A complete fertility evaluation is the first step in a treatment plan
When you come to see a fertility specialist, we will first want to talk to you about your medical history. We will want to know if you have any medical problems, what your menstrual cycle is like and if you have had any pregnancies in the past. After we gather a history, we will typically perform a physical examination. The information we gather from your history and physical will then usually help us determine what type of additional evaluation you will need. In order to conceive naturally (or even with minimal assistance), each couple needs a normal uterus, normal ovaries that contain plenty of eggs, normal fallopian tubes, and normal sperm. Your fertility work-up will therefore focus on evaluating and optimizing each of these things.
Very early in your evaluation, usually at the first visit, we will want to perform a transvaginal ultrasound examination. This simple test is done in the office and it is typically painless. We use a vaginal probe rather than an abdominal probe because that gives us the best look at your uterus and ovaries. During the ultrasound we will be looking for things that can reduce your chance for pregnancy, like uterine fibroids, uterine polyps and certain types of ovarian cysts. The ultrasound examination can be done at any time in your menstrual cycle.
Fertility blood work
The next step in the basic evaluation often involves blood work. One of the most important tests is a determination of your “ovarian reserve”, i.e. how many eggs you have left in your ovaries. Although it is not yet possible to give a woman a precise count of the number of eggs she has left, by drawing blood on the third day of the menstrual cycle, we can get a pretty good idea of where someone is in her reproductive lifespan. Unlike men, women are born with all the eggs they will ever have. This number declines with age. Some women lose eggs faster than others. The fewer eggs you have, the harder it is to get pregnant. There are two specific hormonal tests that will give us information about how many eggs you have left: follicle stimulating hormone (FSH) and antimullerian hormone (AMH). When evaluated together, these tests will give us a much better idea of what your chance for pregnancy is with different types of fertility treatment.
In women who do not ovulate regularly, we will often also test for levels of prolactin, thyroid stimulating hormone (TSH), and occasionally androgens such as testosterone and DHEA-S. If we suspect that a woman has polycystic ovarian syndrome (PCOS), we may also evaluate her ability to metabolize glucose by performing a 2 hour glucose tolerance test (GTT).
Fallopian tube exam
In addition to blood work to evaluate hormones, it is also very important to make sure that the uterine cavity is normal and that the fallopian tubes are open. This is usually done by performing a test called a hysterosalpingogram (HSG). At Texas Fertility Center-San Antonio, we work with San Antonio’s leading radiologists to obtain the best, most accurate HSG possible. During this x-ray, which is performed in a radiology suite during the first half of your cycle, a small catheter is introduced through the cervix into the uterus. Under fluoroscopic (x-ray) guidance, a liquid (contrast dye) is placed into the uterus and then hopefully, out both fallopian tubes. A well performed HSG will allow us to make sure that the uterine cavity is normal and that both fallopian tubes are open.
Up to this point in the discussion, we have focused exclusively on the evaluation of the woman. As 50% of cases of infertility are caused by abnormalities in sperm production or function, it is also very important to evaluate the male. This is usually done by obtaining a semen analysis. To do this, we will ask the male partner to obtain a sperm specimen either at San Antonio IVF or at home. If the collection occurs at home, the specimen needs to be brought to the laboratory within one hour of the time of collection. Once the specimen arrives, it will be evaluated microscopically for volume, sperm count, sperm motility (the percentage of sperm in the specimen that are alive and swimming), and sperm morphology (the shape of the sperm). Although there are certainly exceptions, it typically takes millions of normally shaped, motile sperm for fertilization to happen naturally, or even with IUI. There is no reason for despair if the number of sperm is lower, however, as in vitro fertilization (IVF) can successfully produce healthy babies even when there are very few sperm present.
Once these tests have been completed, you will be asked to come back to the office to discuss the results of all your tests with your physician. Based on the results, we will be able to give you a reasonable assessment of your chance for pregnancy with different types of fertility treatment. This discussion will include a discussion not only of success rates, but also of potential side effects and the cost of each treatment. Following this discussion, we will help you develop a plan of action so that we can get you started on what we all hope will be a short journey to pregnancy.
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