When getting pregnant proves elusive, you want answers. Here are the basic steps in a typical fertility evaluation, which may be used by an ob/gyn or reproductive endocrinologist (fertility specialist) to determine your level of fertility and to detect potential problems.
Remember that your doctor will schedule tests based on your own situation and medical history. Therefore, you may not require all of these tests, and they may be done in a different order. Finally, keep in mind that practices can vary widely from doctor to doctor and still be safe and effective.
STEP 1: Medical history. A fertility evaluation often begins with an interview with both you and your partner. While taking your medical histories, your doctor will ask about conditions that have a bearing on fertility, such as a hormone imbalance, diabetes, sexually transmitted diseases, and thyroid disease. He or she will need a full accounting of any medication that you've taken or are taking. Other questions may concern your sex life, such as timing and frequency of intercourse, and the reproductive histories of your parents and siblings.
STEP 2: Physical exam. Both you and your partner will be asked to undergo a general physical exam, including a gynecological check-up for the woman.
STEP 3: Semen analysis and culture. Low sperm count or poor sperm quality is the culprit in roughly 30 to 40 percent of infertility cases, so one of the first tests doctors usually advise is an analysis of the man's semen. To do the test, a man collects his ejaculate in a sterile container. The sample is then analyzed to determine whether an adequate number of sperm is present, and whether the shape, appearance, and motility (activity level) of the sperm are normal. The seminal fluid will also be cultured to check for infection.
STEP 4: Hormone screening. The woman's blood and/or urine will be tested to check the levels of various hormones necessary for ovulation and implantation. Blood and/or urine may need to be sampled several times throughout the menstrual cycle to check that each hormone is present at an adequate level at the proper point in time.
STEP 5: Intrauterine ultrasound exam. This painless procedure uses sound waves to examine the body's interior. During the exam, a wand-shaped transducer is inserted into the vaginal opening. The sound waves sent out and collected by the transducer are then converted into images that appear on a nearby monitor. Ultrasound gives the practitioner information about the ovaries, the uterus, and the follicles that hold eggs prior to ovulation. Fibroid tumors and ovarian cysts can often be detected with ultrasound.
STEP 6: Cervical mucus test. The most common cervical mucus test is the post-coital test, in which a bit of the woman's cervical mucus is sampled and examined several hours after the couple has intercourse. This test reveals whether the sperm can survive in the woman's body and move freely toward the egg. It should be done just prior to ovulation, the point in the woman's cycle when the mucus is most receptive to her partner's sperm. To time ovulation, most doctors will ask the patient to use an ovulation prediction kit.
STEP 7: Further evaluation of reproductive organs. The doctor may need to perform one or more of the following procedures to evaluate the woman's uterus, fallopian tubes, or ovaries:
- Hysterosalpinogram (HSG) -- an x-ray procedure in which a special dye is injected through the cervix into the fallopian tubes to reveal whether the passages are open or blocked and whether structural abnormalities exist. Most women report cramping and some discomfort during this procedure; ask your doctor about taking pain relief medication, such as ibuprofin, beforehand.
- Endometrial biopsy -- this test is used to see if the woman has a hormonal imbalance that prevents her from sustaining a pregnancy. It involves inserting a catheter through the cervix into the uterus, then collecting a bit of tissue from the uterine lining (this may cause mild pain or cramping, similar to menstrual cramps). The tissue is then analyzed in a lab.
- Laparoscopy -- in this (surgical) procedure, a narrow fiber optic telescope is inserted through a tiny incision in the woman's abdomen. The telescope allows the doctor to examine the uterus, fallopian tubes, and ovaries and to look for evidence of endometriosis or pelvic adhesions, two conditions that can impair fertility. The test is done under local, regional, or general anesthesia, and can require up to several days post-operative rest and recovery.
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