The fertility workup is a thorough assessment that involves multiple tests and evaluations to identify potential issues with reproductive health. This process is crucial for determining the causes of infertility or confirming that no fertility problems exist. Below, we outline the typical stages involved in a fertility workup.
History Check-up
The first step in a fertility workup is a detailed discussion of your medical history with your doctor. This conversation will cover:
· Chronic illnesses or conditions that may affect fertility.
· Gynecological history, such as menstrual irregularities or previous diagnoses.
· Obstetric history on previous pregnancies, miscarriages or deliveries.
· Surgical history, as past surgeries could have implications for reproductive health.
This will be the initial phase of the workup, after which you will move on to the physical examination process.
Pelvic Ultrasound
A pelvic ultrasound is a non-invasive procedure that examines the uterus, fallopian tubes, and ovaries for abnormalities that could affect fertility. This imaging technique can detect conditions such as uterine fibroids, polyps, or structural abnormalities that may interfere with conception. Additionally, it can reveal pelvic scarring — a tissue that grows as a result of infections, endometriosis, or prior surgeries between two organs in the pelvic area and causes significant pelvic pain. Pelvic scarring can potentially hinder normal reproductive function, therefore detecting and treating it can significantly improve the chances of a successful pregnancy.
Counting Antral Follicles
Another important part of the ultrasound evaluation is counting antral follicles — small follicles in the ovaries that can indicate a woman's potential for adequate ovarian stimulation with fertility medications. Antral follicle counts are currently the most reliable tools for estimating ovarian reserve, predicting the response to ovarian stimulating drugs, and determining the likelihood of successful pregnancy through in vitro fertilization. Therefore, using pelvic ultrasound to check antral follicles will be an important part of your fertility workup.
Blood Tests
Day 3 FSH, LH, and Estradiol Hormone Testing: These tests measure the levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol on the third day of the menstrual cycle. Elevated levels of FSH and LH or abnormal estradiol levels can indicate reduced ovarian reserve.
AMH Hormone Levels: Anti-Müllerian hormone (AMH) levels are measured to provide an estimate of the remaining egg supply. Higher AMH levels generally correlate with a better ovarian reserve, while lower levels suggest a diminished reserve.
Other tests might include the tests of:
· Testosterone: Abnormal levels of which can indicate polycystic ovary syndrome (PCOS) or other endocrine disorders affecting fertility.
· Prolactin: Elevated levels can interfere with ovulation and fertility.
· Progesterone: Levels of which are assessed to confirm ovulation and luteal phase function.
· 17-Hydroxyprogesterone: Used to screen for congenital adrenal hyperplasia, which can impact fertility.
· Thyroxin and Thyroid Stimulating Hormone (TSH): Thyroid disorders can also affect menstrual cycles and fertility.
Hysterosalpingogram
The hysterosalpingogram (HSG) is a specialized X-ray procedure that involves injecting a contrast dye into the uterine cavity. This dye outlines the shape of the uterus and fallopian tubes on X-ray images, allowing healthcare providers to detect abnormalities or blockages. The HSG is typically performed between days 6 and 13 of the menstrual cycle. This timing is crucial as it ensures that the test is conducted after menstrual bleeding has ended but before ovulation occurs. This helps to provide the clearest possible images and reduces the risk of interfering with a potential early pregnancy. The procedure is relatively quick and can often be completed within 30 minutes.
The HSG is important for diagnosing structural issues within the uterus and fallopian tubes that can contribute to infertility, such as:
· Uterine Abnormalities: Including polyps, fibroids, or congenital anomalies that can affect implantation and pregnancy.
· Tubal Blockages: Blockages or damage to the fallopian tubes, which can prevent the sperm from reaching the egg or the fertilized egg from reaching the uterus.
Tubal Factor Infertility
Tubal factor infertility accounts for approximately 25-30% of all infertility cases. This highlights the importance of the HSG in identifying tubal blockages or damage. Detecting these issues early can lead to appropriate treatments, such as surgical intervention or assisted reproductive technologies like in vitro fertilization (IVF), improving the chances of conception.
Laparoscopy
Another test that may be done either early or late in the infertility workup is a laparoscopy. This surgical procedure is performed on an outpatient basis and requires anesthesia. During a laparoscopy, a telescope and other instruments are inserted through a small incision (less than one inch) in the abdomen. This allows the doctor to identify any abnormalities in the uterus and surrounding areas, such as endometriosis.
Endometriosis is a condition where tissue that normally lines the uterus (endometrial tissue) grows in various places in the pelvic area. Laparoscopy can both diagnose and treat endometriosis, and scar tissue can also be removed during the procedure.
The most common post-laparoscopy issues are pain around the incision site, but most women feel well enough to return to normal activities within one or two days after the procedure.
While laparoscopy is effective, its use has decreased as IVF success rates have dramatically improved over the past 20 years. Most couples now opt to bypass invasive laparoscopic surgery, choosing instead to start with treatments like intrauterine insemination (IUI) and moving on to IVF if necessary.
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