Infertility Evaluation of the Female
The infertility evaluation of the female focuses on the number and quality of eggs, and the uterus and fallopian tubes. The initial tests assess these factors which play an integral role in successful conception.
Egg quantity is assessed by measuring certain hormones and counting the number of follicles in the ovaries by ultrasound.
AMH (antimullerian hormone) – AMH is a protein secreted by small cells within a follicle (the cyst that holds the egg). It is secreted most intensely by the small follicles that can be seen in the ovary on a transvaginal ultrasound at the beginning of a menstrual cycle. . AMH is a measure of the ovarian reserve, i.e. how many eggs remain in the ovary. The level varies significantly with age and declines as a woman approaches menopause. The test can be checked at any time in the menstrual cycle. The AMH level helps physicians make decisions on how aggressive to be in a patient's treatment plan. It also allows physicians to understand if IVF (in vitro fertilization) is a viable option for a patient. When the AMH declines below a certain level, IVF is less successful in achieving a pregnancy.
Day 3 Labs - The combination of FSH (follicle stimulating hormone), LH (luteinizing hormone) and estradiol hormones represents the communication pathway from the brain to the ovary, and from the ovary back to the brain. By analyzing all 3 labs together, physicians can detect subtle changes in the ovarian reserve or in the way the brain and ovaries communicate with one another. The most important of these three labs is the FSH.
FSH is the primary hormone secreted by the brain to signal to the ovaries that it is time for an egg and its surrounding follicle to grow. As ovaries age and have fewer eggs, the ovarian response to the brain's signal is suboptimal. In an attempt to correct this, the brain sends out extra FSH signal. The result is an elevated day 3 FSH. This indicates the presence of diminished ovarian reserve (DOR).
Uterus and Tubes
There are several ways to assess the uterus and tubes.
HSG (hysterosalpingogram) - The HSG is an x-ray that allows the physician to evaluate the shape and size of the uterine cavity as well as the appearance of the fallopian tubes. It is performed in our office or at a radiology office. The patient is situated in stirrups on the exam table, similar to when a pap smear is done at the gynecologist's office. A speculum is then placed in the vagina so that the cervix can be seen. A small, soft, flexible catheter (a tube approximately the diameter of a coffee stirrer) is then gently introduced through the cervix into the lower part of the uterus. A small balloon is inflated which keeps the catheter in place. Radiographic dye is introduced into the uterine cavity through the catheter. As the dye fills the uterus and fallopian tubes, x-rays are taken. The physician can then study the x-ray images. These may reveal a fibroid or polyp filling up part of the uterine cavity, or an abnormal shape to the uterine cavity. The fallopian tubes may appear blocked or damaged on the x-ray. This information will allow the physician to determine the best treatment plan.
SIS (saline infusion sonogram) – Sometimes a more detailed evaluation of the uterine cavity is required to make sure there are no abnormalities within the cavity. Specifically, the SIS is a good test to look for endometrial polyps or fibroids that may be on the inside of the uterus or pushing against the cavity. It can also be performed to rule out deformities of the uterine cavity present since birth. The SIS is performed similarly to the HSG. A speculum is placed in the vagina and a small, soft, flexible catheter is introduced through the cervix into the lower part of the uterus. A small amount of saline (salt water) is then placed in the uterine cavity through the catheter. At the same time, a transvaginal ultrasound is performed. This allows for the distended uterine cavity to be evaluated and the presence of polyps or fibroids noted.
Hysteroscopy – Hysteroscopy is a procedure that allows for direct visualization of the inside of the uterine cavity. This can be done in the office, while a patient is awake, or in a procedure room using anesthesia. A small diameter, long metal tube is inserted through the cervix into the uterus. It is attached to a camera that projects a picture onto a TV monitor. Saline is pushed into the uterine cavity so that the doctor can see. The inside of the uterus is observed and evaluated for scar tissue, polyps, fibroids, or inflammation.