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Comprehensive Female Fertility Evaluation

Female Fertility Evaluation Graphic representation of normal female anatomy

With 50% of difficulty with conception being related to the female and up to 35% of couples having more than one problem, being offered and completing the entire work-up is critical, to make sure nothing is missed or overlooked, no matter how small or unlikely the possibility may be. At Arizona Center for Fertility Studies, the work-up is divided into three stages, with each stage being equally important. Prior to any evaluation, a complete medical history, physical examination and review of any pertinent medical records is essential. 80-90% of the time, the cause of female infertility can be identified; and successfully corrected, tricked or "get around-able".
"When it is all said and done, successful treatment boils down to four words... quality of the egg".

Also, all women attempting pregnancy are placed on prenatal vitamins, mainly because of the folic acid, which has been shown to reduce birth defects by one half and spina bifida, or the open spinal cord in the baby by two-thirds; and omega-3 fatty acids, that have been shown to maximize the baby's eye and brain development and fetal growth.

Stage I Fertility Evaluation

Hysterosalpingogram (HSG)

Female Anatomy 2 Graphic representation of normal female anatomy

Hysterosalpingogram (HSG) is an x-ray of the uterus and fallopian tubes to mainly check to see if the tubes are open and there is no scar tissue at the ends. It also can identify any abnormalities of the uterine cavity like a double uterus, polyps or fibroids. It is done between days 7-11 of the cycle and generally at a radiologist's office. The test takes about 10-15 minutes and can sometimes be associated with some cramping, especially if the fallopian tubes are blocked at either end. You may even have some spotting or light bleeding after the test but it should stop within several hours. An hour or so prior to the test, you can take 800 mg of Motrin or Advil or 2 tablets of Alleve. If you are concerned that the test may be "painful" or you are anxious, Arizona Center for Fertility Studies can prescribe a Percocet and/or Valium to take an hour or so before the test (but make sure someone can drive you and don't make any plans for the rest of the day).

A small catheter is placed through the cervix and into the uterus and than a radio-opaque water soluble dye is slowly injected allowing the uterus to be outlined and the tubes to fill and spill freely into the pelvis.

Most radiology clinics charge $800-$900 for this test but Arizona Center for Fertility Studies has worked out a price of $200 with 2 clinics.

Tubal factors make up 20-40% of the causes of infertility in women and can be due to previous pelvic inflammatory disease, previous infection from gonorrhea or chlamydia, previous tubal surgery, ruptured appendix, endometriosis and known or unknown infections following childbirth.

Sonohysterogram (SHG)

Female Anatomy 3 Sonohysterogram (SHG) of an intrauterine filling defect, showing either a polyp or fibroid. Diagnosis is made at hysteroscopy and removed by morcellation.

Sonohysterogram (SHG) is a test where a small catheter is placed through the cervix and into the uterus, similar to an hysterosalpingogram (HSG). Water is then slowly injected into the uterus and transvaginal ultrasound is done to evaluate the uterine cavity.

In Arizona Center for Fertility Studies experience, a Sonohysterogram (SHG) is much more accurate than a Hysterosalpingogram (HSG) in evaluating the uterine cavity for abnormalities like a bicornuate or septate uterus (double uterus) and to rule out any filling defects in the cavity like a polyp or fibroid, that can be overlooked on a Hysterosalpingogram (HSG).

Arizona Center for Fertility Studies has found that it is not uncommon for the Hysterosalpingogram (HSG) to show a normal uterine cavity, but the Sonohysterogram (SHG) will show a filling defect. The Hysterosalpingogram (HSG) is very good at evaluating whether or not the fallopian tubes are open, but Arizona Center for Fertility Studies will always recommend a Sonohysterogram (SHG) to be "sure" not to overlook a filling defect that could affect a woman getting pregnant or result in a miscarriage (Diagnostic Hysteroscopy). It can be done, basically anytime in the cycle, as long as a pregnancy waiver is signed. It is done in the office at Arizona Center for Fertility Studies and takes about 15 minutes. It is associated with little to no discomfort and generally the patient does not have to take any pain medication. Antibiotics are given prophylactically before and after the test.

