The First in Vitro Fertilization Program in North Florida and South Georgia.
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Infertility Tests for the Female and Male
There are many tests available to discover the cause(s) of infertility in both the male and female. The cornerstone male test is the semen analysis which is always ordered by Dr. Shaykh. Fertility tests are used to examine the specific biological processes that must occur for pregnancy to result. In general, fertility tests in the female examine the uterus and tubes, function of the ovaries, hormonal interactions, the cervical mucus, and rule out endometriosis.
Laparoscopy is used to directly examine the tubes, uterus, ovaries and other internal organs. The laparoscope is a “telescope” device inserted through small openings usually located at the pubic hair line or the naval. In addition to visual evaluation of the organs, surgical instruments are inserted through the openings which allow Dr. Shaykh to perform most operations for infertility.
The diagnostic laparoscopy for infertility should always be administered by an infertility specialist. This is because the specialists advanced microsurgical training enables him/her to treat many conditions during the diagnostic procedure. For example, it is often possible to remove severe endometriosis implants during the diagnostic laparoscopy. Physicians without advanced training may have to refer the patient for a second “treatment laparoscopy” performed by an infertility specialist.
Laparoscopy offers many advantages over traditional surgery including: 1) laparoscopy is usually an outpatient procedure 2) there is less internal and external scarring 3) it is less painful 4) recovery time is shortened 5) laparoscopy is less expensive. Nowadays, most procedures including hysterectomies and delicate tubal surgery are performed using the laparoscope.
The HSG is used to evaluate the fallopian tubes and the uterus. During the procedure, dye is inserted into the uterus and followed by x-rays as it “back flows” through the fallopian tubes. An accumulation of the dye at a point in the tubes usually indicates the presence of an obstruction or complete tubal blockage. X-rays of the uterus when filled with the dye will often reveal fibroids or polyps. In a normal HSG, the dye flows freely through the reproductive tract.
The hysteroscope is a small “telescope like” device inserted through the vagina to view the interior of the uterus. Diagnostic hysteroscopy is used to diagnose abnormal uterine conditions such as fibroids, polyps, scarring, and birth defects. Carbon dioxide gas or other special solutions are injected into the uterus and enables the physician to directly view the internal structure of the uterus. Diagnostic hysteroscopy is usually performed after menstruation because the uterine cavity is more easily evaluated and there is no risk of there being an ongoing pregnancy.
Ultrasound is used extensively in the evaluation and treatment of the infertile female. Transvaginal ultrasound is performed by inserting the ultrasound probe into the vagina allowing the physician to view the ovaries, follicles, and other internal structures. Ultrasound will often identify polyps and fibroids and elucidate uterine abnormalities such as the bicornuate uterus.
Ultrasound is used in stimulated IUI and IVF cycles to monitor the number and size of the ovarian follicles. The follicles are located on the ovaries and each follicle contains a developing egg. When the fertility drug FSH is used, more follicles are recruited and their development is followed to help make drug dosage adjustments and minimize the potential for serious side effects such as hyperstimulation syndrome.
The ultrasound is also used to evaluate the width of the endometrium, an indication of the uterus’s ability to support an implanting embryo. Ultrasound is used to document the presence of a fetus.
Dr. Shaykh will order cycle day three evaluations of the hormones FSH, estrogen, LH, and others. Day 3 FSH levels are extremely important in determining the status of the ovaries/eggs. When FSH levels are highly elevated (>12miu/ml), it is usually an indication of ovarian failure and donor egg IVF will often be the treatment of first choice. “Mildly” elevated FSH levels may indicate reduced ovarian reserve, and in these women, treatment must not be delayed. Fertility can decline very rapidly in women especially those in their mid-thirties or older.
Thyroid hormones will also be evaluated as “too high” or “too low” levels may lead to conditions such as irregular, or no, ovulation and increased risk of miscarriage. Androgens or “male hormones” such as testosterone will also be measured. When androgens are abnormally elevated it may indicate the presence of polycystic ovarian syndrome (PCOS). PCOS leads to irregular, or no, ovulation and infertility. X-rays of the ovaries may indicate the presence of numerous “cystic structures”.
Dr. Shaykh will order other hormone evaluations, such as the Clomid Challenge Test, where appropriate.
Sperm are ejaculated into the vagina where they must swim through the cervical mucus into the uterus. The mucus must be of the correct consistency, and in sufficient quantity, to facilitate the sperms passage.
