What are the first steps in the diagnosis of infertility? All doubts will be dispelled by an experienced gynaecologist, Katarzyna Mikołajczyk, Doctor of Medicine from the Medfemina Hospital in Wrocław.
What are the indications for the diagnosis of infertility in women?
Infertility diagnostics is recommended to patients who, despite attempts, did not become pregnant within one year of starting their efforts. However, there are situations in which an earlier diagnosis is recommended. This includes women who:
- have reached the age of 35
- have menstrual disorders – infrequent periods occur or menstruation disappears altogether;
- have suspected malformations of the reproductive organs;
- have the case of infertility in the partner
Where should the diagnosis of infertility in women begin?
A very important step in diagnosing infertility in women is the medical history that is taken at the first visit. Be prepared for a thorough interview, as the questions are very insightful and intimate. The doctor may ask about our menstrual cycle, frequency of intercourse, medical history, miscarriages, birth defects, or genetic diseases (including those in the family).
The more information we provide to the doctor, the easier and faster s/he will be able to determine the initial causes of infertility. Therefore, it is not worth being ashamed and hiding information from the doctor, e.g. about the number of partners, risky sexual behaviour, or strong infections.
What do female fertility problems stem from?
Women’s infertility can have many causes. First of all, these are menstrual disorders, endometriosis, history of surgery – including appendicitis, but also other surgical procedures performed within the pelvis. These procedures can cause adhesions and even disorders of the fallopian tubes; infections, myomas, pain during intercourse, inflammation of the appendages, cysts, congenital malformations of the reproductive system, severe stress, improper diet, hormonal disorders.
What is secondary infertility?
Infertility can also affect couples who already have one or more children. This is then known as secondary infertility. In the diagnosis of disorders responsible for the development of secondary infertility, much attention is paid to the obstetric past, i.e. the course of previous deliveries, possible complications, ectopic pregnancies, miscarriages, and even the development of the children. Every woman seeking help at an infertility clinic is treated very individually. Not every patient will undergo invasive testing. Unfortunately, in 20% of cases, the cause cannot be determined. Ideally, the causes of infertility should be sought from both partners.
When should ovulation be monitored ?
The doctor must have a thorough understanding of a woman’s menstrual cycle. However, information gathered from the patient alone is not enough. For example, your doctor may order 2-3 vaginal ultrasounds and hormone level tests (1-2 times). By compiling the results of these tests, your doctor will determine if you are ovulating, when your fertile days occur and when you ovulate. An ultrasound should be performed at the beginning of your cycle and then on approximately day 12 and 14 of your cycle. When the doctor finds a lack of ovulation in the test, he or she may recommend ovulation-stimulating drugs. Medications can be taken as pills or injections. The most important thing is to take them at the beginning of the cycle. If your periods are regular, you do not need to check your prolactin levels or do a metoclopramide test. However, if a woman’s cycles are irregular (infrequent or frequent) it is worth checking the concentration of:
What hormone tests should be done?
Hormonal testing plays a very important role in diagnosing and treating infertility. The most important are:
- testing the AMH level in the blood – a woman’s ovarian reserve can be determined by the concentration of this hormone. This term refers to the number of ovarian follicles a woman has so a doctor can assess a woman’s fertility. Importantly, this test can be performed at any stage of the cycle, as the level of this hormone is constant, regardless of contraception or hormone therapy used. In situations where the test result is very low, this may be an indication for IVF;
- fSH levels – this hormone is produced by the pituitary gland. Indications to perform it are irregular cycles, which may indicate polycystic ovarian syndrome (in which case LH levels are also checked) or premature cessation of ovarian activity (in which case E2 levels are also checked);
- estradiol levels – the test should be performed in the follicular and perovulatory phase, i.e. on days 2-3/4-5 and 13-14 of the cycle;
- LH (luteinizing hormone) level – the test is performed to check the efficiency of the hypothalamic-pituitary system. The test should preferably be done on days 6-7 and 13-14 of the cycle;
- progesterone level – the test is performed after ovulation, on the 20th-23rd day of the cycle; it evaluates the efficiency of the corpus luteum
- prolactin level
- tSH, FT3, FT4 levels – tests can be done on any day of the cycle;
- progesterone level, ovulation and corpus luteum function – examination
- androgen levels – this test can be done on any day of your cycle. Testosterone, androstendione and dehydroepiandrosterone concentrations are assessed.
In some cases, it is necessary to check the concentration of sex steroid-binding protein, inhibin, it is worth checking glucose and insulin levels or performing a glucose load test If a woman experiences recurrent miscarriages, a blood test for thrombophilia and antiphospholipid syndrome should be performed.
Can we also encounter difficulty getting pregnant in the reproductive tract?
Of course we can. Infertility in women is also often caused by various defects in the structure of the uterine cavity, obstruction of the fallopian tubes, or changes in the epithelium, such as polyps or myomas. In order to diagnose them, it is necessary to conduct:
- hysteroscopy – the examination is performed to assess the structure of the uterine cavity, and in addition, changes such as fibroids, polyps and adhesions can be removed during the examination;
- HyFoSy – during the test, a special foam is injected through a catheter into the cervix, uterine cavity and fallopian tubes. This is how the patency of the reproductive tract is checked. In some cases, the test also allows for the unblocking of the fallopian tubes so that the cause of infertility, the impaired patency of the fallopian tubes, is removed;
- endometrial biopsy scratch test – the test is usually performed for diagnostic purposes in the case of dangerous-looking changes in the cervical mucosa and uterine cavity. For infertility, the test should be done at the beginning of the cycle;
- pap smear – this is a diagnostic test to detect precancerous and cancerous conditions within the cervix, which can also stand in the way of pregnancy;
- diagnostic laparoscopy – this examination diagnoses endometriosis, evaluates the structure and position of the pelvic organs, the patency of the fallopian tubes and the location of adhesions;
- PCT test – this is a study of cervical mucus. They should be performed approximately 12 days after sexual intercourse. The test evaluates the degree of sperm activity that is seen in cervical secretions. Based on this, a couple’s chance of getting pregnant can be assessed. Before the test is done, the man’s semen must be tested;
- fertilization – a new, comprehensive test to diagnose female infertility. This method uses a variety of methods to examine the uterine cavity, patency of the fallopian tubes, diagnose ovarian endometriosis, and abdominal peritoneum. These methods include transvaginal laparoscopy (hydrolaparoscopy), transcervical chromotubation, microsalpingoscopy, and minihysteroscopy. The test can be used instead of laparoscopy;
- hysterosalpingosonography – it is a traditional method of examining the patency of fallopian tubes using a contrast medium and X-rays, which is more and more often replaced by HyFoSy examination
When should I go for genetic diagnosis and what are the indications?
Genetic testing is performed when genetic causes of infertility are suspected. Karyotype testing can detect changes and abnormalities in the structure or number of chromosomes. The main indication for genetic testing, is a thorough history and analysis of the couple’s genetic background.
The indication for testing is:
- congenital hypogonadotropic hypogonadism,
- primary amenorrhea
- premature expiration of ovarian function,
- abnormality in genital development,
- abnormal development of tertiary sexual characteristics,
- congenital morphological changes in body structure and recurrent miscarriage,
- family history of genetic diseases
- lack of sperm production in the male
- no apparent causes of infertility