Diagnostic Processes and Procedures To Evaluate Infertility
When a patient comes in to Monterey Bay IVF with infertility concerns they will sit down with Dr. Ramirez in his office for an hour-long consultation. The patient(s) health history will be discussed and a decision will be made how to proceed with an infertility evaluation at that time. If the patient decides to be followed at our center, they will undergo what we call a “Basic Infertility Evaluation”. Dr. Ramirez has seen many patients either referred or self-referred. Some have never undergone a complete infertility evaluation. The reason for this is that many physicians approach this haphazardly, checking some things but not others. Like other disease states, in order to find the diagnosis, all the different possibilities must be ruled out.
In 30% of cases, there is more than one problem, and in 30% of cases it involves both the man and women. Therefore all these systems must be checked. There are basically nine steps that are required to become pregnant. These steps are a sequence of events, such that, if there is a disturbance in any part of the sequence, then the entire process fails.
These steps are:
1. Brain sends signals (FSH hormone) to the ovary to begin the ovulation process, and the Ovary begins the maturation of the egg.
2. Ovulation occurs where the egg is expelled from the ovary into the culdesac.
3. The egg has to find the fimbria of the tube.
4. The egg enters the tube where the sperm needs to be waiting, such that, the sperm needs to have proceeded from the vagina into the cervix, into the uterus then into the tube.
5. The sperm has to fertilize the egg.
6. The egg begins developing and dividing and passes through the tube (7-days).
7. The formed embryo now enters into the uterus.
8. The embryo has to hatch.
9. The embryo has to implant into the lining of the uterus.
The infertility evaluation that we recommend checks each one of these steps. They are listed in accordance with the respective steps above in the sequence. Keep in mind that our goal is always to make our patient’s visits and procedures as comfortable and effortless as possible given the difficult and often frustrating nature of infertility:
1. Hormonal Evaluation
The first step for the patient is to test her hormone levels on cycle day # 2 or 3 in order to evaluate the ovarian hormones, thyroid function and pituitary function. This is a blood test to see if the hormone levels, that the brain is producing, are normal at the start of the cycle. This can also give an indication of how the ovary is functioning and able to be stimulated. If the FSH level is elevated, it could indicate that the ovary is already beginning to slow down and/or approaching menopause. If the FSH is elevated, some physicians will proceed with a “Clomid Challenge Test” to see if the ovary is past the point where it can be stimulated by fertility medications. The only way to see if the ovary is maturing an egg is to do an ultrasound, in sequence, and see if a growing ovarian follicle is present. This is not usually done as part of the basic infertility evaluation. Ovarian resistance is usually encountered in women over the age of 36 years old but can be at any age. This test will also give Dr. Ramirez an indication of whether or not there is urgency in choosing a more aggressive treatment.
2. Mid-Luteal Phase Progesterone Test
In order to know whether ovulation occurs, there should also be a mid-luteal progesterone blood test on cycle days 20-22. This is a blood test done around the 21 st day of the menstrual cycle, to evaluate if there has been ovulation and whether or not there is adequate Progesterone hormone in the Luteal phase. Progesterone is a requirement of the Luteal phase for preparation of the endometrium for implantation of the embryo and for maintenance of the early pregnancy. The progesterone level is increased when ovulation occurs, so this in an indirect test of ovulation. This blood test can evaluate if there has been ovulation and whether or not there is adequate Progesterone hormone in the Luteal phase. Progesterone is a requirement of the Luteal phase for preparation of the endometrium for implantation of the embryo and for maintenance of the early pregnancy.
The egg needs to find the fimbria of the tube. About 40% of infertile women whose initial fertility work-up is unrevealing will demonstrate abnormal tubal or uterine findings on a laparoscopic examination. Laparoscopy requires two small incisions (one at the navel and one above the pubic bone). Carbon dioxide gas is injected into the abdomen, distending it and pushing the bowel away. The laparoscope, a hollow tube equipped with a tiny camera, lenses, and a fiber optic light source, is inserted through the umbilical incision. A probe is then inserted through the second incision allowing the physician to directly view the outside surface of the uterus, fallopian tubes, and ovaries. Endometriosis, pelvic scar tissue, and blockage at the ends of the fallopian tubes can all be identified using laparoscopy. Some of these conditions can be corrected during the procedure by cutting away any scar tissue that may be binding organs together or by destroying endometrial implants.
The procedure is usually done under general anesthetic at a local surgery center. The wound itself is minimally painful. Dr. Ramirez has performed hundreds of laparoscopic procedures as an out-patient procedure for his gynecologic and infertility patients with great expertise and precision. His patients normally go home with minimal post-operative pain and can return to work often within a few days.
