Sunday, March 2, 2008


I thought I would share my approach to the infertility evaluation. I have seen many patients referred to me, who have not undergone a complete infertility evaluation. Many physicians approach this haphazardly, checking some things but not others. Like other disease states, in order to find the diagnosis, all the different possiblities must be ruled out. In 30% of cases, there is more than one problem, and in 30% of cases it involves both the man and women. Therefore all these systems must be checked. There are basically 9 steps that are required to become pregnant. These steps are a sequence of events, such that, if there is a disturbance in any part of the sequence, then the entire process fails. These steps are 1. Brain sends signals (FSH hormone) to the ovary to begin the ovulation process, and the Ovary begins the maturation of the egg > 2. Ovulation occurs where the egg is expelled from the ovary into the culdesac > 3. The egg has to find the fimbria of the tube. > 4. The egg enters the tube where the sperm needs to be waiting, such that, the sperm needs to have proceeded from the vagina into the cervix, into the uterus then into the tube. > 5. The sperm has to fertilize the egg. > 6. The egg begins developing and dividing and passes through the tube (7-days). > 7. The formed embryo now enters into the uterus. > 8. The embryo has to hatch. > 9. the embryo has to implant into the lining of the uterus. The infertility evaluation that is recommended, checks each one of these steps and I've listed them with the respective step in the sequence:

1. Hormone levels on cycle day # 2 or 3. This is to test to see if the hormone levels, that the brain is producing, are normal at the start of the cycle. This can also give an indication of how the ovary is functioning and able to be stimulated. If the FSH level is elevated, it could indicate that the ovary is already beginning to slow down and/or approaching menopause. If the FSH is elevated, some physicians will proceed with a Clomid challenge test to see if the ovary is past the point where it can be stimulated by fertility medications. The only way to see if the ovary is maturing an egg is to do an ultrasound, in sequence, and see if a growing ovarian follicle is present. This is not usually done as part of the basic infertility evaluation.

2. Mid-luteal progesterone test on cycle day # 20-22. The progesterone level is increased when ovulation occurs, so this in an indirect test of ovulation.

3. Laparoscopy. Any abnormalities in the culdesac, the part of the female pelvis where the egg passes through and where the fimbriated end of the fallopian tubes sit, such as endometriosis or adhesions or tubal abnormalities, can affect the eggs ability to be picked up by the tube. The only test for this is laparoscopy, where a scope is inserted through the belly button to look inside.

4. Hysterosalpingogram. Sperm and egg get together in the fallopian tube. A hysterosalpingogram (HSG) is done to test if the tube is open. This is an x-ray test where a dye is injected into the uterus and passes through the tubes. X-rays are taken in various intervals to confirm that the dye passes into the pelvis.

5. Semen Analysis. We do not have a test to see if fertilization can occur. Therefore, we test the sperm as an indirect method to assess its potential. This is done with a semen analysis. In this analysis we test for the number of sperm, the number of sperm that are swimming (motility)-which is also a measure of the number of live sperm, and the number of normally formed sperm (morphology). This is not just a test of numbers. It is an indirect indication of sperm function. If there is an abnormality then this may indicate that the sperm may not be able to fertilize an egg. The only way to assess if your husband's sperm can fertilize your egg is to remove your eggs and put them together with his sperm, then see what happens. That cannot be done without in vitro fertilization.

6. There is no test for this step, but the HSG indirectly gives evidence that the tube is open and the egg has the potential to pass through.

7. Hysteroscopy. The uterine cavity is tested by a procedure called a hysteroscopy. In this test, a scope is passed through the cervix and the uterine cavity is visualized directly to make sure it is normal. I do this test in my office but most gynecologists do this test in a surgery center.

8. There is no test for this step.

9. An endometrial biopsy is done at the end of the cycle, just before onset of menses, usually cycle day # 26-28. The biopsy tells us if the uterine lining is developed adequately for implantation.

10. Pelvic ultrasound. I do one additional test, which is a pelvic ultrasound. This allows me to assess the uterus, especially the muscle layer and anatomy, the ovaries to rule out cysts and tumors, and if there are any adnexal abnormalities (the areas around the ovaries). Sometimes a dilated tube can be seen.

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