Female Fertility Evaluation
An integrated fertility plan that takes into account both male and female issues offers couples the best chance of establishing a pregnancy. While this book offers the latest guidelines for evaluating and managing male fertility problems, it is important to keep in mind what is going on from the female side as well. I always recommend that couples going through the Sperm Boot Camp also make sure that the woman is undergoing an evaluation during this period, if she has not done so already.
There are some exceptions, such as couples in which the man has no sperm at all (azoospermia) and the woman decides to put her evaluation on hold until the cause of her partner’s issue can be determined. This is a reasonable approach. However, for the majority of couples, a simultaneous evaluation of both the male and female sides is best.
Where to Get the evalation
Women often have their initial fertility evaluation with their regular ob-gyn, the doctor they see for their routine Pap smears and other general gynecologic issues. Most ob-gyns have been trained to perform a basic female fertility evaluation and may offer basic treatments such as clomiphene. If these initial efforts are not successful, then the woman is usually referred to a fertility specialist.
Specialists in female fertility are called reproductive endocrinologists, or REs. REs generally see only fertility patients, and most do not deliver babies; they will pass the woman back to her regular ob-gyn once she is eight to ten weeks pregnant.
At the initial appointment, the RE looks over the woman’s history, performs a physical exam, and reviews the results of whatever previous fertility testing has already been performed. On the basis of this assessment, he or she will determine if further testing is indicated. The fertility evaluation checks to see whether the woman is ovulating normally, whether she has any hormone abnormalities, and whether there are any structural problems (such as with the fallopian tubes or the uterus) that may be contributing to an inability to conceive.
Besides treating any potentially reversible problems that are diagnosed, REs offer a variety of treatments that can be used to increase the chances of pregnancy for a couple. See "Female Fertility Treatments" for more information.
Basic Female Fertility Evaluation
Basic fertility testing for a woman includes some combination of:
1) Basic fertility history
2) Blood hormone testing
3) Ovarian reserve testing
4) Transvaginal ultrasound
5) Hysterosalpingogram
6) Sonohysterogram
7) Laparoscopy
Not all of these tests (other than a basic fertility history) are indicated for every woman. Testing should be individualized for each patient depending upon her personal history and clinical situation.
Basic fertility history
A basic female fertility history will review:
1) Prior pregnancy history
2) Abnormal cycle length (less than 27 days or greater than 32 days)
3) History or symptoms of endometriosis
4) History of cervical procedures (such as LEEP for cervical dysplasia)
5) Known tubal or uterine problems
6) Family history of known female fertility problems
7) Prior history of surgery involving any of the reproductive organs
Blood hormone testing
Generally involves some combination of:
1) Day 21 progesterone: 3 ng/mL or greater is consistent with ovulation, while over 10 ng/mL increases the likelihood of conception
2) Thyroid hormone level
3 )Prolactin
4) Estradiol
5) FSH or AMH (anti-Mullerian hormone)
Ovarian reserve testing
Ovarian reserve can be evaluated in multiple ways:
1) Day 3 FSH: normal is under 10 IU/L, abnormal is over 15 IU/L
2) Anti-Mullerian hormone (AMH) levels- higher numbers consistent with better ovarian reserve
-For example of woman under 35yrs of age: Normal AMH 1.5-4.0 ng/mL
Low Normal 1.0-1.5 ng/mL
Low 0.5-1.0 ng/mL
Very Low < 0.5 ng/mL
3) Antral follicle count by transvaginal ultrasound, performed within the first four days of the cycle: 5 or more follicles is good, 2–4 follicles is fair, 1–2 follicles is poor
4) Clomiphene challenge test, with FSH levels checked on day 3 of the cycle, clomiphene taken on days 5 through 9, and the FSH level repeated on day 10: normal FSH on day 3 is less than 10 IU/L, while on day 10 it should be less than 3 IU/L; an abnormal FSH level on either day would be more than 15 IU/L
Imaging Studies
Transvaginal ultrasound
Transvaginal ultrasound can be used to do an antral follicle count (see above). Also used to evaluate for pelvic masses, ovarian cysts, fibroids, and structural uterine abnormalities
Hysterosalpingogram
An imaging test that can look for structural abnormalities of the uterus and fallopian tubes
Sonohysterogram
A test which uses ultrasound to check for abnormalities of the uterus and uterine lining
Laparoscopy
An outpatient procedure in which a small, lighted scope is used to look into the abdomen under anesthesia, checking for problems such as endometriosis, ovarian cysts, and scar tissue
Common Female Fertility Problems
Ovulatory Dysfunction
Women with ovulatory dysfunction may be releasing an egg at only irregular intervals or not at all. A variety of treatments are available for women with ovulatory dysfunction. Some treatments are aimed at the source of the problem, such as metformin in women with polycystic ovarian syndrome. Medications such as clomiphene, tamoxifen, and letrozole can often normalize abnormal ovulation. Ovulation can also be triggered with an injection of HCG given at the correct time in a woman’s cycle. Gonadotropins can also be used to overcome ovulatory problems.
