A detailed guide to fertility testing for women and men

An overview of fertility testing for women and men

It’s likely if you’re reading this then you have been trying to conceive for a while. Fertility testing is the first step in the journey to empowering yourself towards a positive fertility journey.

The latest research and guidance states that anyone under the age of 35 who has been actively trying for 12 months or 6 months over the age of 35 should approach their GP about referrals into a specialist for fertility investigations. The reason for this is those with normal fertility have about a 20% chance per cycle and 80% of those become pregnant within the first year of trying so this is an important first step and one which you should feel no embarrassment about.

Depending upon which NHS trust you fall under you will either be referred to see a gynecologist or a fertility clinic. Unfortunately, the process is not always quick, and you could wait 3 months or more for an appointment so whilst your waiting it’s worth thinking about how to increase your chances of trying to conceive which we have a great article on. As such it is important if possible, for both partners to attend this initial appointment. For those of you who like to listen and watch here’s Rachel discussing fertility testing for women.

Initial Appointment for Fertility Testing

It’s in your best interest if both partners attend. This appointment will usually be around 20 minutes but can vary depending upon the complexity of your past medical history, level of examination required and planning, and discussion of investigations required.

It’s worth being prepared for this appointment and you will be asked some personal questions, but please don’t feel anxious about answering these, the doctors and nurses are professionals and deal with this every working day. But be sure to prepare the following.

 

  1. Pregnancy history including any miscarriages
  2. Your menstrual cycle history – this includes average length, regularity, the amount of bleeding and the level of pain experienced and whether they have disappeared or happen infrequently. These are to ascertain the ease of prediction of ovulation and other specific illnesses and conditions which impact fertility such as PCOS (Polycystic ovarian syndrome).
  3. Sexual history – including how long you have been trying to get pregnant, how many times a week you have intercourse, any previous STD’s this is important as it will allow the specialist to infer whether on a normal distribution curve expect to have become pregnant during your time TTC (trying to conceive).
  4. Specific medical history – They will be interested in chronic conditions, any treatment especially in the pelvic area for both men and women, any prostate problems. A full list of medications you are currently taking.

 

They will likely ask some lifestyle questions about smoking, alcohol intake, exercise and take a weight and height. From this information the doctor will build a picture about your specific case. They will likely perform an examination – they know that you are likely to be anxious and worried about this and are used to dealing with this. They will take a slow and relaxed approach ensuring you understand exactly what is being done and that you feel comfortable – remember if you don’t feel comfortable speak up its ok to ask them to stop.

Following this, they will decide upon an appropriate investigation plan and they should talk you through it. Doctors have a lot of pressure in terms of waiting lists and numbers which they have to see in clinic and as such can sometimes rush these explanations, please remember that you are perfectly within your rights to understand what’s happening when you leave the room, so if there is something either of you don’t understand ask for clarification.

Fertility Tests and Investigations.

Unfortunately, fertility is a complex issue which means there is no standard investigation pathway and each one is specific to the findings of the initial appointment and the couples’ possible issues. However below we talk about the most common tests.

Blood Work

This is the most common start point with fertility investigations and one that almost all couples will have performed. These are to check levels of hormones in the body which can be a cause themselves or point to specific issue which may be causing infertility challenges. There is a complex relationship between the brain, pituitary gland and ovaries and these tests are designed to look at these pathways.

Hormone

When

Why

Normal Range

What it could mean

Follicular Stimulating Hormone (FSH)

Day 2-4 of your cycle

This is your baseline level and a good predictor of ovarian reserve

3mlu/ml – 10mlu/ml

Your FSH levels inversely correlate to your ovarian reserve – which means a higher result means less reserve. A result greater than 12 mlu/ml can indicate impaired ovarian reserve and greater than 25mlu/ml is often associated with ovarian failure and the menopause.

Luteinising Hormone (LH)

varies

 

Female:

Follicular: 3.3 – 11.3 mIU/mL

Ovulatory: 17.8 – 111mUI/mL

Luteal: 1.1 – 13.4mIU/mL

 

Men: 1.3 – 8.0mIU/mL

 

Females: LH is very complex in its interactions and is linked to FSH and Progesterone. It stimulates growth and maturation of the follicles. As such it useful in the diagnosis of Polycystic ovary syndrome (PCOS) when looked at with the relationship with FSH, and some rare fertility issues such as Turners Syndrome.

Men – LH promotes testosterone production by the Leydig cells, and along with FSH, maintains spermatogenesis

Oestradiol (E2) main biologically active Oestrogen

Specific named point in cycle

It is an indicator for ovarian function.

Follicular: 45 – 854pmol/L, Ovulatory: 151 – 1461 pmol/L, Luteal: 82 – 1251 pmol/L, Postmenopausal < 505

This test is not commonly used in isolation, but results are interpreted with other hormone levels to support diagnosis and treatment.

Progesterone

Usually 7 days before the start of your cycle.

To look for ovulation and to see if your body can support a pregnancy

Follicular:           < 5.0nmol/L

Luteal: 3.5 – 67 nmol/L

Progesterone is vital in ovulation and maintaining a pregnancy after fertilisation. Low levels can show your ovaries aren’t functioning correctly and non-ovulation. It can also show that you may be unable to support an early pregnancy. If you are not pregnant high levels can point to issues with your glands, ovarian cysts and rarely cancers of the ovaries or adrenal glands.

Infections

Anytime

To ensure you don’t have any specific infections

N/A

They may specifically look for HIV, Rubella, Hepatitis B & C

There are many other less common blood tests which may be done.

