Diagnostic Procedures

In a single cycle, the likelihood of conception (achieving pregnancy) for a healthy young couple is approximately 20 percent. Over twelve months, the combined likelihood of achieving pregnancy is about 85 percent. It is important to know that these numbers will begin to decrease beginning in a woman’s early thirties, declining even further after age thirty-five.

Multiple factors can affect a couple’s ability to conceive. Generally, the causes can be divided into male and female categories.

Female Ovulation Disorder (20-25%)

Abnormalities in the ability to produce or release eggs includes Polycystic Ovary Syndrome (PCOS).

Male Factor (40%)

Abnormalities in sperm count, motility, appearance, or function; this also includes the inability to have intercourse, either due to injury or other causes.

Female Pelvic Factor (20-25%)

Abnormalities of the pelvic organs including blocked fallopian tubes, adhesions (scar tissue) around the tubes and ovaries, fibroid tumors of the uterus, and moderate to severe endometriosis.

Unexplained (10-15%)

Infertility with no known cause following a complete work-up.

Female Cervical Factor (5%)

Abnormalities of the cervical mucus that could decrease the ability of sperm to reach the fallopian tubes.

Therefore, a thorough evaluation of the infertile couple begins with investigation for both male and female causes of infertility. The specifics of each test are covered in more detail in subsequent sections.

Diagnostic Procedures

Semen Analysis

This test provides an indication of how your semen compares with the general population. The following parameters are measured in a semen analysis: volume and consistency of semen, sperm count, percentage of sperm that are progressively motile, the strict morphology (structural appearance) of the sperm, and sperm survival. A semen analysis does not diagnose fertility or infertility but provides a relative measure of semen quality compared to the general population of men. It can suggest possible conditions associated with reduced fertilization at in vitro fertilization (IVF) and indicate the need for intracytoplasmic sperm injection (ICSI).

The cause of infertility may be due to a problem with the man’s reproductive system or a problem that involves both partners. The cause of male infertility is often unknown. However some cases have been identified, including problems related to: sperm production, the anatomy or structure of the man’s reproductive organs, and the man’s immune system. When male factor infertility is suspected, the initial test performed is a semen analysis. A semen analysis allows the doctor to examine the count, motility and morphology of the sperm.

• Sperm count – The normal range for sperm is between 40 and 300 million sperm per milliliter of ejaculate. A low sperm count is fewer than 20 million per milliliter of ejaculate.

• Motility – Low sperm motility (movement) may reduce the chances of conception, especially when paired with low sperm count. In a normal semen sample, at least half of the sperm have typical movement.

• Morphology – Sperm that do not have normal morphology (shape) are often unable to swim effectively or penetrate an egg. A normal sperm has an oval head, slender midsection and tail that moves in a wave-like motion.

In order for a physician to evaluate the count, motility and morphology of sperm, a semen sample must be provided. The sample is most often collected by masturbation in a private, comfortable room in the fertility center. In some cases, the sample may be collected at home by masturbation or during intercourse with the use of a special condom provided by the physician. In some cases, the test results are not normal due to problems during sample collection and the test must be repeated.

Depending on the results of the semen analysis, more tests may be ordered to diagnose specific causes of infertility. If the semen analysis shows clumping or signs of infection, a semen culture, prostate fluid culture and urinalysis may be ordered. An antisperm antibody test may also be ordered to evaluate potential immune system disorders. A fructose test may be used to evaluate structural problem or a blockage of the seminal vesicles.

Facts About Semen Analysis

• A semen analysis is a test that tells your doctor the number of sperm in your semen, whether they are normal, and how well they move.

• Your test results will tell your doctor the number of sperm in your semen (your sperm count), whether they are normal (morphology), and how well they swim (motility).

• A low sperm count may be caused by certain medications or a medical problem such as a blocked duct, low testosterone level, or a condition in which sperm back up into the bladder.

• Fever can also reduce sperm count.

• Some men may have enough sperm, but their sperm may not swim well enough to reach the egg.

• Also, sperm that are not normal in shape may not be able to penetrate or fertilize the egg.

• A low sperm count is fewer than 20 million sperm per milliliter ejaculated. The normal range is between 40 million and 300 million sperm per milliliter of ejaculation.

Reporting Test Results

Allow at least seven days for your physician to receive and review your test result. Our physician will review the result with you, and interpret the significance of the test result.

Although you may already have a recent semen analysis report available, we highly recommend that an IVF semen analysis be performed at RFC to ensure the best possible number of fertilized eggs. RFC operates an andrology laboratory to support its Assisted Reproductive Technologies.

How To Schedule an Appointment

Please call (949) 453-8600 between 6:00AM and 6:00PM Monday to Friday; from 7:00AM to 1:00PM on Saturday; Sunday is by appointment only.

