Our initial step in creating your personalized treatment plan is to determine the cause of your infertility. The diagnostic procedures described below provide important information that can allow us to identify or eliminate the common causes of infertility.
Ovarian reserve is the term used to describe the size of the remaining egg supply and is an important part of the infertility evaluation. There are three different methods for evaluation of ovarian reserve:
- Measure of the antimullerian hormone (AMH) level in the blood.
- Measure of the follicle-stimulating hormone (FSH) and estrogen (estradiol) levels in the blood on cycle day 3.
- An antral follicle count obtained by transvaginal ultrasound examination.
The AMH level is the most common method for measuring ovarian reserve. The hormone is made by the follicles in the ovaries that are in the earliest stages of development; the more there are, the higher the AMH level is. Abnormally low levels of AMH indicate a declining ovarian reserve, or an advanced stage of reproductive aging.
A cycle day 3 FSH and estrogen level is another method for measuring ovarian reserve. FSH levels rise progressively with increasing reproductive aging, a change that is most clearly revealed early in the menstrual cycle. An elevated FSH or estrogen level on cycle day 3 is, therefore, a sign of a low ovarian reserve, but a change that occurs later in reproductive aging than the decrease in the antimullerian hormone (AMH) level.
An antral follicle count is a third method for measuring ovarian reserve. Transvaginal ultrasound is performed early in the menstrual cycle (cycle day 1-4) to count the number of small follicles in the ovaries. Because the number of follicles that begin to grow each cycle decreases as the overall number of follicles remaining in the ovaries declines, a low antral follicle count is a sign of a low ovarian reserve. This method is a good predictor of how well a patient will respond to treatment with fertility drugs, so it is often performed just before treatment begins as a prognostic indicator and to help in decisions about how much medication should be used.
A sonohysterogram, also called a saline sonogram, is a method for evaluating the inside of the uterus and to detect abnormalities, such as polyps, fibroids (common benign tumors of the uterine wall) or intrauterine adhesions or scar, any of which may impair fertility or increase risk for pregnancy loss or complications. It is commonly performed before a planned cycle of In Vitro Fertilization (IVF) to exclude abnormalities that might interfere with embryo implantation. It also is often used in the evaluation of abnormal menstrual bleeding, to determine if polyps or fibroids may be the cause.
A very thin catheter (a flexible tube) that has a very small balloon on its end is inserted into the cervical canal and the balloon is inflated with approximately one-half teaspoon of air to block the canal. An ultrasound probe is then inserted into the vagina and a small amount of sterile saline is then injected through the catheter into the uterus to gently push apart the internal walls of the uterus, allowing identification of any abnormality inside of the uterine cavity. A sonohysterogram is more sensitive and accurate than standard transvaginal ultrasound for revealing potentially important abnormalities. The procedure is quite brief and seldom results in any discomfort more than some mild and transient uterine cramping.
When a sonohysterogram is performed as part of the preparations for an In Vitro Fertilization treatment cycle, a mock embryo transfer is usually performed at the same time. The procedure involves the passage of an empty transfer catheter, just like the one that will be used later to transfer an embryo(s) into the uterus, to learn in advance whether the later embryo transfer might be difficult to perform or might require any special or specific technique. The procedure is very brief and rarely causes any discomfort.
Office hysteroscopy is another method for evaluating the uterine cavity. The physician introduces a thin telescope, attached to a camera and light, through the cervix and into the uterus. Hysteroscopy can be performed as an alternative to a sonohysterogram (described above), but because it is a more involved procedure, it is most often used to treat or remove abnormalities that are first identified by simpler methods, such as standard transvaginal ultrasound or a sonohysterogram.
A hysterosalpingogram (HSG) is a diagnostic test used to evaluate both the uterine cavity and the fallopian tubes and is performed in the office. A very thin catheter (a flexible tube) that has a very small balloon on its end is inserted into the cervical canal and the balloon is inflated with approximately one-half teaspoon of air to block the canal. A small amount of a clear fluid that can be seen by x-ray is injected slowly through the catheter into the uterus. X-ray television, called fluoroscopy, is used to watch the fluid fill the uterine cavity, revealing its internal size and shape, and then enter, travel through, and escape from the fallopian tubes into the abdomen, which proves that the