Female Fertility Tests
Several biologic processes must occur in the female and male for a pregnancy to result and for a healthy baby to be carried to term. The female must produce eggs that can fertilize and develop and these eggs must travel unimpeded through the fallopian tubes to the site of fertilization. Once fertilized, the embryo must attach to the lining of the uterus and develop into a viable fetus. These processes are examined by the fertility specialist by using fertility tests specific to each event that must occur for pregnancy to result.
The male must produce enough sperm of high quality to cause fertilization. The sperm are ejaculated into the female's vagina and travel through the cervix to the uterus. One sperm must reach, attach to, and penetrate, an egg causing fertilization. A disorder of any of these processes causes infertility. When moderate to severe male infertility are present, IVF with ICSI is often the treatments of first choice.Day Three Hormone Measurements
Follicle stimulating hormone (FSH), luteinizing hormone (LH), and estradiol measurements will be taken on day three of the menstrual cycle when the hormones and tissue(s), such as the shedding endometrium, have returned to the baseline.
An elevated FSH level (>12) may indicate impending ovarian failure or reduced ovarian reserve and the need to use an egg donor. Dr. Goldstein also compares the levels of the various hormones including androgens (male hormones). If FSH is elevated, the clomiphene citrate challenge test may be ordered to rule out reduced ovarian reserve. "Over the counter" non prescription tests to assay FSH and estradiol are available. However, they are not as accurate hormone assays done at our office and we perform a pelvic ultrasound to rule out any abnormalities such as cysts and fluids. We also follow follicular development via ultrasound
Simplistically stated; the female endocrine system is a complex interaction of hormonal events known as the hypothalamic, pituitary, ovarian, axis (H.P.O.) The hypothalamus is the “regulator” gland and adjusts hormone production based upon various inputs from the brain and from the environment. Several different fertility tests are used to measure the hormones intricate to the action of the hypothalamic pituitary adrenal axis.
FSH stimulates the recruitment and development of ovarian follicles, each containing an egg. As a healthy follicle develops, it increases production of estrogen. Estrogen travels to the hypothalamus and it adjusts the production of FSH by the pituitary. In a stimulated cycle, FSH is given thus "short circuiting" this cycle and causing the development of numerous follicles. Once the follicles are mature, the hypothalamus signals the pituitary to release a surge of LH, which will trigger ovulation. In an IVF cycle, the fertility specialist administers FSH to cause the recruitment of many follicles needed to supply enough eggs for fertilizing and culturing to the embryo stage.Androgens and Prolactin Levels
Androgens are male hormones, including testosterone. Elevated androgens and free testosterone levels in the female may indicate the presence of polycystic ovarian syndrome (PCOS), a common cause of infertility. Increased body hair, a classic body shape, and other male characteristics evidence PCOS. Most PCOS patients are also hyperinsulinemic (have decreased sensitivity to insulin). PCOS patients can have an exaggerated response to fertility drugs and should only be treated by a trained infertility specialist.
Prolactin is the hormone produced by pregnant women that causes breast milk production. An abnormally elevated level in non-pregnant women is termed hyperprolactinemia. It causes anovulation (lack of ovulation) and usually results from a benign tumor at the base of the brain. Hyperprolactinemia is treated with the medication Parlodel (bromocriptine) or the tumor may be removed via surgery.Endometrial Biopsy
An endometrial biopsy may be done to rule out a luteal phase defect. The biopsy is taken using a small catheter usually twelve days after ovulation. The biopsy should show a thickened and vascular endometrial lining. This development occurs to accept and nourish the embryo. If the thickening is not present, hormonal support will usually be prescribed.Basal Body Temperature (BBT) Measurements
The BBT is not an effective way to monitor ovulation because the temperature rises only when ovulation has already occurred. However, if no other means of measurement are available, in a woman with regular cycles, one can predict the ovulation time by averaging three precious cycles time of ovulation (when the temperature increases for 2 days).
In places where no other means of monitoring are available, the LH kit can suffice. However it must be remembered that the change in color is not always followed by ovulation.
The best way to predict ovulation is by measuring blood estradiol and progesterone levels and by ultrasound performed at the expected time of ovulation. For example, in a natural cycle (no medications taken for ovulation induction) on day 12-13 of a 28-day cycle. The sonography should report a mature egg of 20 mm to 22mm, estradiol of 180 pg/ml or more. (During the process of ovulation between 1ng/ml to 6-8 ng/ml.) Therefore both sonography and blood tests overlap and confirm how close the patient is to ovulation.
In spite of measurements, we do not know whether the egg from inside the follicle was indeed released. If the suspicion is aroused one has to perform another sonogram after ovulation (day 19-20). Fifteen percent of the population will show evidence of ovulation (high progesterone) even though the follicle did not release.Post Coital Test
The post coital or, after intercourse, test is used to identify abnormalities that may be present in the cervical mucus. The couple has intercourse at home and comes to our New York fertility clinic offices within 24 hours. A sample of the mucus is taken and if numerous "dead" sperm are seen an antibody problem may be present. Sometimes the female's body recognizes sperm as invading pathogens and produces antibodies to destroy them. Rarely, a man may produce antibodies to his sperm. When female antibodies are present, IUI is used to bypass the cervical mucus.Laparoscopy
The laparoscopy is a diagnostic test that can also be therapeutic, when performed by a reproductive endocrinologist, fertility specialist. Small incisions are made usually near the belly button and at the pubic hairline. Dr. Goldstein inserts operative tools through one opening and a "telescope" device through the other. He can visualize the reproductive organs and diagnose conditions such as endometriosis. Many times he can remove the endometriosis during the laparoscopy, which is why a reproductive surgeon should perform the surgery. The laparoscopy is performed as an outpatient procedure under general anesthesia.Hysterosalpingogram, Sonohysterogram, Hysteroscope
These test access the condition of the fallopian tubes and uterus. The hysterosalpingogram (HSG) is performed at the hospital. Dye is injected into the uterus and its flow through the fallopian tubes is monitored via x-ray. Obstructions or blockage appear on x-ray as a concentration of the contrast media.
In a sonohysterogram, saline solution is injected into the uterus through the vagina. The vaginal probe ultrasound is used to visualize the uterus, with the contrast solution, and abnormalities such as fibroids or polyps are usually visible.
A hysteroscopy is performed by inserting a “telescope like” device through the vagina into the uterus. The uterus is expanded with a gas, such as carbon dioxide, making obstructions including fibroids, polyps, adhesions, or other abnormalities, visible.
Dr. Goldstein may order numerous additional fertility tests based upon each couple's individual case and suspected causes of infertility.