomes a corpus luteum. The corpus luteum then secretes progesterone in increasing amounts, which prepares the endometrium for implantation of the embryo. If the lining is lacking progesterone, a progesterone supplement is needed. The endometrial biopsy dates the lining. The tissue is obtained 10-12 days after ovulation in a protected cycle. The biopsy must be done before menses begins to obtain appropriate tissue samples. A speculum is placed in the vagina, the cervix is prepped with an antiseptic, and a small catheter is placed through the cervix. The tissue is gently removed from the uterus. This procedure may cause minimal discomfort, and sedation is available for those that prefer. An Integrin biopsy is performed to check for the presence of beta-3 Integrin. Integrin is a glue-like substance that is necessary for implantation to take place. If you are lacking Integrin, the fertilized egg may not attach properly to the uterine wall. This decreases chances for a successful pregnancy. The Integrin biopsy is obtained much like an endometrial biopsy, however the timing of the biopsies are different. An Integrin biopsy is taken 8-10 days after ovulation. A protected cycle must be maintained. The HSG is a procedure done in the hospital radiology department. It is a basic fertility test to determine and identify if there are any blockages in the fallopian tubes and problems of the uterus such as abnormal shape or structures (i.e. fibroids, polyps). During an HSG, a dye called contrast material is injected through a thin tube that is inserted through the vagina and cervix into the uterus.The contrast material is observed as it passes through the uterus and fallopian tubes as continuous pictures are taken. This procedure can be uncomfortable for some women with some cramping occurring afterwards, therefore most women will be advised to take ibuprofen prior to and after the procedure. All patients have the option for mild IV sedation given by a nurse during the procedure, however, the patient would need to bring a driver and plan to rest at home for the duration of the day. Hysterosonogram/Sonohysterogram A sonohysterogram is a simple, minimally invasive procedure to evaluate the uterine cavity. It is usually performed in the first half of a woman's menstrual cycle after menstrual flow ends but before ovulation. The endometrium (uterine lining) needs to be thin for an accurate evaluation and the lining is the thinnest during the first half of the menstrual cycle. During the procedure, sterile saline is instilled with a thin catheter into the uterus through the cervix to evaluate the shape and contour of the uterine cavity. As the saline is gently flushed into the uterus, numerous pictures are taken with the transvaginal ultrasound probe in the vagina. The saline fills and distends (expands) the endometrial cavity, providing good visualization of the anatomic structures within. If desired, the patient can request mild IV sedation to help her relax during the procedure, however, she would need to come with someone that could drive her home. Hysteroscopy is a procedure that allows a physician to evaluate the lining of the uterus, help collect a biopsy, and guide tiny instruments to remove growths such as polyps from the inside of the uterus. The patient receives intravenous conscious sedation administered and monitored by a CRNA (Certified Registered Nurse Anesthetist). The procedure takes about 30 minutes and is usually done in our office. Due to the medications used, the woman needs to have someone waiting to drive her home. She should plan on staying at home for the duration of the day.
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Laparoscopy is a surgical procedure that enables the physician to view the internal female organs. It can reveal problems within the pelvic cavity such a scar tissue (adhesions), fibroids, ovarian cysts/abnormalities, endometriosis, ectopic pregnancies, tubal occlusions, and other conditions which may not have been identified by previous non-invasive testing. Surgical repair of any of these conditions may also be undertaken at this time. This procedure is typically reserved as the last step in the female infertility investigation. It is however, essential when there is unexplained infertility. Laparoscopy is performed under general anesthesia in the hospital's same-day surgery unit. Arrangements need to be made by the woman for someone to drive her home and stay with her for 24 hours post-op. 
A semen analysis gives an accurate measurement of the number of sperm, the motility of the sperm cells, the size and shape of the sperm cells, and the volume of the ejaculate. The Institute's Andrology lab offers a full complement of semen studies including sperm survival and Hamster Egg Penetration Assays(HEPA) which are typically also undertaken to provide further information about the sperm's function and fertilization capability. Semen cultures to rule out infection are also routinely performed. Blood tests may also be performed on the male partner if indicated. ©1997-2009 K. Paul Katayama, M.D., S.C. All rights reserved.