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A thorough history should include information about past surgical history, medical history, exposures to tobacco, alcohol, environmental toxins, a history of sexually transmitted diseases, a careful menstrual history, a history of any past pregnancies, a through review of all organ systems, and any other relevant information.
In order to determine the proper course of treatment, we perform a number of diagnostics.
History and Physical Examination
A thorough history should include information about past surgical history, medical history, exposures to tobacco, alcohol, environmental toxins, a history of sexually transmitted diseases, a careful menstrual history, a history of any past pregnancies, a through review of all organ systems, and any other relevant information. In addition, an equally thorough history of the patient's partner should be obtained. The patient should then undergo a thorough physical exam to help investigate and find a treatment for infertility. Many times, transvaginal ultrasound will be performed at the time of the initial examination to evaluate the uterus, tubes, and ovaries. Only through an extensive evaluation of a patients history and a thorough physical examination can an appropriate and directed treatment plan be selected and implemented.
It is important that preventative medicine begin before even trying to get pregnant. The first "preconceptual counseling" appointment should occur 4 months or so before beginning to try to conceive. Patients considering pregnancy should be on a vitamin with 0.4mg of folic acid about 3 months before pregnancy. (The spinal cord is developed by 1 month after conception, so by the time a lot of women realize they are pregnant it is perhaps too late to prevent spina bifida and anencephaly). Finally, this consultation is a chance to discuss problems with previous pregnancies, social issues, environmental exposures, and general health. If not previously done, a hematocrit to check for anemia, a rubella titer to check for immunity to rubella, and other blood tests can be performed. A thorough family history and blood tests for genetic diseases (Cystic Fibrosis, Tay Sachs, etc.) may be indicated.
The transducer on a transvaginal ultrasound is a long probe that is inserted into the vagina covered with lubricant and a condom. The ultrasonographer will be able to see the uterus, ovaries, and sometimes the Fallopian tubes. The procedure is not painful, and many women prefer it to an abdominal ultrasound for which the bladder must be full.
It is mandatory that the male partner in all infertile couples undergo a formal semen analysis to assess whether there is adequate sperm number and quality. The doctor may advise the man who is scheduled for semen analysis to abstain from sex for two to four days beforehand. The semen analysis should include basic parameters such as sperm number, motility, and morphology (shape). In a normal ejaculation the total volume of semen is between a half and a whole teaspoon. As part of the semen analysis, the technician will determine the number of sperm present in the ejaculate. A normal sperm concentration falls between 20 million/mL and 200 million/mL. The technician looks at how well the sperm are moving and counts the total percentage of motile sperm by figuring how many sperm per 100 are moving. At least 50% of any given sperm population should be moving. Then the sperm movement is qualified. A well developed sperm can propel itself up a woman's reproductive tract at a rate of more than 2 inches an hour. Finally, the shape or morphology of the sperm is determined. Sperm heads should be oval-shaped without irregularities. In the event that the semen analysis is abnormal, it should be repeated, and referral to a urologist who specializes in male infertility should be considered. The evaluation of the male involves a thorough physical examination, and hormonal testing. In the event that no sperm at all are found on semen analysis, a testicular biopsy may be indicated.
By performing some basic blood tests, a physician can evaluate the hormonal function of a woman trying to conceive. Tests that can be performed at any time include prolactin and thyroid levels. Perhaps the most important hormonal test that a woman should undergo is an FSH (Follicle Stimulating Hormone) test. When performed on Day 3, this test can provide information about the quality of a woman's eggs. An abnormal or high FSH level can mean that it will be more difficult for the woman to conceive, while a low or normal value is more reassuring. It is important that this test be performed in conjunction with an Estradiol to prove that it is a valid test.
This procedure involves a scraping a small amount of tissue from the endometrium shortly before menstruation is due---between 11 and 13 days following ovulation. It should ONLY be performed after a pregnancy test reveals that the woman is not pregnant. This test is often used to determine if a woman has a luteal phase defect, a hormonal imbalance that may prevent a woman from sustaining a pregnancy because not enough progesterone is produced. Due to inconsistencies in evaluating these specimens, and uncertainty over appropriate treatments, fewer infertility specialists consider this an important test.
This test is a quick, painless procedure that can give information how the cervical mucous and sperm interact. The test must be done within one to two days before or after ovulation. Basal body temperature charts or ovulation predicting kits are very helpful in determining the time of ovulation. A couple should abstain from intercourse for 2 days before ovulation, then have intercourse 2-8 hours prior to the office visit for the post-coital test. A speculum is placed in the vagina, as it would be for a pap smear. A syringe without a needle is then used to remove some mucous from the cervical opening. The speculum is then removed and the cervical mucous is evaluated. The specimen is then placed under a microscope to look for the presence or absence of swimming sperm. There have been many studies suggesting that the test is neither accurate nor predictive of fertility. Many fertility specialists skip this step and proceed directly to intrauterine insemination.
This test is used to examine a woman's uterus and fallopian tubes. It is essentially an x-ray procedure in which a dye is injected through the cervix into the uterus and fallopian tubes. This "dye" appears white on the x-ray, and allows the radiologist and your doctor to see if there are any abnormalities, such as an unusually shaped uterus, tumors, scar tissue or blockages in the fallopian tubes. If you are trying to get pregnant in the same cycle as an HSG, make sure to schedule the test PRIOR to ovulation so that there is no danger of "flushing out" a released egg or developing embryo. Although most women report only minor cramping and short-term discomfort during this procedure, some women, especially those who have blocked tubes, report intense pain. Speak to your doctor about taking a pain medication about 30 minutes prior to the actual procedure.
Basal Body Temperature Charting
For women who are unsure of when they ovulate, keeping a basal body temperature chart for several months may help identifying the time of ovulation. Charting involves taking one's temperature every morning upon waking up and recording the results. For optimal accuracy, this must be performed before the woman drinks a cup of hot coffee or brushes her teeth, as these events can interfere with the temperature reading. When the temperature goes up 0.5 degrees, the woman is in the process of ovulating. This is not recommended as a method to plan intercourse, as the rise in temperature is caused by an increase in progesterone after the follicle's release of the egg and the window of opportunity for conception may be missed by the time the temperature rises. Unfortunately, BBT charting is time consuming, frustrating, and is a daily reminder to the patient that she is having difficulty conceiving. Though it is a reasonable first step to attempting conception, if the results are inconclusive after three months, it is recommended that the couple move on to other methods to detect ovulation such as the urinary LH detection kits.
Reprinted with permission of Alan B. Copperman, MD & Reproductive Medicine Associates of New York