TESTING PROCEDURES

The first step in overcoming infertility is to perform a comprehensive, yet cost effective infertility evaluation. We realize that most patients have limited resources to allocate to infertility evaluation and treatment. Our philosophy is to treat patients as quickly, effectively and inexpensively as possible. Time is of the essence, as age is the most significant sole factor in determining success.

The results of the evaluation allow the specialist to determine the cause or causes of infertility in a particular couple for planning an appropriate course of treatment.

History and Physical
Male Fertility Evaluation
Hysterosalpingogram (HSG)
Hysteroscopy
Laparoscopy
Hormonal Evaluation
Endometrial Biopsy
Post Coital Test

HISTORY AND PHYSICAL

The couple's medical history and a complete physical examination of the female is of extreme importance.

The evaluation of the male's medical history includes a discussion of developmental abnormalities, environmental exposures, previous surgeries, testicular trauma or infections and whether he has previously fathered a child.

The female's medical history includes review of previous pregnancies, painful periods, pelvic pain, infections and previous surgeries.

A questionnaire is provided to our patients before the initial appointment to facilitate this process.

EVALUATION OF MALE INFERTILITY

40-50% of all infertility is male factor infertility. Evaluation for male infertility is best initiated with a semen analysis. This allows the doctor to examine the count, motility and morphology of the sperm:

Sperm count - 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 normal forward movement.

Morphology - Sperm that do not have normal morphology (shape) are often unable to swim effectively or penetrate an egg. There are two different types of semen morphology scores. One involves determining only whether or not the shape of the sperm head is abnormal (WHO criteria), while the other (strict or Kruger criteria) takes into consideration the shape and make-up of the entire sperm. The Kruger morphology score is more predictive of the ability of the sperm to penetrate the egg; however, this is a more labor-intensive process for the lab and is only performed in centers that are dedicated to fertility care. In a normal semen sample, at least 13% of the total sperm will have normal morphology according to Kruger criteria, or at least 50% according to WHO criteria.

The sample is most often collected by masturbation at home or alternatively in a private, comfortable room in the fertility center. Male cultures are done routinely on the semen to assure the absence of organisms that can affect fertility. If the semen analysis shows clumping of sperm (agglutination), an anti-sperm antibody test may also be ordered to evaluate for a potential immune mediated fertility problem.

HYSTEROSALPINGOGRAM (HSG)

A hysterosalpingogram is an X-ray of the uterus and fallopian tubes that allows visualization of the inside of the uterus and tubes. The picture can reveal abnormalities of the uterus as well as tubal problems such as blockage and dilation. If the fallopian tubes are not blocked by scar tissue or adhesions, the dye will flow into the abdominal cavity. This is a good sign but it does not guarantee that the tubes will function normally. It can only give a rough estimate of the quality of the tubal structure and its patency (whether or not it is open).

A hysterosalpingogram may also indicate presence acquired uterine cavity abnormalities such as endometrial polyps, fibroids, intrauterine adhesions, and congenital abnormalities such as a uterine septum. The ability of the hysterosalpingogram to detect these abnormalities depends on the technique used by the physician performing the hysterosalpingogram and the experience and ability of the physician who interprets the test. The specialists at ACIRM personally perform and interpret these tests.

Tubal abnormalities such as hydrosalpinx (irreversibly damaged, fluid filled, dilated tube) may also be detected by the hysterosalpingogram depending on the degree of damage. The test is not likely to detect pelvic adhesions or small fibroids or polyps. This test cannot detect endometriosis, which is a correctable factor that is often implicated in fertility problems. Other tests, such as hysteroscopy, hystersonography and/or laparoscopy may be necessary to accurately evaluate your pelvis.

HYSTEROSCOPY

If a uterine abnormality is suspected your doctor may recommend this procedure. The hysteroscopy is 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. The specialist of ACIRM are among the few surgeons in the Central Pennsylvania area that have the expertise and technical ability to operate through the hysteroscope to correct the abnormalities that may be detected with this procedure. Hysteroscopy is a day-surgery performed under anesthesia.

LAPAROSCOPY

In laparoscopy, a narrow fiber optic telescope is inserted through the abdominal wall to look at the uterus, fallopian tubes, and ovaries and to find endometriosis or pelvic adhesions, and is the best diagnostic tool for evaluating the pelvis.

Fibroids, scar tissue, endometriosis and blocked fallopian tubes are all causes of female infertility. The injection of dye through the fallopian tubes (chromotubation), similar to HSG, may also be performed at this time to detect blockage in the fallopian tubes. If your physician determines that any of those causes are present and contributing to infertility during the procedure, it may often be treated on the spot with surgical instruments inserted through small incisions in your lower abdomen.

