The Female Infertility Evaluation

• Infectious Screen (Chlamydia antibody, Gonorrhea, Hepatitis B, Hepatitis C, Syphilis serology, HIV): having one of these organisms or viruses could adversely affect your treatment outcome, pregnancy, and your general health if left undiscovered or untreated. All of these infections with the exception of gonorrhea may go undetected for periods of time without adequate testing.
  
  
• Pre-Pregnancy Screen (Complete Blood count, Blood type & Rh Factor, Rubella titer) These tests are performed in order to avoid serious complications to the fetus during pregnancy and screen for anemia and possible other heritable disorders. While most people have been immunized for Rubella, in some cases a booster will be required to provide adequate coverage.
  
  
• Pituitary/Thyroid Screening (Prolactin, TSH, Free thyroxin): hormonal tests which screen for abnormalities that can effect your treatment or pregnancy.
  
  
• Genetic (Tay Sach’s, Cystic fibrosis, Sickle Cell): if your history suggests that you may be at risk for certain genetic, autoimmune diseases, or medical diseases, other tests may be ordered prior to initiating the cycle.
  
  
• Pap Smear – should be up-to-date per American College of Obstetric & Gynecology standards (usually within the year).
  
  
• Breast Screening Mammogram – age appropriate.

Ovarian Function and Ovarian Reserve Screening

Ovarian disorders account for approximately 30-35% of female related infertility. Testing is aimed at giving us information on whether or not you are ovulating; if so, how well do you ovulate or what is the egg quality. Some women may have regular, ovulatory periods, but the egg quality may still be reduced. This is a natural phenomenon.

• Baseline Ultrasound: Performed on day 2, 3, or 4 of the cycle. Provides information on the overall size and volume of the ovaries as well as the antral follicle count (number of early immature eggs available per menstrual cycle) in the early part of the menstrual cycle, just after onset of the menstrual bleed.
  
  
• FSH, LH, Estradiol: By looking at hormone levels such as FSH (follicle stimulating hormone), LH (luteinizing hormone) and Estradiol drawn at the beginning of the menstrual cycle (days 2, 3, or 4) your physician will get a good indication of a woman’s “ovarian reserve.” This is a measure of how well the ovaries are expected to respond to stimulation with fertility medication. Since ovarian reserve begins to decline approximately 6-7 years prior to menopause (average age is 50-51) and the onset of menopause occurs earlier for some women, all women will be tested in order to provide appropriate counseling and determine which procedures and protocols would be of most benefit.
  
  The “Day 3 hormone test” is a very sensitive test and provides us with a great deal of information which may impact your treatment. Since their can be quite a discrepancy in results between different laboratories, we require that this test be performed in our facility to assure accurate interpretation.
  
  
• Clomiphene Citrate Challenge Test (CCCT): Changes that decrease a woman’s chances to reproduce may start many years before early menopause. These changes include but are not limited to decreases in the number of oocytes (eggs), as well as increased number of chromosomal abnormalities within the oocytes. While age itself is an important factor, not all women of the same age have the same reproductive potential. All women age 35 and over, as well as those who have a medical history suspicious for possible decreased ovarian reserve will be asked to undergo a CCCT. In order to complete the CCCT, blood is drawn on day 3 and 10 of the menstrual cycle (FSH, Estradiol, LH), while taking a medication called Clomiphene Citrate (100mg) on days 5, 6, 7, 8, 9 of her cycle. These tests must be performed by our own laboratory.

Tubal Evaluation

Issues with the fallopian tubes may account for approximately 30% of female infertility problems. Common problems we see are related to tubal blockage or scarring from previous, sometimes undiagnosed, pelvic infection, abdominal infections like appendicitis, prior surgeries, prior ectopic pregnancy, or endometriosis. Prior tubal ligation (tying of the tubes) for contraception would also fall under this category.

• Hysterosalpingogram (HSG): This is an X-ray test that will be performed in the office by Dr. Zoneraich in which a small amount of dye is put through the uterus and tubes in order to determine if the tubes are open. Some structural defects of the uterus may also be visible with the HSG, but the primary role for the HSG is to determine if the tubes are open.
  
  
  • Those patients with allergies to iodine or shellfish will undergo this procedure in an outpatient radiology center rather than the office.

Uterine Evaluation

The uterus is lined by a specialized layer of cells called the endometrium. It is to this lining that embryos implant and begin to develop in pregnancy. It is critical to thoroughly evaluate the uterine cavity for potential defects or obstacles to implantation of the embryo. Examples of such would be uterine scar tissue (from previous pregnancies or procedures), polyps (benign glandular growths), fibroids, or other structural defects in the uterus. Depending on your specific situation, the evaluation may include the following tests:

• Complete physical examination and external palpation of the uterus. This will also include a Pap’s Smear (if not done within the last year), breast examination, and cervical cultures.
  
  
• Baseline Pelvic Ultrasound: this is a transvaginal ultrasound examination usually performed at the onset of your menstrual cycle on Day 2, 3, or 4. It gives the physician information on the direction and length of the uterine cavity.
  
  
• Hysterosalpingogram (HSG): as described in the tubal evaluation, may provide some information on structural defects of the uterine cavity. This test is performed by Dr. Zoneraich in the office.
  
  
• Sonohysterography (saline sonography): sonographic evaluation of the uterine wall and inner uterine cavity performed while filling the uterus with a very small amount of sterile fluid. Performed by Dr. Zoneraich in the office, this test provides information on abnormalities of both the uterine wall and endometrial cavity which may affect implantation of an embryo, increase miscarriage rates, and interfere with subsequent delivery of the baby. In some cases, findings on this test prompt the physician to recommend further evaluation with office/diagnostic hysteroscopy (see below) or proceed to surgical correction of an abnormality.
  
  
• Office Diagnostic Hysteroscopy: this test may be recommended for patients undergoing advanced reproductive treatments such as IVF or for those who have an equivocal or suspicious finding on sonohysterography. Performed by Dr. Zoneraich in the office, this test uses extremely high resolution fiber optic cameras to visualize and provide color pictures of the inner lining of the uterine cavity and openings of the fallopian tubes.
  
  
• Endometrial Biopsy: this test is only performed in certain circumstances in order to diagnose problems in development of the endometrium, called luteal phase defect, or to diagnose possible infection of the endometrial lining.
  
  
• Trial (or Mock) Transfer: this is a very quick and painless test performed on patients undergoing IVF in which a very thin plastic catheter is used to assess the length and curvature of the cervical canal and uterine cavity in order to facilitate placement of embryos in the uterus at the time of actual embryo transfer.