The post coital test is used to evaluate the sperm after its exposure to the cervical mucus. The couple has intercourse at home and the female comes to our office where we sample her cervical mucus and examine it under a microscope. The presence of numerous “dead” or immobile sperm may indicate a cervical mucus problem. A woman’s immune system may produce antibodies to her partner’s sperm known as “antisperm antibodies”.
Antisperm antibodies are produced because the immune system “mistakes” sperm for invading pathogens such as viruses or bacteria. The immune system mounts a response that “kills” or disables the sperm. Intrauterine insemination (IUI) is often the treatment of first choice when antisperm antibodies are present. This is because the specially prepared sperm are placed directly into the uterus thus avoiding the cervical mucus and the antisperm antibodies.
Knowing when ovulation is most likely to occur during the monthly menstrual cycle allows the couple to time intercourse for the most fertile periods. In the past, basal body temperature (BBT) charts were created by tracking several menstrual cycles and noting the time when the body temperature increased slightly signaling impending ovulation. Once several months of data are collected, it is possible to predict future ovulation times. BBT charting is extremely inconvenient as it requires taking the body temperature daily immediately upon waking before getting out of bed. It is also comparatively inaccurate and the only advantage is low cost.
BBT charting has been replaced by urine test kits which identify the LH surge that immediately precedes ovulation. These tests are extremely accurate and easy to administer. “Quality” ovulation is usually indicated by a rise in the hormone progesterone after ovulation.
The endometrium (uterine lining) must thicken and become more vascular during the menstrual cycle to support a developing embryo. Increased blood flow is needed to support the embryo as it develops into a fetus and throughout the pregnancy.
An endometrial biopsy involves removing a small section of the endometrium and examining it under the microscope. If the endometrium has not proliferated, it may be an indication of insufficient progesterone. Estrogen and progesterone are the hormones primarily responsible for endometrial development. Progesterone levels rise after ovulation providing needed stimulation to the endometrium.
Lack of sufficient progesterone is sometimes termed a “luteal phase defect”. Insufficient endometrial development is often treated with external progesterone drug. Progesterone is always administered in IVF cycles because drugs used to control the cycle interfere with natural progesterone production.
Male Infertility Tests, The Semen Analysis
We now know that “some degree” of male infertility will be present in up to half of infertile couples. This makes the semen analysis one of the most important fertility tests and no female treatment should begin until the semen analysis has been completed.
Sperm are produced in the testicles and require three months to develop. A semen analysis conducted today is actually a reflection of conditions affecting the sperm three months prior.
The sperm travel from the testicles through the vas deferens and are ejaculated out the penis into the vagina. Once in the vagina, the sperm swim “in” the cervical mucus into the uterus to the opening of the tubes. Once a single sperm attaches to and fertilizes an egg no other sperm can attach.
During fertilization the male and female gametes (sex cells) known as haploid cells (half of the genetic material) combines to from an embryo (diploid or full complement of genetic components). The developing embryo undergoes several cell divisions as it develops into a fetus.
Most fertility laboratories use the Kruger Strict Criteria when evaluating semen. It is very important that an experienced reproductive medicine laboratory be used for the semen analysis. Oftentimes, sperm will have “minor” qualitative defects that can only be identified by an andrologist with extensive experience evaluating sperm. Commercial laboratories are not always specialized for semen evaluation and may lack experience. We recommend a reproductive lab even if the expense is “out of pocket”. Given the importance of the test, due to the prevalence of male infertility, the first consideration should be the labs fertility experience.
The sperm/semen are analyzed as follows:
- Volume (amount of fluid that makes up the semen, usually expressed in milliliters)
- Sperm count (number of sperm in a standard given volume)
- Motility (percent of sperm moving when the semen is examined under the microscope).
- Progression (forward movement of sperm cells)
- Viability (percent of sperm that are shown to be alive by use of a special staining technique)
- Sperm morphology (shape)
- Additional semen contents, such as white blood cells (which can indicate infection)
A normal semen specimen has the following characteristics:
- More than 20 million sperm per milliliter
- More than 50% actively motile
- More than 14% highly normal forms suggesting excellent fertilizing capacity
- Less than five white blood cells per high power microscopic field
IUI may be the treatment of choice in cases of mild male factor infertility. Using IUI, the washed and concentrated sperm are injected directly into the uterus. In cases of moderate to severe male factor infertility, the treatment of choice is in vitro fertilization often utilizing intracytoplasmic sperm injection (ICSI). These couples may also choose to use a sperm donor. When ovarian reserve is very low our Florida donor egg program is an option.