Infertility work up for female
A variety of tests are available for evaluating female infertility but it may not be necessary to have all of these tests. The evaluation starts with a medical history, a thorough physical examination, and some preliminary tests.
Medical history: your previous health, surgical history and family history may provide some clues about the cause of infertility.
Physical examination: A physical examination usually includes a general examination, with special attention to any signs of hormone deficiency or signs of other conditions that might impair fertility.
Blood tests: Blood tests can provide information about the levels of several hormones that play a role in female fertility. In women, the key hormones are produced by the hypothalamus, the pituitary gland, and the ovaries. These hormones include follicle-stimulating hormone (FSH), Luteinising hormone (LH) and estrogen levels to assess how well the ovaries are functioning, TSH to test thyroid function, and prolactin to assess the presence of a benign pituitary tumor.
Tests to evaluate ovulation: Ovulation (the release of an egg from an ovary) is essential for fertility. Abnormalities of ovulation can often be determined from a woman’s menstrual history or hormone levels such as the pre-ovulatory LH surge or luteal phase progesterone levels (day 21 of the cycle)
Menstrual history: Amenorrhea (absent menstrual periods) usually signals an absence of ovulation, which can cause infertility. Oligomenorrhea (irregular menstrual cycles) can be a sign of irregular ovulation; although oligomenorrhea does not make pregnancy impossible, it can interfere with the ability to become pregnant.
Basal body temperature: Monitoring of basal body temperature (measured before getting out of bed in the morning) was previously recommended to determine if ovulation occurred. A woman’s temperature usually rises by 0.5 °F to 1.0 °F after ovulation. However, basal body temperature patterns can be difficult to interpret and are not generally recommended in the evaluation of infertility.
Hormone levels: Levels of luteinizing hormone (LH) rise abruptly approximately 38 hours before ovulation. This hormone surge can be detected using an over-the-counter home urine test. However, this kit fails to detect the hormone surge about 15 percent of the time. Therefore, a clinician may recommend a blood test to confirm ovulation.
Blood levels of the hormone progesterone are a more accurate indicator of ovulation. Normally, levels of progesterone rise after ovulation. A test to measure the progesterone level is usually performed 18 to 24 days after the first day of a menstrual period.
Tests to evaluate the uterus and fallopian tubes: Uterine abnormalities that can contribute to infertility include congenital structural abnormalities, such as a uterine septum (a band of tissue that makes the uterine cavity); fibroids; polyps; and structural abnormalities that can result from gynaecologic procedures.
Scarring and obstruction of the fallopian tubes can occur as a result of pelvic inflammatory disease, endometriosis, or pelvic adhesions (scar tissue) from abdominal infection or surgery.
Hysterosalpingogram: Hysterosalpingogram (HSG) is used to help identify structural abnormalities of the uterus and fallopian tubes. It involves inserting a small catheter through the cervix and into the uterus. A liquid that can be seen on x-ray is injected through the catheter, which fills the uterus and fallopian tubes. An x-ray is taken after the liquid is injected, which shows the outline of the uterus and tubes. An abnormally shaped uterus or blocked fallopian tube would be visible on the x-ray.
The test is done while the woman is awake and lying on an x-ray table. Most women experience moderate to severe pelvic cramps when the liquid is injected, but this usually improves after 5 to 10 minutes. The test is usually performed five to seven days after the menstrual period (before ovulation has occurred).
Hysteroscopy: In a hysteroscopy, a small tube containing a light source is inserted through the cervix and into the uterus to directly visualize the lining of the uterus and the sites where the fallopian tubes enter the uterus. Fluid is injected to expand the uterus and to allow the physician to see inside the uterus.
A hysteroscopy is usually performed in women who are thought to have an abnormal uterus, based upon history, hysterosalpingogram, or ultrasound. Hysteroscopic surgery if necessary is usually performed in a day surgery operating room under general anesthesia.
Pelvic ultrasound: In a transvaginal ultrasound, a small ultrasound probe is inserted into the vagina; this provides a clearer image of the uterus and ovaries than ultrasound that is performed through the abdomen. It does not require that the patient is sedated or anesthetised, and has few to no risks. It is used to measure the size and shape of the uterus and ovaries and to determine if there are structural abnormalities (such as fibroids or ovarian cysts). If abnormalities are seen, further testing may be needed.
Laparoscopy: During laparoscopy, a thin, lighted tube is inserted through a small incision in the abdomen, allowing the physician to view the uterus, ovaries, and fallopian tubes. Laparoscopy is performed as a day surgery procedure and requires that the patient receive general anaesthesia.
Laparoscopy can detect damage and obstruction of the fallopian tubes, endometriosis, and other abnormalities of the pelvic structures. It is the best test for diagnosis of endometriosis or pelvic adhesions (scarring). Furthermore, endometriosis can be treated during laparoscopy, which can help to improve pregnancy rates in women with infertility. Dye can be injected through the cervix and the tubal patency can be assessed by visualising the spillage from the tubes.
Genetic tests: Genetic testing may be recommended if there is a suspicion that genetic or chromosomal abnormalities are contributing to infertility. These tests usually require a small blood sample, which is sent to a laboratory for evaluation.
Although assisted reproductive techniques may be able to overcome genetic or chromosomal abnormalities, there is a possibility of transferring the abnormality to a child. Genetic counselling is often recommended to educate a couple about the possibility of parent-to-child transmission, possible impact of the abnormality, and treatments available to prevent parent-to-child transmission.