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A Guide to Fertility Testing

By Natalie Burger, M.D.
When you have your first visit with your fertility specialist they will review your medical history along with your partner’s history for clues as to why things are not working. For some folks, the reasons will be obvious, while other couples may not have a clear reason for infertility based on history alone. Fertility testing can help identify potential problems and guide your fertility specialist in recommending the most appropriate and efficient treatments for success.
Typically, fertility testing will include the following 4 ‘tests’: Bloodwork, ultrasound/examination, hysterosalpingogram (HSG a.k.a. x-ray dye test) for ‘her’ and semen analysis for ‘him’.

Bloodwork: For some patients, especially for women who are 35 years or older, bloodwork will be ordered for the 3rd day of your menstrual period. If it is inconvenient to go on this particular day, day 2 or 4 of your menstrual period are okay as well. The 3rd day of your period is defined as 2 days after the 1st day of red, heavier flow.
FSH/estradiol: To test ovarian function, your specialist may order levels of FSH (follicle stimulating hormone) and estradiol. FSH is a hormone produced by your brain, and estradiol is a hormone produced by your ovaries. A normal level for FSH is <10 miu/ml; between 10-15 miu/ml is considered ‘borderline’; above 15 is considered very concerning for diminished ovarian function. It is important, however to test estradiol along with FSH since a high estradiol can ‘mask’ a high FSH. A normal level for estradiol is <50 pg/dl; between 50-80 pg/dl is considered ‘borderline’; above 80 pg/dl is concerning for diminished ovarian function. Thus, an ideal test result would be both a low FSH and a low estradiol level.

TSH: Your specialist may screen for a thyroid problems with a TSH (thyroid stimulating hormone) test. Thyroid problems can contribute to irregular or absent periods and thus problems with infertility.
Prolactin: This is a hormone that, if elevated, can subtly or significantly change your menstrual pattern. Thus, your provider may check this as well.

Ultrasound/examination: It is important to rule out general physical problems as well as to evaluate the uterus and ovaries through a combined physical examination and internal ultrasound. Depending on your situation, your fertility specialist may want this done during a certain time of your menstrual cycle.
Physical examination: This commonly involves listening to your heart and lungs and also having a brief pelvic examination.

Ultrasound: This ultrasound is commonly done internally (via the vagina) as it gives much better pictures and information than an abdominal ultrasound about the pelvic anatomy. This ultrasound helps your doctor to identify certain abnormalities of the uterus (e.g. septum, fibroids) and also gives important information about the ovaries (e.g. are there cysts – what kind; how big are the ovaries; how many follicles (egg sacs) do they contain; are the ovaries in the right location?)

Hysterosalpingogram (HSG): Since the ultrasound generally gives no information about the patency of fallopian tubes, it is important to look at them through a test called an HSG. This test is done by a radiologist and involves placing a thin catheter into the uterus and injecting dye into the cavity of the uterus (where a pregnancy would grow). This dye shows up on x-ray, and pictures are taken during this test to determine if both fallopian tubes are open. This test can also give more information about the inside of the uterus. This test is generally short (about 15-20 minutes usually), but it can cause cramping. Consider talking to your nurse about taking extra pain medication (e.g. ibuprofen) 30-60 minutes before the procedure. Even though it is not a comfortable test, it can be very informative for evaluation of anatomy – there also appears to be a mild fertility boost for some couples in the first few months following this test.

Semen analysis: As sperm problems affect around 30% of couples with infertility, it is important to do a semen analysis to identify any issues. After 2-5 days of abstinence, the male partner can provide a semen sample into a sterile cup. This can be done at home if the couple lives within an hour of the clinic. Alternatively, a collection room can be available. Usually collection is done via masturbation; however, a ‘collection condom’ can be used to collect sperm during intercourse. The semen analysis will give information about sperm numbers, the percentage of sperm moving, and the percentage of sperm that look ‘normal’. Certain treatments are not successful with low numbers of moving sperm, so this is important information for your fertility specialist to have.

The above tests are commonly done for couples having problems with fertility. Your doctor will let you know if there are further tests to consider for your specific situation. After basic testing, the next step will typically be a consult visit with your doctor to determine the best approach to get you closer to your goal of growing your family!

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