Polycystic Ovarian Syndrome (PCOS)
Women with PCOS produce too many androgens (male hormones), which can interfere with ovulation. Obesity is a significant risk factor for PCOS, but women who are not obese can have this hormonal problem as well. Treatments include exercise and weight loss for women in whom obesity is contributing to their hormone imbalance. Medications such as metformin are often used to decrease insulin resistance and help to normalize ovulation. If these are not effective, then hormonal medications such as clomiphene, tamoxifen, or letrozole are often helpful in reestablishing normal ovulation. A more aggressive treatment option involves making small holes in the ovaries; these holes reduce the amount of ovarian tissue present, which helps alleviate the hormonal problems.
Endometriosis
Abnormal deposits of endometrial tissue can cause blockage of the fallopian tubes, as well as interfere with the transfer of eggs from the ovaries to the fallopian tubes. Endometriosis is often painful, but sometimes there are no symptoms at all. One type of treatment involves prescribing medications that suppress hormone production, but a pregnancy cannot be established while these medications are being taken. The diagnosis of endometriosis is generally made by laparoscopy, and definitive treatment is typically achieved by laparoscopic ablation (destroying the abnormal tissue in a laparascopic procedure).
Pelvic Adhesions
Scar tissue can be present within the pelvis as a result of prior surgeries, infections, or endometriosis. Known as adhesions, this scar tissue can cause fallopian tube obstructions or interfere with the transfer of eggs from the ovaries to the fallopian tubes. Adhesions can be treated laparoscopically, but the scar tissue may come back over time.
Uterine Abnormalities
Abnormalities of the structure of the uterus, such as a uterine septum (congenital malformation), polyps (spots of abnormal endometrial tissue growth), and fibroids (abnormal growths of muscle tissue), can make it difficult to establish or maintain a pregnancy. Some of these uterine problems can be managed with a minimally invasive procedure called a hysteroscopy. However, larger fibroids or more severe structural abnormalities may require laparoscopic or open surgical repair.
Ovarian Cysts
An ovarian cyst is a fluid-filled sac or pocket on the ovary. Many ovarian cysts come and go, and do not cause fertility problems. However, if ovarian cysts get large enough, they can interfere with normal ovulation, or even cause obstructive problems. Large cysts can be treated laparoscopically or sometimes aspirated (drained).
Decreased Ovulatory Reserve or Premature Ovarian Failure
A woman is born with all of the eggs she will ever have. Menopause is reached when the reserve of eggs has been exhausted. Decreased ovulatory reserve, or a low egg supply, is more common in women over the age of forty, but it is sometimes seen in woman as young as their late twenties. Normal ovulatory cycles become less common when the egg supply is low, and these women do not respond as well to fertility medications such as gonadotropins. Premature ovarian failure is defined as the onset of menopause before the age of forty.