Ultrasounds for Fertility testing

Ultrasounds are another very common test for women during fertility testing. There are two key types, an external scan which is completely painless. You will go into a room and will be scanned by a sonographer; some cold jelly will be applied to the abdominal skin to improve the visibility during the scan. The second is a transvaginal scan where a small probe will be inserted into your vagina so they can more clearly see the anatomy of your womb, ovaries, fallopian tubes and lining, this can be uncomfortable but is not generally painful.

The ultrasound is often used as part of an initial assessment to determine whether there could be more specific issues which require further examination. This can include endometriosis, fibroids, blockages in your tubes or cysts

Hysterosalpingo-contrast sonography (HyCoSy)

This test also utilises ultrasound technology. The test takes about 15 minutes and is relatively painless but a little intimate in nature. It is done as an outpatient and requires no form of aesthetic or sedation and has no exposure 

to ionising radiation so is a very low risk test. You will have a small tube inserted into your womb through your cervix, where a fluid will be flooded in. During this you will have a transvaginal ultrasound probe inserted with the image recording on a screen. It will show the fluid filling the womb space and then moving through the fallopian tubes. It is used to further identify any potential blockages.

Hysterosalpingography (HSG)

A hysterosalpingogram is a fertility test which uses X-ray image of the uterus and Fallopian tubes. The test is performed in the X-ray department. It can cause you to experience a moderate amount of discomfort rather like period pains. A special dye is used which will clearly show on an x-ray it is inserted into the womb and this then fills the womb fallopian tubes.

If the dye doesn’t enter the tubes this may indicate an obstruction at the junction between the womb and the tubes or simply a temporary spasm of the tubes at this site. Sometimes the dye can be seen to enter the tubes which then become distended owing to an obstruction at their outer ends. The HSG is a good diagnostic tool to indicate the site of any fallopian tube obstruction and indicate any irregularity in the shape of the cavity of the womb.

Hysteroscopy

This procedure allows the medical team to get a good view and inspect the inside cavity of the womb. It does this through insertion through the cervix of a very fine telescope names a hysteroscope, which is where the procedure gets its name. This sometimes involves the use of a small forceps or clamp to ensure that the cervix remains in place. This procedure can be done with local anesthetic and sometimes under general anesthetic. The womb is then distended (made rigid and open) using either carbon dioxide or a fluid. This test is often performed for those who have experienced repeated miscarriages or those where a possible womb shape irregularity was noticed on another test. Key fertility issues which can be picked up from this test is fibroid s which are thought to have an impact upon fertility and anatomical and genetic issues which mean that implantation may happen but the pregnancy can’t be maintained due to less blood flow to that area of the endometrial layer. Some risks do come with procedure and you could experience heavy bleeding and rarely damage to the cervix and womb.

Laparoscopy

This is a more complex issue which requires the use of general anesthetic and therefore admission to hospital, however it does allow the surgeon to get an uninterrupted view of pelvic organs. A very small incision is made at the base of the bellybutton and the abdomen is filled with carbon dioxide to allow for a clear view of the areas of interest. A small telescope is then used to look at the womb, fallopian tubes, cervix. Finally, a dye is inserted into the womb through the cervix and watched to check the flow through the womb space and into the fallopian tube. This test is used in the diagnosis of severe endometriosis, fibroids, cancers.

Usually you can leave the hospital the same day, however you will need to rest for 48 hours following the procedure. The scar is tiny and over time will virtually become invisible. Below is an interesting video on the pro’s and cons of this procesdure

Male Fertility Tests

Male Fertility testing generally comprises of 3 things bloodwork as discussed above, examination and semen analysis.

Examination – Most external examinations of the genitals are completely normal however some issues can be detected. Sometimes one or both testicles can be small or missing which may prompt a genetic text to see if you have a rare genetic condition with an extra chromosome (XXY). The doctor can also identify the presence of varicose veins around the testicles which can lead to higher blood flow and thus higher temperature which can impact fertility. They can spot excessive fluid around the testicles known as hydrocele. They will look at the anatomy of the penis to ensure that you are able to ejaculate the semen effectively. Finally, they will likely check your prostate to check for signs of infection and or swelling.

Semen Analysis – Please remember that you must abstain from ejaculating for 2-4 days before the test. You will be asked to produce a sample if possible into a container which is then sent to pathology to be analysed. Firstly, they will calculate the exact volume of your sample (normal range is greater than 1.5ml with a pH of 7.2 or higher), from which they will be assessing your sperm under a microscope to identify and calculate the following

  1. Sperm Count – This is the total number of sperms in a sample this can be measured in 2 ways. They will either consider concentration, which in a normal sample you would expect to be higher than 15million sperm per ml or they can use total sperm which should be higher than 39million sperm per ejaculation.
  2. Motility – This is a measurement of the sperms movement and mobility, the normal range is 40% or more motile or 32% or more with progressive motility this means that the sperm are more likely to be able to find their way to the egg efficiently.
  3. Vitality – This is simply whether the sperm cell is live or dead, the normal range is 58% or more live spermatozoa
  4. Morphology – This is the shape or form of the sperm, deformities in the sperm mean that it’s much harder for the sperm to either get to the egg or to penetrate the egg in order to fertilise it. The normal range for this is greater than or equal to 4% normal forms.

Fertility testing will hopefully lead you to a diagnosis of what is causing you challenges in trying to conceive. We have a detailed article on the key fertility diagnoses which you might want to read if you’re interested in where the journey next goes.

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