First of all, to visit a medical fertility specialist you will need a referral from your GP. You should ideally request that the referral be for both you and your partner so you can both be treated if necessary.
Your specialist will first of all need to review your medical history as well as your partners, including issues such as
- chronic illness
- prior surgeries
- birth control methods
- history of STD’s
- have you ever been pregnant before
- are your periods regular
- any changes in your cycle
- Body Mass Index (BMI)
- exercise patterns
- caffeine, alcohol, tobacco or illegal drug use
Every couple is different and will present with their own set of unique circumstances. Therefore there is no ideal test, or set of tests for all couples. Outlined here are some of the tests your specialist may recommend depending on your particular presentation.
Depending on the level of testing your GP has already conducted your specialist will most likely organise some basic tests. These may include some or all of the following
Your specialist will most likely perform a pelvic examination, this involves
- lying on your back on an examination table with your abdomen exposed
- your specialist will manually feel your organs from the outside to assess size, shape and position
- you will then be asked to bend your knees or place your feet in stirrups
- a speculum is placed into the vagina to widen the opening and enable the cervix to be seen
- Pap smear may be performed at this time along with a sample of fluid to test for any potential infection
- A bimanual exam may also be performed where your specialist inserts two fingers into the vagina whilst using the other hand to feel above the area being felt inside to better assess the size and shape of your reproductive organs
- Rubella immunity (German measles)
- Hepatitis B and C immunity
- HIV check
- Full blood count to assess your blood group and thyroid status
Unlike a regular ultrasound through the abdomen, a transvaginal ultrasound is performed by inserting an ultrasound wand into the vagina. Using this tool your specialist can view images of your cervix, uterus and ovaries and diagnose any abnormalities, which may be affecting your fertility including cysts, fibroids and size of your ovaries. A transvaginal ultrasound may be performed in your specialist’s rooms during your first or follow up appointments. It is also commonly used to confirm a pregnancy.
Your specialist may request an ultrasound to assess the health of your reproductive organs. Ultrasounds are generally performed by an ultrasound specialists. Results are then sent back to your fertility specialist for review. An ultrasound is non-invasive and performed by running an ultrasound scanning machine over your abdomen to view your internal organs. An ultrasound allows your specialist to see any abnormalities such as fibroids, polyps and cysts as well as the size and health of your ovaries. Ultrasounds are also routinely performed to confirm healthy growth during pregnancy.
Progesterone level test
A progesterone level test is a blood test your specialist may request to confirm whether you are ovulating. As discussed earlier in this book, your progesterone levels rise after ovulation during your luteal phase, generally peaking between five to nine days after ovulation. Your specialist will generally recommend having the blood test during this period, most commonly on day 21 if your cycle is a normal 26 – 30 days. If ovulation has not occurred, your progesterone levels will not be elevated. This indicates to your specialist that you are not ovulating. Another test will most likely be ordered to confirm the result the following month. If ovulation has occurred your blood test will show elevated progesterone levels. If the egg that has been release is not fertilised, your progesterone levels will drop back down again before the next menstrual cycle commences. If the egg has been fertilised then your progesterone levels will remain high (and congratulations you’re pregnant!). This test is also commonly used when taking Clomid, to confirm that the medication is successfully stimulating ovulation.
Follicle stimulating hormone (FSH) test
FSH helps regulate the menstrual cycle and the production of eggs in the ovaries. FSH levels are tested via a blood test generally performed on day three of the menstrual cycle. Your specialist may also request that the test be performed each day over several consecutive days to confirm your results. Your FSH levels will vary depending on the time of month the test is performed.
If your FHS levels are too low or too high, both these outcomes can impact your fertility. Low levels indicate poor egg production, which can impact ovulation. Low levels are commonly caused by high stress, starvation diets and low body weight. High levels indicate ovarian failure or that menopause has occurred. This test is also often performed to confirm the effectiveness of Clomid treatment. In this case the test will be performed before treatment on day 3 and again after treatment on day 10.
Other tests that may be recommended
Depending on the outcome of your medical history and basic testing, your specialist may recommend further tests to help diagnose the cause of your infertility
Ovarian Reserve (AMH test)
This simple blood test measures Anti Mullerian Hormone (AMH). AMH is secreted by developing eggs within the ovaries. Levels of this hormone provide a good estimate of the number of eggs available in your ovaries, however it does not provide any information about the quality of your eggs. Your specialist will then compare your levels with the average for your age.
This test involves an ultrasound as well as the insertion of a tiny tube into the cervix, which sends a dye into the uterus and fallopian tubes. This enables your specialist to determine if there are any blockages within your tubes.
This test uses x-ray to view the inside of the uterus and the fallopian tubes. A hysterosalpingogram helps determine whether there are any blockages in the fallopian tubes or any problems within the uterus, which may be preventing fertilization. This test is not as commonly performed due to the limited answers it provides in regards to ovarian and uterine health.
A laparoscopy is a more invasive test performed under general anaesthetic. This test is generally only performed if there are other indicators of reproductive issues such as suspected endometriosis or fibroids. One to 3 small incisions are made under the navel and above the above the pubic bone, through which a laparoscope (fibre optic telescope) is inserted. The exact location and number of incisions is generally based on your Specialists experience or your particular presentation. This enables your Specialist to view and assess the outside of your uterus, the ovaries, fallopian tubes and the pelvic cavity.
Laparoscopy may be performed purely for observation and diagnosis, or in some cases your Specialist may also provide treatment during the procedure, such as removal or reducing misplaced endometrial tissue or fibroids. Additional incisions may be required in this case.
Unlike a laparoscopy, a hysteroscopy is performed to view the inside of the uterus, not the outside, and doesn’t require incisions. A hysteroscope (fibre optic device similar to but smaller than a laparascope) is inserted through the cervix and into the uterus. This enables your Specialist to assess the size and shape of your uterus as well as the presence of scar tissue, fibroids or polyps. If abnormalities are found, your Specialist may treat these during the procedure, such as removing any small fibroids or polyps or helping to remove any blockages found in the opening of the fallopian tubes.
Anti-sperm antibody test
In rare cases, the women may develop an immune response to her partner’s sperm, developing antibodies which attack, damage or kill sperm. An anti-sperm antibody test checks to see you are producing any of these antibodies.
A karyotype test is a blood test, which examines the genetic material/chromosomes within cells to look for any problems that may be causing recurrent miscarriage or infertility.
Prolactin is a hormone, which is high during pregnancy and breastfeeding to support milk production for the growing infant. Non-pregnant women and men also produce prolactin a low levels. Abnormally high levels in non-pregnant women can cause amenorrhea, nipple discharge and infertility. Your specialist may recommend a blood test to check your prolactin levels if you are having menstrual cycle issues or lack of ovulation.
A physical examination of the testes is performed to check for the presence of any lumps, swelling, shrinking or any other signs of abnormality. Not all specialists will perform a physical examination for men
A semen analysis is one of the first tests performed for males in couples having difficulty conceiving a child. Issues around sperm production, count and quality affect around one third of all couples experiencing infertility. The test is performed by ejaculating into a clean sample collection cup. This can either be done in a private room or bathroom within the clinic or if you live close to the testing centre you may be able to do the collection at home and then bring it to the clinic for testing. The main aim is that the sample be fresh. You will often be asked to abstain from sexual activity for 2 – 5 days prior to the test to help ensure sperm count is at its peak. However long periods of sexual inactivity can lead to less active sperm so it’s ideal not to avoid sexual activity for more than 2 weeks prior to the test.
The sample will be tested for
- Volume – the amount of sperm present in one ejaculation
- Sperm count – the number of sperm present in one ejaculation
- Sperm morphology – the percentage of sperm that are normal in shape
- Sperm motility – the percentage of sperm that are able to move in a normal forward direction
- Liquefaction time – the time taken for sperm to change from a thick gel consistency at the time of ejaculation to a liquid consistency. This normal occurs within 20 minutes.
- Ph – the acidity or alkalinity of the semen
- Fructose level – fructose is the form of sugar found in sperm to provide energy
Other tests that may be recommended
Depending on the outcome of the medical history and basic testing, your specialist may recommend further investigative testing
Testosterone levels are commonly checked especially if there are symptoms of erectile dysfunction, low sex drive or the result of the semen analysis showed low sperm count. Testosterone levels are checked via a blood test, which is often performed between 7 – 9am when testosterone levels are highest.
Although largely known as a female hormone, men also produce low levels of prolactin. Higher than normal levels can lead to low sex drive, erectile dysfunction and infertility. Your specialist may recommend a blood test to check prolactin levels particularly if testosterone levels are low.
An ultrasound may be performed on the testes to more accurately assess whether there are any issues within the testes, which may be affecting sperm.
A testicular biopsy is used to confirm whether there are sperm within the testes. It is very rare than males will produce no sperm, so this test is unlikely to be required unless there are other signs of lack of sperm production.
A karyotype blood test may also be recommended for the male partner to assess the genetic material/chromosomes within cells for any issues that may be causing recurrent miscarriage or infertility.