We prefer a time and cost efficient approach to investigate infertility. In the majority of cases, we should have a fairly good idea about the causes of your infertility after the first diagnostic cycle. Depend on your history, the diagnostic cycle may consist of the following tests:
Initial Blood Tests
AMH– Check for ovarian reserve which is one of the most important fertility factors.
TSH– Thyroid hormones are important for good ovulation and healthy pregnancy.
Prolactin– A high prolactin level can impair ovulation, suspected in cases of milky breast discharge.
Vitamin D– A deficiency of vitamin D can lower fertility and increase your risk of miscarriage, especially if you have PCOS.
Hemoglobin A1c– A good marker for glucose control over the previous 3 months. Poor diabetic control can lead to poor ovulation and poor obstetrical outcomes.
Sickle Cell Screen– For patients with African heritage. A positive test warrants further evaluation and testing of the male partner.
Obstetrical Panel– Check for anemia, rubella immunity, and communicable diseases such as Hepatitis B and C, syphilis, HIV. Your OBGYN will need this panel to take care of you during pregnancy.
Genetic Screening– Check for genetic mutations that you might have inherited. If the test is a positive for any mutation, your male partner will need to be screened to see if he has the same mutation. If the partners share a genetic mutation, they will need genetic counseling to plan for a healthy child.
The pelvic sonogram is often performed early in the evaluation to allow examination of the internal pelvic structures such as the uterus and the ovaries. Sonograms performed during the first 3 days of the cycle can also allow assessment of the egg reserve by antral follicle count (AFC) .
The hysterosalpingogram (HSG) can provide a better assessment of the shape of the uterine cavity while also providing helpful information about the tubes. A radiographic dye is injected into the uterus through the cervix while X-ray imaging of the pelvis is conducted. As the dye fills the uterus it provides a detailed contour of the uterine surface and can reveal polyps, fibroids, adhesions and various forms of congenital uterine anomalies.
The dye subsequently travels through the tubes and eventually spills into the pelvic cavity. In cases of tubal occlusion, the HSG can also indicate the extent of the tubal abnormality. A severely damaged tube, for example, can appear dilated as a hydrosalpinx. The HSG can occasionally cause intense uterine cramping that closes the tubes and gives a false impression of tubal occlusion.
Because it outlines only the internal surfaces of the uterus and tubes, the HSG cannot reliably detect abnormalities that reside within the pelvis such as endometriosis and adhesions. The HSG is usually performed after the cessation of menses (on day 7-10). An antibiotic (Doxycycline) is taken 1-2 days prior the HSG to prevent infection.
The sonohysterogram (sonoHSG) is a inexpensive and comfortable test to follow up on the HSG finding of a lesion within the uterine cavity. A saline solution is infused into the uterus through a thin catheter while a sonogram is performed to look for any irregularity in the uterine contour. While the sonoHSG is good for detecting polyps or submucous fibroid tumors, it is not very reliable for detecting uterine septum or abnormal configurations of the uterine chamber or checking the patency of the tubes.
Hysteroscopy is a procedure in which a small camera attached to a thin scope is introduced into the cervix to directly inspect the uterine cavity. The examination can be performed easily in the office to confirm suspicious HSG findings before surgery and usually takes only 10 minutes. Any abnormality seen inside the uterus can be removed through a similar approach but under general anesthesia in the hospital setting.
Laparoscopy is reserved as the final diagnostic test in the infertility investigation and is performed in the hospital. Under general anesthesia, a fiber optic scope is inserted into the abdominal cavity via small incisions to allow examination of the pelvic and abdominal organs. Laparoscopy can help to diagnose endometriosis and pelvic adhesions, conditions not detectable by the HSG. Abnormalities found can often be corrected in the same setting.