Trying to conceive can be an incredibly stressful and all-consuming time for any couple. Others around you may conceive seemingly easily but it may not happen immediately for you. Knowing when you can seek help can help you to feel empowered in your journey.
If your own fertility and that of your partner is normal, there will be roughly a 25% chance of becoming pregnant each cycle.
This post explains what tests your doctor may consider, and what the results may mean.
When to see a doctor about your fertility
In most situations, even if women are expected to have reduced fertility eg severe endometriosis, we ideally like to give a good chance for natural conception as it can actually be very difficult to predict who will and wont conceive spontaneously. Therefore giving yourself some time with regular intercourse and cycle tracking to identify ovulation and optimise the chances of conception is important.
If you find you dont conceive spontaneously, here is when you should seek further advice:
1. If you have no medical problems, are under 36 years old with regular cycles – after TTC for 12 months
2. If you have no medical problems, are over 36 or younger than 36 but have irregular menstrual cycles – after TTC for 6 months
3. If you have significant concerns about your fertility already or are taking any medication which may have an effect on pregnancy then see your doctor as soon as you start TTC.
When you do go to see a doctor about your fertility, your partner should come with you to the appointment.
Female fertility tests
Ultrasound scans
A transvagainal ultrasound scan will be carried out to look at your ovaries, womb and fallopian tubes. This will involve a probe being inserted into the vagina to gain the best views of the reproductive organs. The scan can give an initial indication of any issues such as endometriosis, fibroids or cysts. These ultrasound scans are painless.
Blood tests
The chief hormones involved in the process of ovulation are follicle stimulating hormone (FSH), luteinising hormone (LH), oestrogen and progesterone. In addition, another hormone called prolactin can interfere with the normal secretion of FSH.
Your doctor will usually measure the following hormones:
- LH
- FSH
- Oestrogen
- Progesterone (it is best to check this level in the 2nd half – approx day 21 of your menstrual cycle)
- Thyroid hormones
- Testosterone
The commonest condition that affects ovulation is called polycystic ovary syndrome (PCOS) where there is not only an imbalance between LH and FSH, but there is also an excess production of the male hormone testosterone.
Disorders of the thyroid gland can adversely affect fertility too.
Halfway between ovulation and your next period, progesterone should be at its maximum level. Reduced progesterone level at this time of the cycle (about day 21 of a 28 day cycle) will indicate that ovulation is unlikely to have taken place.
Tubal Tests
Hysterosalpingography (HSG)
An HSG is an X-ray of the uterus and fallopian tubes. It can cause you to experience a moderate amount of discomfort rather like period pains.
A special dye is injected into the cavity of the womb which shows up on an X-ray screen and the doctor is able to see the fluid filling the uterus and then passing along both tubes to enter the cavity of the abdomen.
If the dye fails to enter the tubes this may indicate a blockage or simply a temporary spasm of the tubes at this site. The HSG is therefore useful in being able to demonstrate the site of any tubal obstruction and also to show the presence of any irregularity in the shape of the cavity of the womb.
Hysterosalpingo-contrast sonogrphy (HyCoSy)
HyCoSy uses ultrasound instead of X-rays. A fine tube is passed through the cervix. A vaginal ultrasound scan is carried out and the scan picture is seen on the video screen. When fluid is injected into the tube, the screen shows the fluid filling the cavity of the uterus before passing along the length of each fallopian tube.
The big advantage of HyCoSy over HSG is that the test can be carried out in an out-patient clinic without requiring X-ray facilities. Furthermore, there is no exposure to irradiation which can be a cause of concern to some women.
Many women report after an HSG or HyCoSy greater success at natural conception, as many as 25% in the initial 3 months after. This may be because the tubes get flushed with fluid which can displace any mild non-obstructive blockages.
Laparoscopy
This test is performed under a general anaesthetic. A tiny incision is made at the lower border of the tummy button and the abdominal cavity is filled with carbon dioxide gas in order to create more space to accurately view the pelvic organs.
A slim camera called a laparoscope is inserted into the abdominal cavity and the womb, tubes and ovaries are thoroughly inspected to check for pelvic problems such as endometriosis and fibroids. Dye is injected into the womb through the cervix. If the tubes are healthy, the dye can be seen passing along them and escaping through the outer openings of the tubes.
Laparoscopy allows a direct view of the pelvic organs and thereby permits a much more accurate assessment, particularly to identify the presence of endometriosis. The majority of patients are able to leave the hospital the same day.
Hysteroscopy
Hysteroscopy involves the insertion of a camera through the cervix to look inside the womb. The womb can either be distended with carbon dioxide gas or a suitable fluid.
The operation may be carried out under mild sedation and local anaesthetic or under a full general anaesthetic.
Hysteroscopy is a most valuable investigation to investigate any structural changes in the womb that may cause obstructions such as fibroids, or extra walls dividing the cavity. After D & C operations, adhesions may sometimes form between the internal walls of the uterus, preventing implantation which can be identified with hysteroscopy.
Male fertility tests
The basic fertility screening test for the male is the semen analysis. In general, the lower the sperm count and the poorer the sperm quality, the longer it will take and the more difficult it may be for a pregnancy to occur.
He will be asked to produce a sample by means of masturbation directly into a special sterile container. It is important that the semen sample is kept warm and is brought to the laboratory for testing within one hour of production.
After the sample volume has been measured the following calculations are carried out:
- The number of sperm per millilitre (ml).
- The percentage of sperm moving and the graded quality of movement ranging from good motile sperm down to completely non-motile sperm.
- The percentage of abnormal sperm.
- The number of white cells in the sample is noted as this may indicate infection.
There can be considerable fluctuation in the results between different samples from your partner, so a reduced semen analysis will always be checked with one or two repeat tests.
Ovarian reserve tests
Ovarian reserve tests were developed by IVF clinics to predict how a woman having IVF treatment would respond to the drugs used to stimulate the ovaries and ultimately how many eggs she may produce.
Recently, however , there has been a trend for women to have their AMH levels checked to determine if they should freeze their eggs or not.
Ovarian reserve can be assessed by measuring 2 important hormones:
- Follicle stimulating hormone (FSH)
- Anti-Müllerian hormone (AMH)
or by an ultrasound scan that counts the growing follicles within each ovary.
As FSH levels vary through the cycle it must be measured in the first
few days of menstruation (day 2-5 of the cycle). In contrast AMH is produced by the growing follicles and is a direct marker of the number
of follicles.
AMH varies with age but normal levels are somewhere between 3 and 35.
Lower levels are indicative of poor reserve and higher levels associated with, but not diagnostic of, polycystic ovaries. AMH varies less through the cycle and so can be measured at any time.
The growing follicles can be seen on ultrasound. During the scan, the follicles are counted to give a total antral follicle count (AFC).
Age is, however, the ultimate marker of ovarian reserve. In general, older women with good reserve are likely to do less well in IVF than younger women with poor reserve.
It is important to remember that these tests were developed to inform IVF treatment and not your natural fertility. Many women with low ovarian reserve will conceive without any problems whilst others with a good ovarian reserve may take time and need fertility treatment.
There is no doubt that tests showing a good ovarian reserve are reassuring
but they do not guarantee a baby. Equally a poor or impaired ovarian reserve does not mean you will struggle and need fertility treatment. Therefore it is not generally advised to have these ovarian reserve tests unless fertility treatment is already required. Instead, they can be used to predict response to treatment and guide dosing of medications.
Fertility guidelines: