Testing

Many clinics will have their own preferred methods of testing, and will carry out at least some of the following range of tests.

• Tests for the woman
• Tests for the man

Tests for the woman

• Temperature charting (Basal Body Temperature Chart)

This is one of the oldest and most basic of fertility tests, involving the woman measuring her body temperature every morning throughout her cycle and creating a chart which indicates when, and if, she ovulates. Some women may already be familiar with this method, and have been using it as a method of contraception. Approximately 24 hours before ovulation occurs there is a fall in body temperature, followed swiftly by a recognisable rise (accompanying a rise in the hormone progesterone) which usually indicates ovulation. If there is no discernible alteration in body temperature, it may be that ovulation has not occurred in that cycle, triggering further tests.

• Progesterone tests

These are simple blood tests, sometimes taken over several days and most usually on day 21, to measure the level of progesterone in the blood. Progesterone rises a few hours after ovulation and peaks about seven days later, so any increase would indicate that ovulation had taken place in that particular cycle.

• Prolactin tests

The hormone prolactin stimulates milk-production following pregnancy and appears to prevent ovulation. It has long been recognised that women are less likely to conceive whilst they are breast-feeding, although this has been found to be an unreliable method of contraception.

• Hormone profiling

These are blood tests to measure the reproductive hormones, including FSH, LH, testosterone, oestrogen and progesterone, etc.

• Endometrial biopsy

Performed in the second half of the cycle, usually about 3 days before bleeding is expected to begin, this tests whether the endometrium has responded properly to progesterone, and developed sufficiently in expectation of pregnancy and implantation. The test involves inserting a fine pipe into the vagina and through the cervix into the uterus, taking a small sample of tissue from the uterine lining for biopsy. No anaesthetic is necessary, and the procedure causes brief, period-like cramps.

• Tubal patency tests

There are two tests currently used to check the condition of the fallopian tubes and the uterus:

Hysterosalpingogram (HSG)

The HSG is an X-ray of the uterus and fallopian tubes, usually performed using local anaesthetic. This is reputed to be a painful procedure, but this depends very much on the skill of the practitioner. Dye is squirted through the cervix into the uterus and tubes, and its progress monitored on a TV screen. A good X-ray result will reveal any obstruction, swelling, spasm, adhesions or blockages in the tubes, as well as any fibroids, adhesions or other abnormality in the uterus.

Laparoscopy

This is deemed to be the most important test for female infertility. In The IVF Revolution, Professor Winston states that in his view it should almost always be considered before entering an IVF programme.

Laparoscopy is performed under general anaesthetic and short hospital admission. A small incision is made on the interior of the navel and a small amount of carbon dioxide is released into the abdominal cavity. This has the effect of separating the reproductive organs, so the doctor can get a clearer picture. A thin telescope the width of a fountain pen is inserted into the naval incision, and through this the doctor can not only get a full picture of the condition of the uterus, including the presence of endometriosis, fibroids, but will also be able to test the patency of the fallopian tubes by injecting coloured dye through them. The ovaries will also be inspected for cysts.

Laparoscopy is usually performed in the second half of the cycle, so that the surgeon can inspect the ovaries for signs of recent ovulation, and also so that an endometrial biopsy can be taken, if it has not already been carried out. The procedure takes 20-40 minutes.

Most women will be allowed to go home within 4-6 hours of the operation. Side effects may be unpleasant but not serious, mostly related to the anaesthetic. They might include pain in the shoulders, due to the carbon gas which can irritate the stomach lining. This is because the nerves which supply this area also supply the shoulder area. There may be vaginal bleeding, lasting 2-3 days. A particularly unpleasant side effect affects the bladder, making it difficult and painful to pass urine. Sufferers are advised to drink lots of water, which is not always easy advise to take under the circumstances!

The operation will leave a small scar just inside the navel. There may also have been a second incision just underneath the pubic hairline, where the surgeon inserted fine probes to get a better view of certain areas.

Professor Winston states the benefits of laparoscopy to be considerable, and the best investigative procedure to detect many conditions, including endometriosis and tubal damage.

• Hysteroscopy

This might be carried out at the same time as a laparoscopy, or separately using a light anaesthetic with mild sedation, or a quick general anaesthetic. The hysteroscope is a small telescope which is inserted into the uterus via the vagina, allowing detailed examination of the interior of the uterus. It can be an excellent means of detecting polyps, fibroids, adhesions or congenital abnormalities of the uterus which might have been indicated by a prior HSG.

