Diagnostic Testing
Basal Body Temperature Charting
A woman who is unsure of when she ovulates may be able to identify the time of ovulation by keeping a basal body temperature (BBT) chart for several months. Charting involves taking one's temperature every morning upon waking up and recording the results. For optimal accuracy, this must be performed before the woman drinks a cup of hot coffee or brushes her teeth, as these events can interfere with the temperature reading. When the temperature goes up 0.5 degrees, the woman is in the process of ovulating. Basal body temperature charting is not recommended as a method to plan intercourse, as the rise in temperature is caused by an increase in progesterone after the follicle's release of the egg, so the window of opportunity for conception may have passed by the time the temperature rises. Unfortunately, some patients find that BBT charting is time consuming, frustrating, and is a daily reminder that they are having difficulty conceiving. Though it is a reasonable first step to attempting conception, if the results are inconclusive after three months it is recommended that the couple move on to other methods, such as urinary LH detection kits, to detect ovulation.
Endometrial Biopsy
This procedure involves scraping a small amount of tissue from the endometrium shortly before menstruation is due, typically between 11 and 13 days following ovulation. It should ONLY be performed after a pregnancy test reveals that the woman is not pregnant. This test is often used to determine if a woman has a luteal phase defect- a hormonal imbalance that may prevent a woman from sustaining a pregnancy because not enough progesterone is produced.
Female Hormone Testing
Tests of specific hormones may provide important clues about a woman's hormonal function and reproductive system. Perhaps the most important hormonal test that a woman should undergo is an FSH (Follicle Stimulating Hormone) test. Typically performed on day 3 of the menstrual cycle, this test can provide information about the quality of a woman's eggs. An abnormal, or high, FSH level can mean that it will be more difficult for the woman to conceive.
History and Physical Examination of the female
A thorough medical history should include information about:
o Past surgeries
o Exposure to tobacco, alcohol, drugs, or environmental toxins
o Past or current sexually transmitted diseases
o Menstrual cycle patterns
o Any past pregnancies, terminations, or miscarriages
o A physical examination that may include a transvaginal ultrasound
In addition, if there is a male partner, his medical history should also be obtained. Only after evaluation of medical history and a thorough physical examination can an appropriate treatment plan be determined. This plan may include further diagnostic testing than what is performed at the initial consultation.
Hysterosalpingogram
This test is used to examine a woman's uterus and fallopian tubes. It is essentially an x-ray procedure in which a dye is injected through the cervix into the uterus and fallopian tubes. This dye appears white on the x-ray, allowing the radiologist and physician to see if there are any abnormalities, such as an unusually shaped uterus, tumors, scar tissue or blockages in the fallopian tubes. If a woman is trying to conceive in the same cycle as an HSG, it is important schedule the test PRIOR to ovulation so that there is no danger of "flushing out" a released egg or developing embryo. Although most women report only minor cramping and short-term discomfort during this procedure, some women, especially those who have blocked tubes, report intense pain. Patients have the option of having a pain medication prescribed, which can be administered 30 minutes prior to the actual procedure.
Post-coital Test
The post-coital test is a quick, painless procedure that may give information on how the cervical mucous and sperm interact. The test must be done within one to two days before or after ovulation. Basal body temperature charts or ovulation predicting kits are very helpful in determining the time of ovulation. A couple should abstain from intercourse for 2 days before ovulation and then have intercourse 2-8 hours prior to the office visit for the post-coital test. A speculum is placed in the vagina, as it would be for a pap smear. A syringe, without a needle, is then used to remove some mucous from the cervical opening. The speculum is then removed and the cervical mucous is evaluated. The specimen is placed under a microscope to look for the presence or absence of swimming sperm.
Pre-conception health
To increase the probability of a healthy baby, basic steps should be taken prior to attempting conception. The first "pre-conceptual counseling" appointment with an OB/GYN should occur approximately 4 months before attempting to conceive. This consultation is also a chance to discuss problems with previous pregnancies, social issues, environmental exposures, and general health. If not previously done, a hematocrit to check for anemia, a rubella titer to check for immunity to rubella, and other blood tests can be performed. A thorough family history and blood tests for genetic diseases (Cystic Fibrosis, Tay Sachs, etc.) may be indicated.
o Basic recommendations: About 3 months prior to pregnancy and through the first couple of months of pregnancy, the Center for Disease Control recommends taking a folic acid vitamin or consuming foods on a daily basis that contain a minimum of 0.4mg. Repeated studies have shown that the intake of 0.4mg of folic acid daily prior to conception and during early pregnancy helps to significantly reduce the risk of the baby being born with a serious neural tube defect such as spina bifida, anencephaly, or encephalocele. Other pre-conception health habits include:
* Limiting intake of alcohol, coffee, tea, soda, and other foods and beverages containing caffeine
* Avoiding use of recreational drugs (such as marijuana) and overuse of prescription and over-the-counter drugs
* Avoiding exposure to toxic substances, such as industrial chemicals, herbicides, and pesticides.
* Maintaining good personal hygiene and health practices.
* Attempting to maintain a body weight within 15% of ideal body weight for one's height and body frame. Obesity has been found to affect regular ovulation; therefore, maintaining a healthy diet and staying within an acceptable BMI can aid conception.
Semen analysis
Sperm count and quality of the male partner is easily assessed by a semen analysis. The most accurate test results are achieved when abstaining from ejaculation for 2-4 days prior to the semen analysis appointment. The semen analysis will include basic parameters such as sperm number, motility, and morphology (shape). In a normal ejaculation, the total volume of semen is between a half and a whole teaspoon. As part of the semen analysis, the technician will determine the number of sperm present in the ejaculate. A normal sperm concentration falls between 20 million/mL and 200 million/mL. The technician looks at how well the sperm are moving and counts the total percentage of motile sperm by figuring how many sperm per 100 are moving. At least 50% of any given sperm population should be moving to be considered motile within an acceptable range. A well-developed sperm can propel itself up a woman's reproductive tract at a rate of more than 2 inches an hour. Finally, the technician determines the shape or morphology of the sperm. Sperm heads should be oval-shaped without irregularities.
In the event that the semen analysis is abnormal, it should be repeated. If repeated semen analyses are abnormal or if the male partner is known to have any medical conditions or history that may be contributing to fertility complications, he should seek the help of a urologist specializing in male-factor infertility. The evaluation of the male partner will typically include a physical examination and further diagnostic testing. In many cases, male and female treatment can be concurrent to expedite the fertility treatment process.
Transvaginal Ultrasound
An internal ultrasound is used to evaluate a woman's uterus and ovaries. The transducer on a transvaginal ultrasound is a long probe that is inserted into the vagina covered with lubricant and a condom. The reproductive endocrinologist will be able to see the uterus, ovaries, and sometimes the fallopian tubes. The procedure is not painful, and many women prefer it to an abdominal ultrasound, for which the bladder must be full.