Sonohysterogram (SHG)

Although an older test and in many clinics not done anymore; a Post-Coital Test (PCT) checks a woman's cervical mucus-sperm interaction. Only around ovulation is a woman's cervical mucus good and receptive to sperm, which generally is a small window of 2-3 days. The test can be timed by an over the counter ovulation detection kit (ODK) being positive or by transvaginal ultrasound to measure when the egg follicle is mature, both indicating that ovulation is imminent. The couple is then asked to make love and is seen 2-12 hours later. Sperm can live in the cervical mucus for 3-4 days and there is evidence of sperm living up to, as long as, 10 days. After intercourse, in patients with good cervical mucus, sperm have been found in the fallopian as soon as 3 minutes. The test is done by placing a speculum and cervical mucus is then collected in a small syringe, examined for clarity and stretchiness (spinnbarkeit), and placed on a slide under the microscope. The mucus is than checked for the number of sperm seen per high powered field, percentage of motility or movement of the sperm and the number of normal appearing sperm (morphology). Although, there can be many interpretations of what is a normal Post-Coital Test (PCT), and hence the controversy, Arizona Center for Fertility Studies feels that the test is simple, painless and inexpensive, and gives valuable information about sperm-mucus interaction, which is responsible for 15-20% of the causes of infertility. Anything that damages the cervix can cause an abnormal Post-Coital Test (PCT) including cervical and vaginal infections, cryosurgery or cautery for an abnormal PAP smear, cervical conization, LEEP procedure, DES exposure, the use of Clomid for ovulation and the normal hormonal flux of the vagina.

Female Anatomy Graphic representation of the mechanics of doing a Post-Coital Test (PCT)
Female Anatomy Evaluation and interpretation of a normal and abnormal post-coital test

Endometrial Biopsy (EMB)

Also an older test and not recommended by many clinics anymore, an Endometrial Biopsy (EMB) tests whether the uterine lining is preparing itself adequately for implantation of the embryo. The test is done several days before the onset of the menstrual cycle (usually cycle day 25-26). A small plastic instrument, called a Pipelle, is inserted through the cervix and into the uterine cavity where a very small piece of endometrial lining is removed by pulling back on the center piece of the Pipelle and creating a weak suction. The tissue is then sent to pathology to be evaluated for which day in the cycle the lining of the uterus is at. That is then compared to where the woman is chronologically in her cycle. The two have to be read within 1-2 days of each other, or the lining is out of phase, known as a luteal phase defect, which can prevent implantation from occurring or result in an early miscarriage. An abnormal Endometrial Biopsy (EMB) is treated with progesterone lozenges, suppositories or intramuscular shots. If these are not successful, then HMG has been shown to be very effective in correcting the abnormal Endometrial Biopsy (EMB). The test can be interpreted differently by different pathologists, and hence the controversy. An Endometrial Biopsy (EMB) at Arizona Center for Fertility Studies is always read by the same pathologist and he is either consistently right or consistently wrong, but at least he is consistent. Arizona Center for Fertility Studies feels that the test still has value in evaluating why a couple is having trouble conceiving, if taking Clomid has altered the uterine lining preparation, in diagnosing a luteal phase defect which can increase the risk of a miscarriage, or as part of the evaluation for repeated pregnancy loss. At Arizona Center for Fertility Studies, the test is associated with little discomfort and the literature does not show an increased risk of miscarriage if you were to be pregnant (even though Arizona Center for Fertility Studies will ask you to sign a waiver).

Endometrial Biopsy (EMB)

Since 50% of the causes of infertility are due to the male, a complete Semen Analysis (SA) is very important. The test is usually done by having the partner collect a masturbated sample after abstaining from intercourse for 2-3 days. The sample is ejaculated into a sterile container, usually a sterile wide mouth urine cup, either at home or in the office and then evaluated for sperm numbers, motility, morphology, volume, clarity and time to turn from a gel to a liquid. Fifty percent of men are comfortable collecting a sample in the office, the other 50% would prefer collecting at home. There is no disadvantage of collecting a sample at home and the sample can be brought to the office within an hour. Occasionally, a man is not comfortable with masturbation and, if that is the case, then Arizona Center for Fertility Studies can provide him with a sterile condom, that can be used during intercourse, to collect the sample. When doing a SA it is important that the morphology be done by strict Krueger's morphology testing. This is where the sperm are inactivated on a slide, stained, and carefully examined for normal morphology. At most outside labs, like LabCorp or Sonora Quest, strict Krueger morphology testing is not done and thus, there is a wide interpretation of the percentage of normal sperm morphology.

Arizona Center for Fertility Studies works with many valley urologists that specialize in reproductive services.

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