Female Infertility Diagnosis
Female Infertility Diagnosis
Richard Paulson (Chief, Division of Reproductive Endocrinology and Infertility, USC) gives expert video advice on: How will my doctor test for female infertility?; How will my doctor test for male infertility? and more...
How will my doctor test for female infertility?
If we have a couple who comes and they say they've been trying for a year and it's not working and they've ruled out <a href="http://www.videojug.com/interview/male-infertility-2">male infertility</a>, or perhaps we even have a woman come to the office by herself and say, "I'm getting married next month; I really want to make sure my fertility is normal," the kinds of tests we run really pertain to the two main factors that are important in a woman's fertility. One of them is ovulation and the other one is the presence of a normal uterus and normal fallopian tubes. For ovulation, first of all we get a history, because if someone has regular menstrual cycles, the chances are 90 percent that they're ovulating. Another way of thinking of that is that a woman who has regular cycles has a ten percent chance of not ovulating. It's really quite simple to do a blood test for progesterone in what we call the Late Luteal Phase or perhaps even to have the patient do a urinary ovulation kit at home and see that she is ovulating during a particular time of the cycle. For the uterus and the fallopian tubes, there are a number of tests that can be done. The simplest by far is the X-ray, which is called a hysterosalpingogram, or HSG. In other instances we may do a laparoscopy or some other kind of imaging study, for example an ultrasound, to verify that the uterus and the fallopian tubes are normal.
What is a "hysterosalpingogram" or "HSG"?
The word hysterosalpingogram is Greek and it means uterus - hystero, salpingo - fallopian tube, gram - picture. So it's a picture of the uterus and the fallopian tubes. And the way that it's done is that dye is injected through the cervix into the lower part of the uterus and then the dye is watched to flow into the uterus and out of the fallopian tubes. And it turns out that the dye that is used is taken up by x-rays and so you do an x-ray of the lower part of the abdomen. Some women worry that the x-rays will damage their ovaries but it's a very low dose and it's not a problem. And since hysterosalpingogram is such a mouthful we all just abbreviate it HSG, which is a lot easier to say and a lot easier to write.
What is a "pelvic ultrasound"?
A pelvic ultrasound is actually a very non-invasive way of looking at the uterus. The problem with ultrasound is that you can't see the fallopian tubes except in very specific conditions. Under general circumstances, the fallopian tubes just blend into the background and you really just can not see them with an ultrasound. But you can see the uterus and you can see a number of things about the uterus that you really cannot see in any other way. For example, the uterus very commonly has little tumors, little bumps that are called fibroids and they can be quite problematic. They can grow into the wall of the uterus and they can disrupt implantation. They can cause pain and irregular bleeding and so on and you might not see that with any other way. Most fibroids are inconsequential. They're located some place where they just don't matter, but if they are in a critical spot, you want to know about it because you'd like to go and remove those before the patient tries to get pregnant. That's the primary thing we look for with ultrasound. The other thing that the ultrasound tells you is whether the uterus has a normal shape . Some women have a double horn uterus or one that is shaped like a "y" or like a 'v' as opposed to the usual kind of pear-shaped that is thought to be normal. There would be no other way for you to know that other than to go through an ultrasound test or perhaps to use an HSG.
How will my doctor test for male infertility?
It's important to remember that it takes two to make an embryo. So, just as there are female factors involved in infertility, there are male factors in infertility. The male has to produce a sufficient number of sufficiently viable sperm to be able to achieve fertilisation, and the delivery of the genetic material from the sperm into the egg that causes that egg to become an embryo. The best test that we have for this is a simple semen analysis. In other words, the man is asked to produce a specimen, typically into a cup or other kind of container, and then this sample is analysed in the laboratory. We measure the volume of the semen, we look at the concentration of sperm within the sample, we look at what proportion of the sperm are swimming, and then we also look under high magnification to see what proportion of the sperm heads have a normal shape. If the sperm heads are abnormally shaped, this may be an indication of male factor infertility, and a strong indication that if we put those sperm in with an egg, that fertilisation in fact will not be achieved. It's important to realise that semen analyses vary from time to time, and therefore, that first of all we need a standardised period of time of abstinence, meaning a lack of ejaculation for at least forty eight hours, and no more than seven days. Also it's important to repeat the test at least once. In other words, it's good to have at least two tests to substantiate that whatever the finding is, is really true; that a normal sperm is normal again, perhaps a month later, or that an abnormal sperm specimen is an indication of an abnormal semen analysis.
Are infertility tests commonly covered by insurance?
Insurance coverage for infertility testing and infertility treatment is extremely variable in different parts of the country. For example, in New York, Massachusetts, Illinois there is what is called “manadated coverage,” so couples have coverage both for the testing as well as for the treatment. In other states, the diagnostic testing is covered but not the treatment. In other states nothing is covered at all. You really have to check with your insurance carrier. Here in California, the majority of insurances do not anything to do with infertility. Some insurance companies do cover the diagnostic testing, but generally exclude any kind of treatment, whether it is insemination or fertility medications or even in vitro fertilization. We've been working long and hard to get this changed, so perhaps by the time you're seeing this, the circumstances surrounding this issue will have changed.