• Ultrasound scan

There are two types of scan used in infertility investigation. Both work on the same principle of using high frequency sound waves which, when they hit tissue, give off an echo which shows as a black shape on a monitor. From this, organs inside the abdomen including the ovaries and any cysts or follicles growing on them, can be measured in detail. The ovarian ultrasound uses an external scanner which is passed over the abdomen. Water conducts sound well, and consequently better quality images are possible where the bladder is full, although this can become an uncomfortable experience for the woman. However, a full bladder is not necessary for the vaginal ultrasound, where a small probe covered with a rubber sheath is inserted directly into the vagina. The probe is then manipulated inside the vagina to pick up images of each ovary and follicular development. It is not painful although it can be uncomfortable. Better quality pictures are available using this type of scan, and most IVF units use them to monitor ovulation. It is also useful in detecting cysts on the ovaries and damage caused to the ovaries by disease, such as endometriosis.

Tests for the man

The three main causes of male infertility are hormonal, genetic or physical, and are usually identified with the following tests:

• Semen analysis

The man provides a sample by ejaculating into a sterile container, either at the clinic or at home (in which case it must be delivered to the clinic within two hours of its collection). Usually the clinic will provide an appropriate room for the man to produce his sample in comfort, if he prefers. Wherever the semen is produced, the man will be instructed to ensure that all of the ejaculate gets into the pot, otherwise the sample will be incomplete and will result in an abnormally low sperm count. Some men understandably find the process disturbing and embarrassing, and consequently are able to produce only a very small amount of ejaculate, if they can manage at all. However, good clinics are aware of these factors and assess a man’s fertility on the results of several tests.

A routine sperm analysis will calculate the following:

- volume.

The average ejaculate is between 2 to 5 millilitres, which is approximately a teaspoon. Less than 2 millilitres may indicate that the man is not producing enough secretions or that part of the ejaculate may not have been collected.

- density.

This measures the number of sperm. The average fertile man will produce more than 40 million sperm per millilitre of semen. Fewer than 20 million per millilitre may indicate a problem.

- motility.

This measures the number of sperm able to move properly. At least 40% should show normal forward progressive movements within one hour of ejaculation.

- morphology.

At least 65% of the sperm should look normal under microscopic inspection.

- ‘clumping’ bacteria, white blood cells

The presence of either may indicate infection or that the man is producing antibodies to his own sperm.

- antibodies.

Antibodies are usually produced as part of the body’s natural defence system, in response to injury or infection. They will prevent sperm from working normally.

• Hormone tests

As with the hormone tests on women, these will be blood tests to measure FSH, LH, testosterone and also prolactin. An abnormally raised -or lowered- level of FSH is particularly significant, because it can indicate that the testes are having problems with sperm production.

• Testicular biopsy

This is an exploratory operation, usually performed under general anaesthetic, often as a day case in hospital. An incision is made in the scrotum, and a small piece of tissue is taken from the testes and examined under a microscope. This will show whether the testes is capable of normal sperm production. Also the procedure can test whether any tubes are blocked, damaged, or diseased.

• Thermography

This measures the temperature in the testes.

• Ultrasound

This scan is external, with the probe placed directly on the scrotum, so there is no need for a full bladder. Small cysts and tumours may be identified, and other abnormalities such as blocked tubes.

• Chromosome testing

Sometimes, infertility may be the result of a genetic abnormality. For example, Flinefelter’s Chromosome is a genetic abnormality which leads to low testosterone levels, and usually prevents the man from producing any sperm. This condition is extremely rare but untreatable where it does exist. Chromosome testing may be able to identify this, and other abnormalities which cause poor sperm production. Where some sperm are still being produced, IVF techniques may be an option, although the couple will have to be advised on the genetic implications. Testing is by blood test, and the results take up to four weeks.

Getting the results

It may seem like stating the obvious but the above tests may produce results which will have a devastating impact on some couples’ lives. For this reason, it seems advisable for both partners to be together when they receive test results. Couples should also consider how they can support each other in the event of bad news, and indeed how they will cope themselves. Counselling may be an option.

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