The sperm and egg need to get together in the fallopian tube with the sperm journeying through the vagina to arrive at the final destination. To determine if there are any problems with this step, the patient will be referred to a radiologist who will perform a hysterosalpingogram (HSG) in order to see if the tube is open. This is a non-invasive test whereby a small catheter with a balloon is inserted into the uterine cavity. The balloon is then inflated to close off the cervix. Radio-opaque dye is then injected and x-rays are then taken at various stages. The purpose of this test is to determine if the tubes are open or not and where the blockage may be. This test is done between cycle days 5 and 12 of the patient’s menstrual cycle.
5. Semen Analysis
We do not have a test to see if fertilization can occur. Therefore, we test the sperm as an indirect method to assess its potential. This test can be done at Monterey Bay IVF, where we have comfortable, private collection rooms for our male patients and a CLIA Certified laboratory where the analysis will be done the same day. A complete semen analysis must be done to evaluate sperm count, the ability of the sperm to swim i.e. live sperm (motility) and the anatomy of the sperm (morphology). In addition, cultures are sent to be done by Quest Laboratories on the semen for sexually transmitted diseases and other bacteria that might interfere with sperm viability or function.
Our in-house laboratory will test for the number of sperm, the number of sperm that are swimming (motility)-which is also a measure of the number of live sperm, and the number of normally formed sperm (morphology). This is not just a test of numbers. It is an indirect indication of sperm function. If there is an abnormality then this may indicate that the sperm may not be able to fertilize an egg. The only way to assess if the husband’s or partner’s sperm can fertilize the egg is to remove the woman’s eggs and put them together with his sperm, and then see what happens. That cannot be done without in vitro fertilization.
6. Egg Development And Division
There is no test for this step, but the HSG indirectly gives evidence that the tube is open and the egg has the potential to pass through. At this time, the only place where egg development and division can be observed is in the embryology laboratory during an in vitro fertilization cycle.
7. Hysteroscopy and Cervical Cultures
Is the uterus a hospitable environment for the embryo? The patient will be scheduled for a hysteroscopy, whereby her uterine cavity will be tested. This is a simple, out-patient procedure that Dr. Ramirez will perform in our comfortable, ambulatory surgery center. In this test, a scope is passed through the cervix and the uterine cavity is visualized directly to make sure it is normal.
The scope is a narrow telescope-like instrument which is inserted through the vagina and cervix into the cavity of the uterus (endometrial cavity). The uterine cavity is then distended with fluid and visualized. This procedure allows the doctor to determine whether there are any defects such as fibroid tumors, polyps, scar tissue, a uterine septum, or other uterine problems inside the cavity. It is a quick procedure taking 5-15 minutes and generally painless. No medication of any sort is required for the procedure. Some offices will do this procedure in the operating room of an outpatient surgery center under General Anesthesia. This makes the procedure more expensive.
- Cervical Cultures
Cultures are taken from the cervix and vagina for various bacteria that might interfere with sperm survival, uterine environment or tubal patency. Sexually transmitted diseases are tested for as well. If found, then antibiotic treatment may be required before infertility treatment can proceed.
8. The embryo has to hatch.
Although there is no test for this, when a patient undergoes IVF they can include “assisted hatching” as an option to aid the embryo in this particular step.
9. Endometrial Biopsy
Since the embryo has to implant into the lining of the uterus, the endometrial biopsy is done at the end of the cycle, typically on days 26-28. This simple biopsy is performed just like a PAP smear in our clinic. The biopsy will tell the doctor if the uterine lining is developed adequately for implantation. A sample is taken of the endometrial lining of the uterus and it is sent to Quest Laboratories for analysis. The doctor looks for evidence of ovulation and degree of maturation of the uterine lining. The test can also reveal uterine cancer, uterine fibroids, uterine polyps, and adenomyosis. It can also reveal if the woman has a luteal phase defect – a hormonal imbalance which prevents a woman from sustaining a pregnancy because not enough progesterone is produced. The test is typically performed 1-3 days before onset of woman’s menstrual flow.
10. Pelvic ultrasound
Dr. Ramirez does one additional test, which is a pelvic ultrasound. This allows him to assess the uterus, especially the muscle layer and anatomy, the ovaries to rule out cysts and tumors, and if there are any adnexal abnormalities (the areas around the ovaries). Sometimes a dilated tube can be seen. This is a noninvasive method for evaluating the uterus and ovaries by using high frequency sound waves rather than x-rays to show what is inside your body. Because the body contains over 90% water, sound can be used just as sonar is used in the ocean. Each time the sound hits a tissue interface, like a blood vessel, an echo is sent back. The sophisticated, high-speed computer of our ultrasound machine can use these echoes to create a picture of the patient’s internal organs. Ultrasound carries little risk or discomfort while producing clear images that enable the physician to count any mature follicles present and examine the endometrium. Fibroid tumors and ovarian cysts can be diagnosed as well. Our center has the latest in ultrasound technology with the 2012, G.E. Logiq P5, an advanced imaging machine that scans with high resolution and definition.