INFERTILITY EVALUATION ABC'S

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.

THE INFERTILITY PATIENT AND THE INSURANCE COMPANY...THE ODD COUPLE.

Here is some advice regarding getting coverage for infertility testing. Consumers need to keep in mind that medical insurance companies are not your advocates. They make their money by keeping the premiums that you have paid, if you don't use them. Therefore, their goal is to keep as much of your money as they can (profit); and they have been doing a good job of it. Evaluation of their stock and company perfomance show that they are one of the best businesses to invest in because, despite a recession, they continue to make lots of money. That being said, here is one way that insurance companies shortchange infertility patients.

As many infertility patients know, once they determine that they have been unable to become pregnant, they need to undergo an evaluation. Also, patients undergoing higher level treatments, such as in vitro fertilization, are required to undergo testing as mandated by the FDA and CDC. In most cases, these tests are general health screening tests and not specifically infertility tests. They are tests such as infectious disease testing, hepatitis, AIDS, hormone testing, pelvic ultrasounds, etc. These are tests that are done for many reasons and for many diagnoses, not specifically or only for infertility. Coding requirements mandate that the most specific diagnosis is used when billing. Infertility, is not a very specific diagnosis. In most instances, there is a diagnosis that is a more specific illness, which as a consequence of their effect, can lead to or cause infertility. These are illnesses such as:

• irregular menstrual cycles


• polycystic ovarian syndrome


• sexually transmitted disease screening


• abnormal bleeding, endometriosis


• uterine fibroids, etc.

Make sure that your doctor or clinic is using the most specific diagnosis that they can.

In terms of insurance coverage, if you do not have infertility coverage, then insurance companies will not pay for infertility services. As mentioned above, many of the tests, if coded with the specific illness, are not infertility codes. Therefore, these tests should be covered. However, many, if not most, insurance companies will automatically flag your account if there is ANY reference to infertility. They then will deny all claims that can be related to infertility testing or treatment thereafter, including general health tests. Remember, their goal is to not pay for as much as possible and this is one way that they get away from paying for tests. Keep an eye on your EOB's, the statements you receive from your insurer that tells what they covered and did not cover. Also, check your test requisitions too and ask what diagnostic code they used. If they used an infertility code, ask if there is a more specific diagnosis code pertaining to your condition that they can use. Then if the lab test is denied, YOU need to contact your insurance company and file an appeal. It should be done in writing and keep all records of your attempts. Do not rely on the doctor's office to do this for you. Remember, you are the insurance company's client, NOT the doctor. You have more leverage than they do. Ultimately, if the insurance company denies a justified claim, that you have repeatedly appealed, you can go to the next level of appeal, which is the Commissioner of Insurance for your State and file a complaint.

Word of Caution! I am NOT advocating that you commit fraud. If there is no other diagnosis or illness that applies to your test, and infertility is the only diagnosis that can be used, then that is the correct diagnosis. In that case, the insurance company has the right to deny the claim. Do Not ask your doctor to lie about your condition by using another diagnosis code. Both you and your doctor can be criminally liable if you commit fraud. Remember, honesty is your greatest weapon when dealing with the insurance companies. They are required to be honest with you as well. If you are not honest, you have nothing to stand on to refute their denial. If you are, and your claim is legitimate, then the insurance company has to accept your claim. You are paying them for the services they have promised to provide. Be a wise and diligent consumer and make sure they are providing you with all the services you are entitled to.