In order to identify the cause of infertility and prescribe the best treatment options a thorough infertility work-up is performed to determine the following:
The release of the egg is a necessary component for pregnancy. In general, regular, predictable menses indicate that ovulation is occurring. The menstrual cycle is divided into two parts: the proliferative phase and the luteal phase. The luteal phase is the second half of the menstrual cycle following ovulation and typically lasts 13-14 days in most women. For example, if a woman has a 28-day cycle, she usually ovulates on day fourteen; a woman with a 32-day cycle would typically ovulate on day eighteen. Ovulation can also be presumed by testing the blood for progesterone level or if a monitor or kit indicates the presence of high levels of LH. There are many reasons for ovulatory disturbance including pituitary hormone imbalance, polycystic ovarian syndrome, stress and weight gain or loss. These issues can be overcome by using an oral medication called clomiphene citrate (Clomid), by injection of the hormone FSH, or by In Vitro Fertilization.
A semen analysis is performed to evaluate semen volume, sperm count, percentage of normal motility and percentage of normally shaped sperm. Sperm factors account for twenty-five percent of all infertility and may be due either to malignancies or to genetic, hormonal or environmental issues. There are several treatments used to improve sperm function. Among these are artificial insemination, in which the sperm are washed and the healthiest are introduced into the uterus with a catheter; and IVF using intracytoplasmic sperm injection (ICSI), the injection of a single sperm into an egg. For men who do not ejaculate sperm, vasectomy reversal or harvesting procedures such as MESA, or TESE can be performed.
In order for the egg and sperm to meet and for the embryo to be transported to the uterus, the fallopian tubes must be open. Once the embryo reaches the uterus, it must be able to implant in the uterine cavity. If the tubes are scarred and blocked as a consequence of prior pelvic surgery, sexually transmitted disease or a condition called endometriosis; or if polyps, tumors or scar tissue are present in the uterus, implantation may not occur. A hysterosalpingogram (HSG) is a test to assure that the tubes are open and that the uterine cavity is normal. Radiologists conduct the HSG on an outpatient basis. In this test, a small balloon is placed in the cervix and dye is introduced into the uterus and tubes with a syringe. The dye makes it possible to see the fallopian tubes and the contour of the uterine cavity by x-ray. Alternatively, a hydrosonography can be performed. This test utilizes saline rather than dye and makes the uterus (and to some extent, the fallopian tubes) visible via ultrasound. If the tubes are blocked they may need to be opened or removed prior to fertility therapy.
The quantity and quality of a woman’s eggs decline with age. Typically, by age 35 less than 10% of the lifetime egg supply remains. There are several tests that can be used to determine if a woman has fewer eggs than expected for her age (diminished ovarian reserve). Tests used to determine ovarian reserve include day 3 FSH and Estradiol, Anti-Mullerian Hormone and Antral Follicle Count. For an egg to be fertilized and develop into a genetically normal embryo, it must be of good quality. Egg quality cannot be determined with fertility testing, but it is strongly correlated with age. As the egg ages it is more likely to give rise to a genetically abnormal embryo. Usually, such embryos will not give rise to a pregnancy or are miscarried during the first trimester. Thus, as a woman ages, she experiences more infertility or miscarriage. In such cases, egg donation may be considered, as the function of the uterus does not decrease with age and an older woman can successfully carry a pregnancy to term using donor eggs.
Occasionally, a couple may be unable to conceive, yet their infertility tests yield normal results. This condition is called unexplained infertility and is usually caused by sperm-egg interactions and factors related to the female reproductive tract. Fertility treatments can be very effective in treating this condition.
An investigation for recurrent miscarriage is warranted when two or more pregnancies are spontaneously lost. Though recurrent miscarriage can be caused by inherited chromosomal or genetic abnormalities from one or both parents, these are seen less frequently. Instead, most miscarriages are the result of chromosomal and genetic abnormalities that arise during embryo development. These losses frequently correlate with the age of the female partner. Other causes for recurrent miscarriage relate to anatomical distortion of the uterine cavity caused by birth defects, fibroids or scar tissue, and to autoimmune conditions of pregnancy that give rise to blood clots in the developing placenta. The work-up for recurrent miscarriage can include testing the blood for diabetes, thyroid problems, autoimmune antibodies, and parental chromosomes (karyotype). An HSG can also be performed to determine the configuration of the uterine cavity. There are proven treatments for most causes of recurrent pregnancy loss.
At Santa Monica Fertility, we coordinate and interpret all of these factors in order to determine the best course of treatment.