The specialists of ACIRM are among the few surgeons in the Central Pennsylvania region that have the expertise and technical ability to perform the more difficult laparoscopic procedures that may be required to correct abnormalities found during the laparoscopic evaluation. Laparoscopy is a day surgery done under general anesthesia.

In cases of severe tubal disease or scar tissue, removal of the fallopian tubes followed by in vitro fertilization may be your best option for conceiving a child.

Again, the value of having an appropriately trained reproductive endocrinologist (fertility specialist) perform your surgical infertility evaluation is derived not only from the ability to perform the most difficult procedures, as required, but also the expertise required to make the appropriate surgical decisions for optimization of your future care.

EVALUATION OF HORMONES

We may run tests to determine the levels of the following hormones that play a role in ovulation and implantation of the embryo:

Follicle stimulating hormone (FSH) - stimulates the recruitment and growth of follicles (each of which contains an egg). If the level of FSH obtained on day 3 of the menstrual cycle is high, this could mean that there is poor ovarian reserve (the number of follicles remaining in the ovary is low).

Estradiol (E₂) - is produced by the cells in the follicles and stimulates the production of cervical mucus, and stimulates the growth of the endometrium (uterine lining) in preparation for implantation of the embryo.

Luteinizing hormone (LH) - stimulates the final maturation of the egg and release of the egg from the follicles (ovulation).

Progesterone (P₄) - performs the final preparation and stabilization of the uterine lining for implantation of the embryo, to support pregnancy. A single luteal phase progesterone level is valuable for documenting ovulation. Because progesterone levels fluctuate throughout any given day of the luteal phase, a single progesterone level is not valuable in diagnosing a problem with progesterone production that may contribute to a luteal phase defect (see below under endometrial biopsy).

The overproduction of the following hormones can negatively affect ovulation:

Androgens - normally small amounts of androgens (testosterone, androstenedione, DHEAS) are produced in women; excess production can interfere with development of the follicles, ovulation and cervical mucus production.

Prolactin - stimulates milk production; prolactin levels may be higher than normal in certain disorders or when certain medications are taken. Elevated prolactin levels can interfere with the entire process of follicle recruitment and ovulation.

Thyroid - an underactive or overactive thyroid can also interfere with the entire process of follicle recruitment and ovulation.

ENDOMETRIAL BIOPSY

Endometrial biopsy is sometimes performed in the luteal phase (last half of the cycle) in an attempt to diagnose luteal phase defect (a problem with the preparation of the endometrial lining for embryo implantation that can result from inadequacies in estrogen and/or progesterone production during the menstrual cycle). The endometrial biopsy is fraught with difficulties in interpretation. First, dating of the biopsy is subject to differences in interpretation between pathologists. Second, if two biopsies are performed, women with normal fertility will have one out of phase biopsy 30% of the time and two out of phase biopsies 5% of the time. This data has been used to suggest that two biopsies must be performed in separate menstrual cycles to determine that luteal phase defect is a factor in a couple's infertility. The trouble with this reasoning is that the data simply suggest that even women with normal fertility have luteal phase defects in many of their cycles, and this may be one of the reasons that even fertile women do not get pregnant every cycle.

POSTCOITAL TEST

Near the time you ovulate each month, estrogen production from the ovaries stimulates mucus production by your cervix. Sperm must penetrate and swim through this mucus, then travel through the reproductive tract to reach the egg for fertilization. In some cases, there is an incompatibility between the sperm and the cervical mucus, causing the sperm to become immobile or die, thus preventing fertilization. The postcoital test (PCT) is supposed to evaluate the interaction between the sperm and your cervical mucus at a time near ovulation to determine if an incompatibility exists. Abnormal mucus may occur because of infections, cervical surgery, or Clomid therapy. If it is done too early before ovulation or too late after, the results may be falsely abnormal. The PCT has been found in studies to be a poor predictor of fertility. Many centers have therefore removed it form their evaluative steps.

TREATMENT OPTIONS

Nearly 80% of all infertility cases, both male and female factor, are treatable successfully, using surgical and medical techniques.

We treat the patient as partners. That is, we work with each couple to determine the treatment option that will be most appropriate for their situation based on financial, social, religious, ethical and medical factors.

We perform ovulation induction and superovulation to enhance the production of eggs, intrauterine insemination to increase the chances for egg fertilization by the sperm and surgery to repair reproductive organs.

More aggressive treatment modalities offered include assisted reproductive techniques such as In Vitro Fertilization (IVF), Gamete Intrafallopian Transfer (GIFT), Intracytoplasmic Sperm Injection (ICSI) and Assisted Hatching (AH).

When needed, egg donation and gestational carrier (surrogacy) services are available.

Details and description of procedures are provided during the consultation.