InterNational Council on
Infertility Information Dissemination
Routine Fertility Workup
The following is a listing of tests generally included in a routine fertility work-up. Please note that every reproductive endocrinologist (RE) has his or her own standard protocol, and the following is intended to be a basic guideline.
If you are not seeing an RE and your OB/GYN does not have the facilities to conduct these routine tests, you should seriously consider switching to a doctor who does. Minimally, a doctor treating fertility patients should have the following:
1. Availability of staff and technicians seven days per week. If your doctor or clinic does not offer weekend and holiday hours, you are clearly not in the hands of someone whose priority is helping you get pregnant.
2. Transvaginal ultrasound equipment. You should not undergo clomid, metrodin or pergonal treatment unless this equipment is available for routine monitoring. Though many OBs prescribe Clomid without doing this monitoring, it is in your best interest to have periodic ultrasounds to ensure that the Clomid is indeed stimulating ovulation and that the follicles are releasing the eggs. Under no circumstances should a patient undergo metrodin or pergonal treatment without ultrasound monitoring. If you are using intra-uterine insemination (IUIs), ultrasounds are required for accurately timing insemination with ovulation.
3. An on-site, certified lab to do semen testing and prep for IUIs and post coital tests, as well as facilities to do E-2, blood HCG beta and progesterone tests.
YOUR FIRST APPOINTMENT: Try to schedule your first appointment with your RE during the first week of your cycle. This will enable him/her to take baseline levels of FSH (follicle stimulating hormone) and LH (lutenizing hormone). Most REs also do routine screening of both partners---AIDS, hepatitis, etc. Medical histories for both partners will be taken. Try to keep track of the length of your menstrual cycles for several months beforehand. Charting Basal Body Temps (BBTs) for several months will also give your doctor some insights---as will using home Ovulation Predictor Kits and recording the results.
YOUR SECOND APPOINTMENT: This appointment should be scheduled on the day of LH surge---BEFORE ovulation. In most cases, you will be directed to use home ovulation test kits and call for an appointment on the day you detect a surge. Included in this exam will be:
CERVICAL MUCUS TESTS: including a post-coital test (PCT) to see that sperm can penetrate and survive in the cervical mucus, and a bacterial screening. It is important to note that the appropriate time to do PCTs is just before ovulation when mucus is the most "fertile." PCTs at other times may give false results.
ULTRASOUND EXAM(S): On the day of LH surge are used to assess the thickness of the endometrium (lining of the uterus), monitor follicle development and assess the condition of the uterus and ovaries. If the lining is thin, it indicates a hormonal problem. Fibroid tumors can often be detected via ultrasound, as well as abnormalities of the shape of the uterus and ovarian cysts. In some cases, endometriosis can also be detected. Many doctors order a second ultrasound two or three days after the first. This second ultrasound confirms that the follicle actually did release and can rule out lutenized unruptured follicle (LUF) syndrome---a situation in which eggs ripen but do not release from the follicle.
HORMONE TESTS: if the blood test at your first appointment indicated a high LH to FSH ratio, an indication of polycystic ovarian disease (PCOD), your doctor will order an "Androgen Panel" to check levels of free testosterone and dihydroeprandrostone (DHEAS). Other tests tests that should be conducted on the day of LH surge include LH, FSH, Estradiol and Progesterone. Tests which can be done at any time (and therefore done at the second appointment) include: Prolactin, Thyroid Stimulating Hormone (TSH), Free T3, Free Thyroxine (T4), Total Testosterone, Free Testosterone, DHEAS and Androstenedione.
The normal hormone levels for each of these during specific parts of your cycle are as follows:
Lutenizing Hormone (LH)
Follicular Phase (day two or three): <7miu/ml Day of LH Surge: >15mIU/ml
Follicle Stimulating Hormone (FSH)
Follicular Phase: <13miu/ml Day of LH Surge: >15 mIU/ml
Day of LH Surge: >100 pg/ml Mid Luteal Phase (seven days after O): >60 pg/ml
Day of LH Surge: <1.5 ng/ml Mid Luteal Phase >15 ng/ml
Prolactin: <25 ng/ml
Thyroid Stimulating Hormone (TSH): 0.4 to 3.8 uIU/ml
Free T3: 1.4 to 4.4 pg/ml
Free Thyroxine (T4): 0.8 to 2.0 ng/dl
Total Testosterone: 6.0 to 89 ng/dl
Free Testosterone: 0.7 to 3.6 pg/ml
DHEAS: 35 TO 430 UG/DL
Androstenedione: 0.7 to 3.1 ng/ml
<= less than;>= greater than; mIU=milli International Units; ml=milliliter; pg=picograms; ng=nanograms; uIU=micro International Units; dl=deciliter; ug=micrograms
NOTE: These levels are those used at the Chapel Hill Fertility Center laboratory, and have been excerpted from "The Couple's Guide to Fertility" by Berger, Goldstein and Fuerst, published by Doubleday.
ADDITIONAL TESTING: After the initial workup, many doctors continue with some of the following tests.
HYSTEROSALPINOGRAM (HSG): This test is used to examine a woman's uterus and fallopian tubes. It is essentially an x-ray procedure in which a radio-opaque dye is injected through the cervix into the uterus and fallopian tubes. This "dye" appears white on the x-ray, and allows the radiologist and your doctor to see if there are any abnormalities, such as an unusually shaped uterus, tumors, scar tissue or blockages in the fallopian tubes. If you are trying to get pregnant in the same cycle as an HSG, make sure to schedule the test PRIOR to ovulation so that there is no danger of "flushing out" a released egg or developing embryo.
Although most women report only minor cramping and short-term discomfort during this procedure, some women, especially those who DO have blockages, report intense pain. Speak to your doctor about taking a pain medication about 30 minutes prior to the actual procedure.
HYSTEROSCOPY: If a uterine abnormality is suspected after the HSG, your doctor may opt for this procedure, performed with a thin telescope mounted with a fiber optic light, called a hysteroscope. The hysteroscope is inserted through the cervix into the uterus and enables the doctor to see any uterine abnormalities or growths. "Photos" are taken for future reference. This procedure is usually performed in the early half of a woman's cycle so that the build-up of the endometrium does not obscure the doctor's view. However, if the doctor is planning to do an endometrial biopsy at the same time, it is done near the end of the cycle.
LAPAROSCOPY: A narrow fiber optic telescope is inserted through a woman's abdomen to look at the uterus, fallopian tubes, and ovaries and to discern endometriosis or pelvic adhesions, and is the best diagnostic tool for evaluating the ovaries. This test us usually done two or three days before menstruation is expected, and only after an HCG beta blood test ensures the woman is not pregnant.
ENDOMETRIAL BIOPSY:This procedure involves a scraping a small amount of tissue from the endometrium shortly before menstruation is due--- between 11 and 13 days from LH surge. It should ONLY be performed after an HCG blood test shows the woman is not pregnant. This test is used to determine if a woman has a luteal phase defect, a hormonal imbalance which prevents a woman from sustaining a pregnancy because not enough progesterone is produced.
Information compiled by:
Theresa Venet Grant
Public Information Director
InterNational Concil on Infertility Information Dissemination (INCIID)
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The information reproduced above is provided in an unedited form as received from INCIID and therefore may not accurately or completely reflect the medical advice or opinion of Georgia Reproductive Specialists or Dr. Mark Perloe. This information is not intended as a substitute for medical advice of physicians. The reader should regularly consult a physician in matters relating to his or her health and particularly with respect to any symptoms that may require diagnosis or medical attention.