If your partner’s semen analysis comes back normal (see below), the doctor may order one or more tests to determine whether ovulation is taking place, whether there are adequate quantities of the hormones required to produce a healthy endometrial lin ing and healthy cervical mucus, and whether the reproductive tract is free of any scar tissue and anatomical defects that might otherwise prevent fertilization and implantation.
Here’s a brief description of the types of tests your doctor might order:
■ Serum progesterone blood test: This test is done to con
firm that you are ovulating. Blood samples are drawn in the middle of the luteal phase (that is, on day 21 of a 28 day cycle). If the progesterone level is significantly ele vated, it’s likely that you’re ovulating. Note: If your cycles are irregular, you may have to go in for weekly blood tests starting at day 20 and continuing until you menstruate. More often, however, your doctor will assume that your irregular cycles indicate an ovulation problem, and will order a more extensive blood test (that is, one to check a number of your hormone levels) instead.
■ Prolactin blood test: Prolactin is a hormone that inhibits
ovulation in nursing mothers. If you have excessively high levels of prolactin, you may have a benign (that is, non cancerous) pituitary tumor, in which case your doctor may refer you for further tests, such as a CAT scan.
■ Thyroid hormone blood test: Abnormal amounts of thy
roid hormone can indicate that you have problems with your thyroid. Women with underactive thyroid glands (hypothyroidism) are prone to menstrual and ovulatory disorders. Those with overactive thyroids (hyperthy roidism) have more variable menstrual patterns but can become seriously ill if the condition is not recognized and treated during pregnancy.
■ Blood tests for other reproductive hormones: Depending
on the results of your medical history and your physical examination (your degree of menstrual irregularity, if any, or any problems with excessive body hair growth, for example), your doctor may need to obtain specific hor mone levels to uncover a variety of endocrinologic condi tions. This may involve testing at specific times of the cycle or testing after receiving certain medications.
■ Hysterosalpingogram (HSG): A hysterosalpingogram is
used to determine whether any damage has occurred to your fallopian tubes. It involves filling your reproductive tract with a special type of dye that shows up on X-rays. The test — which is conducted during the follicular phase — involves inserting dye into your uterus through a tube that is placed through your cervix. If one or both of your tubes are blocked, the dye will outline where the obstruction lies. If only one tube appears to be blocked, it may simply be due to the fact that the open tube provided the pathway of least resistance to the dye. (Pregnancy rates aren’t very different between women whose HSGs show one tube open to the passage of dye as opposed to both tubes.) An HSG can also be useful in identifying the loca tions of any scarring or growths such as fibroids in your uterus (see following). Some women — particularly those with blocked tubes — find this procedure to be quite painful, so you might want to talk with your doctor about the advisability of taking a pain medication prior to the procedure. Note: The value of HSG as a diagnostic tool is clear. What is more controversial is whether the procedure can actually enhance fertility. There has long been an anecdotal claim among doctors treating infertile patients that there is a blip in the fertility curve in the months fol lowing HSG. Studies have demonstrated, however, that this enhancement is seen only with the use of oil-based dyes and not with water-soluble dyes.
Watch Out!
If you have a history of pelvic infection, pelvic surgery, or pelvic tenderness, you may be at risk of developing an infection after the HSG. Ask your doctor if it would be advisable for you to take a course of antibiotics before you go in for the procedure.
■ Endometrial biopsy: An endometrial biopsy can confirm
whether you’re ovulating and indicate whether your endometrial tissue is sufficiently hospitable to allow a fer tilized egg to implant. The biopsy is taken within several days of when you are expected to start menstruating. The doctor inserts a speculum in your vagina and cleanses your cervix, and then a tissue sample is removed from the uter ine lining through a combination of suction and gentle scraping. If you’re concerned that this procedure may cause a miscarriage in the event that you have managed to conceive, you may find it reassuring to know that the odds of having an endometrial biopsy cause a miscarriage are extremely small. If you are worried about this possibility, you might choose to use some sort of contraceptive during the cycle in which the endometrial biopsy will be taken or plan to undergo a sensitive blood pregnancy test the day before the procedure to determine whether you are, in fact, pregnant.
