When a couple has been unsuccessful at achieving pregnancy after one year, both partners need to go through a comprehensive physical and medical assessment.
During this first appointment, your medical history (1) and lifestyle will be discussed extensively. Ovulation days, pregnancy history, current and past sexual practices, drugs used, surgical history, other health issues as well as your work/living environment will all be discussed. A pelvic exam is also an important part of evaluating fertility, along with a Pap smear (4) and a transvaginal pelvic ultrasound (3) Echography is used to assess the thickness of the lining of the uterus (endometrium), to monitor follicle development and to check the condition of the uterus and ovaries (presence or not of myomas or cysts). An ultrasound may be conducted two to three days later to confirm that an egg has been released.
After the first round of the medical tests, the Reproductive Specialist Gynecologist, asks for the following:
- Then your fertility specialist will ask for your AMH (4). Antimullerian Hormone is important as it shows the biological age of a lady and where exactly is her ovarian reserve (women are born with a certain number of oocytes and each month sacrifice 1000 to 3000 in order to select the one for ovulation).
- Ovarian function tests (5): These tests are looking to see how the hormones are functioning and working during your ovulation cycle. Tests include the Day 3 FSH (measuring follicle stimulating hormone) LH (luteinising hormone), Day 3 Estradiol (measuring estrogen), and blood tests to determine the levels of Prolactin, Testosterone, DHEA-S, Progesterone, TSH and Inhibin B.
- Thyroid function (6) should be tested either with hormone levels alone or accompanied with ultrasound. TSH, T4, F-T4, Thyroid Antibodies, should be measured.
- Vaginal and cervical swabs (7) should be obtained in order to identify possible infections with ureoplasma, mycoplasma, and chlamydia. HPV and HSV test could be also offered.
- Karyotype (8) is now performed as a standard evaluation in most of the cases. It represents our chromosomal constitution 46 chromosomes (23 from our mother and 23 from our father).
- Hysterosalpingogram (HSG) (9): This is an x-ray of your uterus and fallopian tubes. A dye is injected through the cervix into the uterus and fallopian tubes. The dye enables the radiologist to see if there is the blockage or some other problem.
- Hysteroscopy (10) is a procedure that may be used if the HSG indicates the possible presence of abnormalities. Under sedation or even local anaesthesia. The hysteroscope is inserted through the cervix into the uterus, which allows your fertility specialist to see any abnormalities as polyps or myomas, or adhesions in the uterus. The hysteroscope allows the physician to take pictures which can be used for future reference. Moreover, at the same time, the procedure can be converted into operative one and all the abnormalities been identified to be treated.
In case all the previous tests had failed to establish a diagnosis, then we might perform the following:
- Laparoscopy (11). This is a procedure done under general anaesthesia, that involves the use of a narrow fiber optic telescope. The laparoscope is inserted into a woman’s abdomen to provide a view of the uterus, fallopian tubes, and ovaries. If any abnormalities such as endometriosis, scar tissue or other adhesions are found, they can be removed by a laser. It is important to confirm that you are not pregnant before this test is performed.
- Anti-ovarian antibodies (12) are asked in the case of premature ovarian failure or poor ovarian response.
- Thrombophilia (13) testing is performed in cases of recurrent pregnancy loss, or repetitive implantation failures.
- Endometrial biopsy (14) this is a procedure that involves scraping a small amount of tissue from the endometrium just prior to menstruation which is sent for histological examination or even genetic analysis (ie ERA test). This procedure is performed to determine if the lining is thick enough for a fertilised egg to implant in and grow.
- Complete Immunological profiling (15) is asked rarely in cases of recurrent pregnancy loss, or repetitive implantation failures. Although popular among patients and blog readers, keep in mind that a really autoimmune factor is rare to justify multiple implantation failures.
- Genetic exams (16) are proposed for special indications such as CFTR for cystic fibrosis, Fragile X for premature menopause, KAL1 for Kallmann syndrome, FSH mutation, LH receptor mutations.
- MRI (17) of internal genital organs and pelvis is only asked in cases of possible adenomyosis or large myomas or cysts of unidentified origin.