Infertility Work Up
The infertility work up needs to be comprehensive but not
over labored or prolonged. Our philosophy is to employ an effective work up aimed at
guiding the couple to the fastest route to a baby with the minimal intervention. The use
of surgery or assisted reproduction is employed only after less invasive and less
expensive measures have been fully attempted. At the same time surgery and assisted
reproduction are introduced when appropriate without drawing out basic treatment long
after it has been shown to be ineffective. This balance as well as consideration of the
couple’s personal circumstances creates the individualized care that is the hallmark
of the center. The center strives to be equally excellent at surgery and ART so that
patients are not ‘steered’ only to treatments that favor the center.
Blood hormone levels. This is done on the morning of day 3 of the menstrual cycle. It gives information on the status of the ovary, the thyroid gland, and other factors relevant to female health. The usual tests are FSH, LH, prolactin, DHEAS, TSH.
- Hysterosalpingogram. This is a test done in the x-ray department that takes very little time and is relatively painless when done by very experienced doctors. It is not unlike a pelvic examination with a speculum. A small catheter is placed in the cervix (lower end of the uterus) and a small balloon is blown up. Liquid is injected into the uterus which is viewed on a TV screen. This liquid is seen to enter the cavity, enter the fallopian tubes, and spill out of the fallopian tubes. When all of the above happens, it constitutes a normal test. Patients are asked to take some Ibuprofen one hour before the procedure. This test is done between day 7 and 10 of a menstrual cycle in order to avoid the possibility of harming a pregnancy as yet undiagnosed. Also, in the early part of the cycle, the uterine lining is not so thick that it might impede the opening of the fallopian tube and thus create a false impression of blockage. When performed by doctors at our center, the procedure is not painful because the dye is injected slowly and if the tube appears to be blocked, no attempt is made to increase the pressure of the injection to force the tube open. Such force is ineffective and only causes intense pain without opening up the tubes. A better method is to introduce a catheter to the beginning of the fallopian tube and then start the injection to unclog the tube (selective salpingography). Patients can usually drive themselves for this test and drive home or back to work after an hours’ rest.
If your regular cycle is 25 days the test should be done as
soon as possible after bleeding has stopped but no later than day 9. If your regular cycle
is 28 days, the test should be done between days 7 and 10, then continue with the rest of
the paragraph. On the other hand, if your cycles are regularly 35 days, the test can be
done up to day 17.
Urine ovulation test.
A urine test kit for the LH surge which precedes ovulation is
the most precise way to anticipate ovulation. Temperature charts are retrospective
instruments and not useful for prospectively predicting ovulation. This test is the basis
for timing of various other tests in the work up as well as timing insemination.
Post Coital Test.
For this test, the couple should have sex the same evening
that the ovulation test kit turns positive and the woman should come to the center the
following morning before 9 a.m. to be tested. This test is again like doing a Pap smear
with a speculum and is not uncomfortable. The lower end of the uterus (cervix) is examined
to check the quality of the mucus (amount, tenacity), the extent of the cervical opening,
and under the microscope, the mucus is examined for ferning, infection, and whether the
sperm are swimming vigorously in it. Deficient or tenacious mucus may impede transport of
sperm from the vagina into the uterus and to the fallopian tube. Alternatively, there may
be antibodies that are detrimental to the sperm. (see Andrology)
Endometrial biopsy.
In this test which is performed with a speculum, like a Pap
smear, a small plastic tube not unlike a coffee stirrer in size(2mm.) is introduced
through the cervix into the uterus. A brief 10-second vacuum is applied and the tube is
removed containing a small sample of the uterine lining. This lining is examined in the
pathology laboratory and when coupled with the date of the onset of the next period, gives
an interpretation as to whether the uterus and its lining is capable of supporting an
implanted embryo. The discomfort of the procedure is brief and patients are asked to take
ibuprofen one hour before the procedure. It is necessary to do two samples to confirm an
abnormal test and treatment includes the use of vaginal progesterone suppositories or gel,
progesterone injections, fertility pills and injections.
The above form the basic and the complete work up protocol
following which a consultation is arranged to discuss the findings and further treatment.
Laparoscopy
Laparoscopy
is surgery using a small telescope through a tiny 2-10mm bellybutton incision. This is not
employed routinely at our center as the gain is minimal in the face of normal
hysterosalpingography, normal pelvic examination, and ultrasound.
Hysteroscopy
This
is a procedure where the inside of the uterus is distended with carbon dioxide gas or
saline fluid and visualised using a small telescope. Office hysteroscopy is performed
where indicated but again is not a routine procedure for work up.
Ultrasound
Transvaginal
sonography is a harmless examination with ultrasound that provides detailed information of
the uterus and the ovaries. It is employed to diagnose ovarian endometriotic cysts,
uterine fibroids, ectopic pregnancies, abnormal uterine septum, and various conditions. It
is also used to monitor the follicles and ovulation as well as advanced fertility
treatment with injection of Pergonal, Fertinex, Metrodin. Hysterosonography is a technique
of instilling the uterus with saline and combining this with a transvaginal sonography.
Much information can be obtained by this complementary test.