■ Laparoscopy: Like an HSG, a laparoscopy is a test
designed to detect obstructions in your fallopian tubes. It’s considerably more high-tech and risky than an HSG, how ever, and can provide more detailed information. The test involves inserting a fiber-optic scope into your abdomen to look for damage caused by endometriosis, pelvic inflam matory disease, or adhesions from any pelvic surgery, and to look for physical evidence that you are ovulating. You
need to go under general anesthetic to have the proce dure, and you may experience some soreness in your abdomen and shoulders afterward. Note: If your doctor suggests that you have a D & C done at the same time as your laparoscopy as part of your infertility workup, get a second opinion. Studies have shown that such D & C pro cedures provide no more information than what can be obtained through a less-expensive and less-hazardous endometrial biopsy. You should also be prepared to put the brakes on if your doctor wants you to undergo a laparoscopy right away: As a rule of thumb, you should be prepared to wait for six months after your HSG — assum ing, of course, that it was normal — so that you can take advantage of the fertility-enhancing effects of HSG. Obviously, if your doctor suspects that you have
endometriosis or significant pelvic adhesions — or if you are over 40 — a waiting period may not make sense.
■ Hysteroscopy: A hysteroscopy also involves inserting a
fiber-optic scope into the body, but in this case, it is inserted into the uterus through the cervix. It is used to detect abnormal growths or anatomical defects in your uterus when your HSG suggests that these may play a role in your fertility problems. (We’ll be discussing these prob lems elsewhere in this chapter.)
Bright Idea
If you’re scheduled to undergo an endometrial biopsy, take some Tylenol or ibuprofen about 45 minutes before the test, and plan to have someone avail able to drive you home afterward just in case you don’t feel up to driving yourself. Because the biopsy can be momentarily painful, you may experience a brief bout of nausea and dizziness — not enough to debilitate you by any means, but enough to make you feel rather crummy.
■ Postcoital test: The postcoital test is used to assess what
happens once the sperm make it inside the vagina. You are asked to have sexual intercourse just before you expect to ovulate (when your cervical mucus is at its best) and to show up at your doctor’s office at a designated time some 2 to 16 hours later. The doctor then uses a syringe or pipette to extract at least two samples of cervical mucus from the cervical canal, and examines it under a micro scope to determine how many sperm are alive and swim ming. The test can show whether your mucus is
inhospitable to your partner’s sperm; it can also suggest whether there are antibodies in either your body or your partner’s body that are interfering with sperm production or killing sperm; and whether the root of the problem is the fact that sperm is not being deposited closely enough to the cervix (as can be the case if the male partner expe riences premature ejaculation). As you might expect, many couples dislike having to have sexual intercourse upon demand and then rush off to the laboratory. That’s why many doctors encourage couples to make love the night before and then come into the laboratory the next morning. Note: It’s possible to fail the postcoital test because you’ve inadvertently missed your most fertile period (that is, the days prior to ovulation when your cer vical mucus is most abundant). If you fail the postcoital test, you will likely be asked to repeat it to ensure that the problem lies with you and your partner, not with the timing.
Bright Idea
Use an ovulation predictor kit to time your postcoital test. You will ensure that it is the optimal time for the test, and you just might find yourself preg nant as a result.
■ Ultrasound: Ultrasound is used during the basic infertility
evaluation only if the internal or pelvic exam is inconclu sive or significant abnormalities are suspected. Sometimes a saline solution is injected into the uterus in order to get a better look at the uterine interior, where problems such as polyps (an overgrowth of tissue that is similar to a wart or skin tag) and fibroids (noncancerous tumors of the uterine muscle) may be seen. When this is done, the procedure is known as sonohysterography or hysterosonography.