What to Expect During Your Appointment:

1. When you arrive, please sign in at the front desk. Notify the front office staff that you have an appointment for a semen analysis. You will be required to pay for semen analysis at the time of the visit if your insurance does not cover the service.

2. You will be called to come back to the lab area where you will be shown into the specimen collection room.

3. You will then be provided with additional instructions on specimen collection. The specimen collection room is set up to provide you a private and comfortable environment in which to produce the specimen.

4. After you have provided the specimen, please label the specimen. Be sure to indicate your full name, the full name of your partner, and the time you have completed collection (not the time you entered the collection room). If a physician outside our practice has referred you, the results will be provided to your physician for interpretation.

5. Notify the staff that you have completed the sample.

Requirements for Producing a Specimen at Home for Drop Off at the Laboratory

We prefer that the specimen be collected at RFC; however, if this is uncomfortable or inconvenient for you, you may collect the specimen at home or another location, and deliver it to the laboratory. In order to do this you must adhere to the following guidelines:

• Deliver the specimen at your appointment time. Let the scheduler know that you will drop off the specimen at the time of your appointment so the laboratory will be prepared to perform the analysis immediately.

• Deliver the specimen within one hour of ejaculation (consider traffic and travel distance).

• You must have a suitable sterile specimen container (sterile and non-toxic to sperm). You or your spouse or partner may pick up a specimen container from the laboratory ahead of time, or you can purchase a sterile specimen cup (like the ones used for urine specimens) from a pharmacy.

• You must follow the collection instructions to ensure that the specimen does not become contaminated, which could yield incorrect results.

• Label the specimen cup with your name and place the sealed specimen cup in a paper bag. Protect the specimen from extremes in temperature and from direct sunlight. It is best to keep the specimen at 75° to 85°F during transport.

Requirements For Proper Collection of a Specimen

Refrain from ejaculation for 2 to 5 days before producing the specimen for analysis. Longer or shorter periods of abstinence will result in specimens that yield incorrect indications.

The semen specimen should be produced by masturbation. Wash your genitals and hands to minimize the chance of contamination of the specimen. Do not use lubricants or saliva when masturbating, since potential toxicity to the sperm can adversely influence the results. Collect the ejaculate directly into the specimen cup and replace the lid immediately to prevent contamination. Do not produce the specimen by coitus interruptus (having intercourse and withdrawing the penis prior to ejaculation) or by oral sex. Both activities can lead to a suboptimal specimen, which may yield falsely abnormal results.

Do not collect the specimen with a regular condom since they contain chemicals that are toxic to sperm. If masturbation is absolutely unacceptable to you, please obtain a special semen collection device from RFC. These devices consist of a special non-toxic condom and a test tube for transporting the semen to the laboratory. There is also a small funnel to use in transferring the semen from the condom into the test tube and detailed instructions on how to use the device.

Notes

Try not to sit in hot tubs or spas during the three months before the treatment cycle.

Use of drugs, alcohol, cigarettes or chewing tobacco should be kept to an absolute minimum during the three months before the treatment cycle. In some cases, the treatment may need to be postponed if a herpes lesion is present at the time of semen collection.

If you have a fever of 101°F or higher within three months before the treatment cycle, sperm quality may be adversely affected. The sperm count and motility may appear normal, but fertilization may not occur. If you become sick, please take your temperature morning and night, and take Tylenol every four hours to keep your temperature down. Report the fever to your nurse.

Ultrasonography

Ultrasound Testing

• Ultrasound uses high- frequency sound waves to create images of your internal organs on a monitor.

• Ultrasound helps your doctor monitor your ovulation and diagnose conditions such as pelvic masses and early pregnancy. In addition, an ultrasound provides your doctor visibility into the thickness and pattern of your uterine lining.

• It is also used during in vitro fertilization (IVF) to help your doctor guide a needle into the follicles to retrieve eggs.

• Ultrasound uses high- frequency sound waves to create images of your reproductive organs on a monitor.

• Transvaginal ultrasound is performed with a scanning probe inserted into your vagina. The scanning probe feels much like a tampon as it is inserted into your vagina. Ultrasound examinations are relatively painless and take only a few minutes to perform.

Hormone Evaluation

• Hormonal evaluation studies help identify hormonal imbalances that may impair your fertility.

• Hormones control every step in achieving pregnancy- from stimulating the development of an egg to ovulation and implantation of a fertilized egg in the uterus.

• Hormonal studies measure the levels of certain hormones produced by your body during your cycle.

• You are likely to have a series of simple blood tests at various points in your cycle.

