Fertility

Introduction:

Lab tests are a valuable assessment tool. They allow the clinician a behind-the-scenes look at the patient, providing both an initial diagnosis and a benchmark for measuring the success of a treatment plan. In the world of fertility, lab tests are a common language shared by the different practitioners.  The most important task of the fertility specialist is to assist patients in maximizing their window of opportunity.

The ability to spot red flags in a patient’s work-up will allow the practitioner to effectively guide the patient in considering the most appropriate treatment options in a timely fashion. Red flags include male fertility factor (poor sperm), diminished ovarian reserve (poor egg quantity and quality), blocked fallopian tubes and/or other structural concerns, hormonal imbalances, and any other significant issues that may interfere with one’s fertility.

When to test:

The fertility work-up for men:

• A semen analysis is best performed as early as possible in the treatment timeline.  Often abnormalities can be addressed naturally, however results may take up to 12 months as it takes several months for a sperm to develop.

The fertility workup for women is age dependent:

• At 30 years old – completed after one year of trying to conceive
• At 35 years old – completed after 6 months of trying to conceive
• At 40 years old – completed at the beginning of trying to conceive

For the gentlemen:

Semen analysis:

What we want to know: how many swimmers are there with each ejaculation?  This is the total motile sperm, or TMS.  Total motile sperm is calculated using the volume, concentration, and motility.

For the ladies:

At home testing:

Ovulation Predictor Kits (OPK):

A surge of  LH (Luteinizing Hormone) occurs approximately 24 hours before ovulation.  With conception, timing is everything. Urine test kits monitor the  LH (Luteinizing Hormone) and help predict the time of ovulation, so you can maximize the timing of intercourse (TIC) or intrauterine insemination (IUI), to help ensure that sperm will be present when the egg is released.

Basal Body Temperature (BBT) charts:

A specific hormone change during your cycle – the secretion of progesterone after ovulation – causes a rise in your BBT.  Keeping track of your BBT (your body temperature at rest, taken when you first wake up) is a way to track your cycles and become more familiar with your monthly patterns, primarily if and when you are ovulating.  BBT charts do not predict when you will ovulate, for that you want to use an OPK.   BBT charts will provide a great deal of insight as to how your cycle is working.  That being said, they can be 1) labor intensive, and 2) prone to variability due to anything that interferes with sleep patterns, including travel.

Blood testing:

AMH (Anti Mullerian Hormone)

AMH is a relatively new marker whose role in assessing a woman’s fertility is still being determined. AMH levels reflect the quantity, but not the quality of the follicles. The most established role for AMH measurements is before IVF is initiated, because AMH can be predictive of the ovarian response, or how many eggs are expected to respond to the stimulation meds.

Cycle Day 3 FSH (Follicle Stimulating Hormone): 

As the ability of the ovaries to produce good quality eggs decreases, the level of FSH rises.  FSH must be evaluated along with estradiol.

Cycle Day 3 E2 (Estradiol): 

High levels of estradiol at this point in your cycle may signal of poor egg quality or quantity.  High levels of estradiol suppress FSH production.

Cycle Day 3 LH (Luteinizing Hormone): 

LH levels in the blood, as distinguished from the urine levels used to monitor LH surge prior to ovulation, provide another marker for determining ovarian function.   High levels of LH are found in polycystic ovarian syndrome (PCOS). Low levels of LH are associated with diminished egg quantity and quality. LH levels must be interpreted relative to levels of FSH and E2.

Prolactin: 

Prolactin is the “pro-lactation” hormone, and is normally made in larger quantities when a woman is breast feeding.  These higher levels can prevent ovulation.  Prolactin levels may be abnormally elevated for other reasons.

TSH (Thyroid Stimulating Hormone): 

The thyroid gland plays a major role in regulating the metabolism of the body.  Abnormal thyroid function can interfere with ovulation, and more significantly, can be a significant risk factor for miscarriage.

Progesterone: 

This is the “pro-gestation” hormone, and adequate levels are needed to maintain a healthy pregnancy.  Progesterone is only secreted after ovulation, so it can also be used to confirm ovulation.  Typically we measure Progesterone 7days past ovulation.

Vitamin D, 25 – OH:

Vitamin D exerts a wide variety of positive biological effects. For pre-conception, Vitamin D enhances the body’s sensitivity to FSH, and promotes better egg development.  For pre-natal care, Vitamin D stabilizes the immune system thus supporting implantation and pregnancy. Vitamin D also contributes to better moods and an overall sense of well-being.

Homocysteine :

Homocysteine levels are linked to to folic acid.  Elevated homocysteine levels may be associated with pregnancy complications such as spina bifida, cleft palate, preeclampsia, and recurrent pregnancy loss. Extra folic acid can help reduce some of the risks associated with elevated homocysteine. Other risk factors are the result of blood clotting issues, and therapies such as Low Dose Aspirin (LDA) or Lovenox may be the treatment of choice. These therapies need to be managed by a perinatal specialist.

DHEA-S:

Elevated levels of DHEA-S are found in PCOS (polycystic ovarian syndrome).  DHEA-S is considered an androgen, along with testosterone, and can interfere with normal ovulation.  Androgens are known as the “boy” hormones.  Women have these hormones, too, just in smaller amounts.  When levels become elevated, they can interfere with our “girl” functions.

Testosterone:

The best known of the androgens, testosterone can significantly disrupt ovulation when it is present in high levels, and is typically seen with PCOS (polycystic ovarian syndrome).

Imaging used to evaluate your reproductive organs:

Hysterosalpingogram (HSG):

Used primarily to determine if the fallopian tubes are open, it can also identify many structural abnormalities in the uterus.  During this procedure a dye is injected into the uterus and imaged as it makes it’s way through the fallopian tubes.  It is performed in the first half of the cycle, usually between day 7 -10.

Ultrasound:

An ultrasound can look at both the ovaries and the uterus.  For the ovaries we are counting the number of the follicles present.  When imaging the uterus, we are measuring the thickness of the endometrial lining, and looking any abnormalities such as fibroids, polyps, or a septum.

Antral follicle count (AFC):

An ultrasound image of the ovaries at the beginning of a cycle, counting the number of immature follicles on the surface of each ovary.  This can be an excellent indicator of ovarian potential.

Questions?  Contact us.