Evaluation of the Female Reproductive Tract

A variety of conditions including endometriosis, previous pelvic surgery, past pelvic infections, uterine fibroids, or other congenital malformations of the uterus can contribute to infertility. These abnormalities are assessed by a variety of tests as listed below.

Hysterosalpingogram (HSG)

A hysterosalpingogram is performed in the Radiology Department. The test is performed in cooperation with both the Gynecologist and the Radiologist. The object of this test is to place a small cannula into the uterus and inject contrast fluid into the uterus and fallopian tubes. This process is viewed by fluoroscopy which is an x-ray technique to demonstrate where the contrast flows. This test allows us to demonstrate the anatomy of the uterine cavity and also allows us to determine if the fallopian tubes are open. It is best that this test is performed in the first half of the menstrual cycle after menstruation is stopped but before ovulation has occurred. The HSG can cause cramping or pain and we recommend that you take Motrin or some other pain medication one hour prior to the procedure. Antibiotics are not necessary unless an abnormality is found during the test. If tubal blockage is found on HSG, an antibiotic will be prescribed for several days.

Transvaginal Ultrasound

We are experts in the field of transvaginal ultrasound for the detection of uterine and ovarian abnormalities. We have published widely in this area and find that ultrasound is a valuable tool in some patients for detecting abnormalities which can lead to infertility. Abnormalities that we are looking for by ultrasound include the presence of uterine fibroids that might impair fertility, the presence of endometriomas within the ovary, and the presence of intrauterine defects which might impair implantation and growth of an embryo.

Laparoscopy

Another means of detecting pelvic disease that might contribute to infertility is by a surgical procedure called laparoscopy. This surgery is a "same-day" procedure meaning that you go home on the same day as the surgery is performed. Laparoscopy uses small incisions and telescope like instruments are used to view the pelvis and abdomen. We do not perform laparoscopy on all women as it is quite expensive and requires a general anesthesia as well as recovery time (usually about 2-3 days) from the surgery. However, laparoscopy is the most sensitive way to detect certain conditions including endometriosis and mild pelvic adhesions (scarring). Endometriosis or adhesions found at the time of laparoscopy can be treated under the same anesthesia thus laparoscopy can be both a diagnostic as well as a therapeutic procedure. Whether or not a laparoscopy will be performed will be discussed in consultation with you and may depend on other symptoms including pelvic pain.

Assessment of "Ovarian Reserve"

It is well known that fertility declines as women age. However, the rate of decline in an individual is variable, for example some 38 year old women are unable to achieve a pregnancy due to their age where as other 38 year old women are quite fertile. Attempting to assess which women are infertile due to poor ovarian function is difficult. A number of tests have been devised which offer a rough guide to what has been termed ovarian reserve. It should be emphasized that these tests are not perfect and some women with normal tests will still be unable to conceive due to poor ovarian function. Some women with abnormal tests will be able to conceive despite this finding. Nevertheless, these tests can offer some guidelines to patients about their ovarian reserve.

Day 3 FSH

FSH values become elevated in women as they age. For example, a menopausal woman would have an FSH value greater than 40 mIU/ml. In contrast, a teenager may well have an FSH value under 10 mIU/ml. Between these extremes, the FSH value gradually increases over time. In some women, we recommend obtaining a Day 3 FSH as a guide to ovarian reserve. A value greater than 12 mIU/ml suggests a poor prognosis for pregnancy. In this circumstance, consideration will be given to using donor eggs in an IVF cycle in consultation with the couple.

Clomid Challenge Test

A more sensitive means of detecting ovarian reserve is through a test called the Clomid Challenge Test. This test consists of a Day 3 FSH value obtained via a blood draw. The woman then takes Clomiphene Citrate, 100 mg (2 tablets) days 5 through 9 of her menstrual cycle. On day 10 a repeat FSH value is drawn. If either value is greater than 12 mIU/ml, this suggests reduced ovarian reserve. This test is thought to be more sensitive than a Day 3 FSH test alone.

Transvaginal Ultrasound

We have demonstrated in several publications that ultrasound measurement of ovarian volume and counting the number of ovarian follicles can also predict ovarian reserve and responsiveness to stimulation by medications. We have found that if a woman has an ovarian volume of less than 3 cc, as measured by ultrasound, that pregnancy rates and numbers of eggs retrieved by IVF are reduced. We also measure antral follicle numbers. A value of less than 10 antral follicles suggests reduced ovarian reserve.

Ovarian reserve testing is performed selectively, predominately in women 35 years of age and older. It is quite unusual for women under the age or 35 to have reduced ovarian reserve. This low prevalence leads to more false positive results in younger women. In addition, we try to order the test only in women where testing will make a difference. At this time, we have no good treatments for reduced ovarian reserve other than the use of donor eggs. If a couple is not interested in using donor eggs, and will likely continue to attempt conception using the female's own eggs, regardless of the results of the test, it is likely that we will advise you not to have the testing done.

There are a variety of other tests which can be ordered. These include assessment of sperm-cervical mucus interaction, by a post coital test (Huhner's test), testing for sperm or cervical mucus antibodies, and assessment of the endometrium by biopsy. These tests are rarely performed in our unit as they seldom make a difference in our treatment recommendations nor do they offer great value in terms of prognosis for pregnancy. However, on occasion, these tests will be ordered.