Diagnostic Testing

When you are visiting your RE (also includes OB/GYN, family physician, etc.) a few things will happen to give them an idea of what might be going on with your reproductive system. They will ask you a series of questions, some may be personal, but they are needed to help correctly diagnose your problem and fix it. To give you an idea, here are a few questions.

• Have you ever been pregnant before?
• How long are your menstrual cycles?
• How often do you engage in sexual intercourse?
• Do you have any sexually transmitted diseases?

These questions are very important to your doctor and may clue him/her to where to begin treatment.

Diagnostic testing should ALWAYS begin with semen analysis. Never let a physician perform any tests on you if your partner has not had a semen analysis. It is simple to perform and almost painless for the man....maybe just a little embarrassing. But hey, after all the woman goes through, a little masturbation isn't going to hurt anyone. Anyway, a semen analysis should be performed on freshly ejaculated semen. They will look for volume, motility, viscosity, total count, and morphology of sperm in the semen. The normals for these will be discussed later in the page under Male Factor.

If there is a normal amount of sperm in the semen, they will move on to tests concerning the woman. The first of these is hormone tests, which include baseline tests for follicle stimulating hormone (FSH) and luteinizing hormone (LH). These tests should be done on day 3 of your cycle. Prolactin, Thyroid Stimulating Hormone (TSH), Free T3, Free Thyroxine (T4), Total Testosterone, Free Testosterone, DHEAS and Androstenedione can be done at any time during your cycle. The norm for these hormones are as follows...

• Luteinizing Hormone (LH)
• •Follicular Phase:(day two or three): less than 7mIU/ml
• •Day of LH Surge: greater than 15mIU/ml
• Follicle Stimulating Hormone (FSH)
• •Follicular Phase: less than 13mIU/ml
• •Day of LH Surge: greater than 15 mIU/ml
• Estradiol
• •Day of LH Surge: greater than 100 pg/ml
• •Mid Luteal Phase: (seven days after O): greater than 60 pg/ml
• Progesterone
• •Day of LH Surge: less than 1.5 ng/ml
• •Mid Luteal Phase: greater than 15 ng/ml
• Prolactin: less than 25 ng/ml
• Free T3: 1.4 to 4.4 pg/ml
• Free Thyroxine (T4): 0.8 to 2.0 ng/dl
• Total Testosterone: 6.0 to 89 ng/dl
• Free Testosterone: 0.7 to 3.6 pg/ml
• DHEAS: 35 to 430 ug/dl
• Androstenedione: 0.7 to 3.1 ng/ml

Ask for your results if you want to compare them to this list. This list is courtesy of Chapel Hill Fertility Center laboratory, and have been excerpted from The Couple's Guide to Fertility by Berger, Goldstein and Fuerst, published by Doubleday.
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The next battery of tests should be done before ovulation, but as close to ovulation as possible. Most doctors will ask that you use ovulation prediction kits to time your appointments accordingly. During this visit, you should have a cervical mucous test done as well as an ultrasound exam.

• Cervical Mucus Tests---These include a post-coital test (PCT) to see that the sperm can penetrate and survive in the cervical mucous and a bacterial screening. It is important to note that the appropriate time to do PCTs is just before ovulation when mucous is the most "fertile." PCTs at any other time may give false results.
• Ultrasound Exams---on the day of LH surge are used to assess the thickness of the endometrium (lining of the uterus), monitor follicle development and assess the condition of the uterus and ovaries. If the lining is thin, it indicates a hormonal problem. Fibroid tumors can often be detected via ultrasound, as well as abnormalities of the shape of the uterus and ovarian cysts. In some cases, endometriosis can also be detected. Many doctors order a second ultrasound two or three days after the first. This second ultrasound confirms that the follicle actually did release and can rule out lutenized unruptured follicle (LUF) syndrome---a situation in which eggs ripen but do not release from the follicle.

With these inital tests done, your doctor should have some answers to your problem. However, if nothing is found with these tests, there are a few more diagnostic tests that can give your doctor a little more insight.

• HYSTEROSALPINOGRAM (HSG): This test is used to examine a woman's uterus and fallopian tubes. It is essentially an x-ray procedure in which a radio-opaque 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 DO have blockages, report intense pain. Speak to your doctor about taking a pain medication about 30 minutes prior to the actual procedure. Strangely enough, it has been reported that a percentage of women achieve pregnancy immediately following a HSG. This may be due to the fact that forcing the "dye" through the fallopian tubes may actually open up previously clogged tubes. However, if pregnancy is to happen, it will occur in the first three months.
• HYSTEROSCOPY: If a uterine abnormality is suspected after the HSG, your doctor may opt for this procedure, performed with a thin telescope mounted with a fiber optic light, called a hysteroscope. The hysteroscope is inserted through the cervix into the uterus and enables the doctor to see any uterine abnormalities or growths. "Photos" are taken for future reference. This procedure is usually performed in the early half of a woman's cycle so that the build-up of the endometrium does not obscure the doctor's view. However, if the doctor is planning to do an endometrial biopsy at the same time, it is done near the end of the cycle.
• LAPAROSCOPY: A narrow fiber optic telescope is inserted through a woman's abdomen to look at the uterus, fallopian tubes, and ovaries and to discern endometriosis or pelvic adhesions, and is the best diagnostic tool for evaluating the ovaries. This test is usually done two or three days before menstruation is expected, and only after an HCG beta blood test ensures the woman is not pregnant. Occasionally, this diagnostic tool is turned into a theraputic procedure. Laser surgery is often accompanied with laparoscopy in order to free the uterus, fallopian tubes, and ovaries of endometriosis or scar adhesions that may be found.
• ENDOMETRIAL BIOPSY: This procedure involves a scraping a small amount of tissue from the endometrium shortly before menstruation is due---between 11 and 13 days from LH surge. It should ONLY be performed after an HCG blood test shows the woman is not pregnant. This test is used to determine if a woman has a luteal phase defect, a hormonal imbalance which prevents a woman from sustaining a pregnancy because not enough progesterone is produced.

This information is courtesy of InterNational Council on Infertility Information Dissemination (INCIID).

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