Basic infertility testing should be individualized to each patient (or couple’s) specific clinical situation. However, most patients will undergo one or more of several common infertility tests early in the diagnostic phase of their infertility treatment.
Ovarian Reserve Testing (ORT) is completed to estimate a woman’s fertility potential and in theory is an indirect measurement of the overall egg quality and quantity. No specific test of ovarian reserve is perfect and optimally multiple measures, along with a patient’s history and examination findings, are considered when making judgments about ovarian reserve.
Ovarian reserve may be measured by:
- Menstrual cycle day 3 (“day 3 labs”) serum (blood test) evaluation. In reality these labs may be drawn on menstrual cycle day 2, 3, or 4 with the first day of full flow (spotting does not count) considered as menstrual cycle day 1. Common day 3 hormones that are tested are follicle stimulating hormone (FSH), estradiol, and luteinizing hormone (LH). In general a higher FSH level (in the context of a normal estrogen level) indicates a compromise in ovarian reserve.
- Anti-Mullerian Hormone (AMH) is a hormone secreted by the supportive (granulosa) cells that surround the egg in resting or pre-antral follicles. In general larger numbers indicate a higher fertility potential. One advantage of AMH testing is that it does not fluctuate significantly and can be drawn on any day of your menstrual cycle.
- Antral follicle count (AFC) is an ultrasound measurement, usually completed on menstrual cycle days 2,3, or 4, of the total number of small and resting eggs present in both ovaries. Larger numbers of antral (resting) follicles usually indicates a higher fertility potential.
- Ovarian volume, or measurement of the total size of the ovary is often meaured. In general, a larger ovarian volume is associated with a better fertility prognosis.
- Age is probably the most important way to evaluate your ovarian reserve. Although not often regarded as a “test” your age is usually the best overall predictor of the ability of your ovaries to produce mature, chromosomally normal fertilizable eggs.
A hysterosalpingogram (HSG) is often completed to confirm patency of the fallopian tubes. In this short procedure, a small amount of contrast dye is injected through a narrow and flexible catheter while viewing your uterus through an X-ray machine. This study will also often identify any abnormalities such as intrauterine (inside the uterus) polyps or fibroids. Despite reports on the Internet, this test is almost always well-tolerated by patients who usually experience a few minutes of cramping which resolves by the time the test is completed. In many cases, you will receive an antibiotic prescription to take prior to your HSG.
Figure: HSG demonstrating open fallopian tubes and a small adhesion (scar tissue band) inside the uterus
Semen Analysis: Because about 40% of infertility is related to abnormalities in sperm, a semen analysis is often ordered early in the infertility evaluation. Usually these results are available to your physician on the same day as your initial evaluation. If you will be undergoing a semen analysis you may be asked to arrive earlier so please review your new patient confirmation letter to cornfirm your arrival time.
Ultrasound Evaluation: In our experience an early ultrasound has proven invaluable not only for ovarian reserve testing but also for evaluation of other abnormalities of the ovary (ovarian cysts or masses), uterus (polyps, fibroids) or other structures found in the female pelvis. Early identification and treatment of any abnormalities often facilitates pregnancy.
History and Physical Examination: Because one of the most important ingredients for a uneventful pregnancy and health baby are a healthy mom, we often also complete a thorough history and physical examination early in the testing process.
Figure: A sonohysterogram demonstrating a fibroid inside the uterine cavity.
Common indications for a SHG are for testing prior to IVF, abnormal HSG, and abnormal bleeding