• Hormones that control ovulation and implantation of the egg include: Estradiol, Follicle-stimulating hormone (FSH), Luteinizing hormone (LH), and Progesterone.

• Other hormones that can interfere with ovulation include: Androgens, Prolactin, and Thyroid.

Endometrial Evaluation

Endometrial Biopsy

• An endometrial biopsy is a test that evaluates the endometrial tissue that lines the inside walls of your uterus.

• Around the time you ovulate your endometrium grows thick with blood vessels, glands, and stored nutrients to allow a fertilized egg to implant and grow. If fertilization does not occur, the endometrial tissue sheds as menstrual flow to mark the beginning of your next cycle. If your body doesn’t produce enough of these hormones, your uterus may not be able to maintain a pregnancy. If your body is not producing enough hormones, medications may be prescribed to regulate them.

• Your doctor will place a speculum inside your vagina, insert a small catheter though your cervix into your uterus, and remove a small sample of the endometrial lining. It usually takes just a few seconds. You may feel a pinch or some cramping.

• This test is usually done 1 to 3 days before you expect your period.

• There is a slight chance that the biopsy may disrupt an early pregnancy if you happen to be pregnant when the test is performed.

Sonohysterogram

A sonohysterogram utilizes a sterile saline solution and ultrasound to examine the uterus to determine possible causes for abnormal bleeding, issues that may be contributing to infertility such as polyps or fibroids, overall health of endometrial lining and/or cancer concerns.  The saline enlarges the uterus and enhances the ultrasound images for clarity in viewing any potential issues.

Hysteroscopy

A hysteroscope is a small telescope that is attached to a video camera and when placed through the cervix it allows direct visualization of the uterine cavity. The uterus is filled with saline solution and abnormalities that are found at this time may be corrected. This procedure may be performed in the office, or in the operating room in conjunction with a laparoscopy. Larger telescopes with an operating channel may be used to remove fibroids, polyps, uterine septa and scar tissue, allowing not only diagnosis, but also treatment. The operative portion of the procedure usually requires anesthesia and is performed as an outpatient procedure.

Submucus leiomyomas bulging into the uterine cavity may be removed with a simple outpatient procedure where a telescope is placed into the uterine cavity and the tumor is cut out.

Hysterosalpingogram (HSG)

An X-ray test that shows the inside of the uterus and fallopian tubes, performed right after the menstrual period is completed. A small amount of dye is injected through a thin tube inserted through the cervix (opening to the uterus) while X-ray pictures are taken. The fluid will fill the inside of the uterus and show its shape. We can determine if the uterine cavity is normal and whether the fallopian tubes are open.

• A hysterosalpingogram (HSG) is a test that lets your doctor examine the inside walls of your uterus and fallopian tubes.

• Having a blocked fallopian tube or a growth in your uterus may reduce your chances for pregnancy. If your fallopian tubes are blocked, the sperm can’t reach the egg. A hysterosalpingogram (HSG) is a test that uses x-rays and a special dye to detect scar tissue, polyps, fibroids, and other growths that may be blocking your tubes or preventing a fertilized egg from implanting properly in your uterus.

What to expect during the HSG

• The HSG is usually done in a radiology lab and takes between 10 to and 30 minutes. Your doctor will insert a speculum into your vagina and then place a thin plastic tube inside your cervix that will lead to your uterus and fallopian tubes. A special dye will be injected through the plastic tube.

 

Laboratory Tests

Laboratory tests performed before a fertility treatment may include evaluation of Follicle-Stimulating Hormone (FSH)/, Estradiol (E2), Anti-Mullerian Hormone (AMH), FDA required infectious disease screening, semen analysis mentioned above, or other hormones that may have caused infertility.  A full evaluation based on your medical history and symptoms may uncover one or more factors that may be the cause of infertility.

 

Screening Appointments

Your screening appointments are to prepare you for an IVF cycle.

  • Lab work – this blood work should be done on day 2 or day 3 of your menstrual cycle, and may include your blood work for day 3 and any other lab work required by your physician.
  • Partner’s lab work and Semen Analysis – these tests may be done on the same day.
  • Ultrasound, Trial Transfer (if needed), and Physical Exam can all be done at the same visit. If a Saline Sonogram is ordered, this is performed between cycle days 7-11, at which time all the above tests can be done at the same visit. A Mid-cycle Ultrasound is usually done between cycle days 14-16 and again all the above tests may be completed at the same visit.
  • Any miscellaneous appointments as ordered by your physician, for example, mammogram, electrocardiogram (EKG), chest x-ray, etc. performed at your primary care physician’s office.
  • Final appointment prior to starting an IVF cycle consists of a visit with your nurse to coordinate your schedule and a consult regarding financial responsibilities. Both partners are required at this appointment.

Treatment Options

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