Fertility Evaluations for Women
Common problems that cause infertility in women include abnormalities in ovarian function or anatomical abnormalities of the uterus or fallopian tubes.
There are many different forms of ovarian dysfunction, which result in ovulation problems or abnormal hormone production throughout the menstrual cycle. Evaluation is primarily through hormone testing. Often thyroid hormone abnormalities, prolactin abnormalities, polycystic ovary syndrome, hypothalamic amenorrhea, and decreased ovarian reserve are discovered. Some of these underlying conditions can be treated to restore normal ovarian function and ovulation but others require the use of fertility medications. Understanding the underlying cause of ovarian dysfunction enables us to choose the most effective treatment option.
Ovarian reserve testing is important for all patients, even if ovarian function appears to be normal. Ovarian reserve refers to the remaining egg supply in the ovaries and is closely correlated with fertility potential using treatment. Women are born with a finite supply of eggs and the supply declines over time. There is a great deal of individual variation in the rate of decline of the egg supply, and of concern is that some women will have decreased ovarian reserve. Most forms of fertility treatment require medications to stimulate the ovaries, but with low ovarian reserve there is a lower chance that the ovaries have the desired response to medications. We typically use blood levels of AMH to assess ones ovarian reserve, but we also use ultrasound to perform an antral follicle count of the ovaries.
Problems with the fallopian tubes are very common. Blockages of the fallopian tubes can prevent the egg from entering the tube after ovulation, or prevent sperm from ascending into the tube to reach the egg. Fallopian tubes can also become swollen and accumulate fluid which is unhealthy for a developing embryo. Tubal abnormalities also increase the risk of having an ectopic pregnancy, where an embryo implants inside the fallopian tube, which is not viable and also dangerous because the tube can rupture. The tubes are evaluated by the hysterosalpingogram (HSG) test. Women with endometriosis, pelvic adhesions, and prior sexually transmitted infections are at increased risk of having tubal abnormalities.
There are both congenital and acquired problems of the uterus. Approximately 2% of women are born with a uterine malformation that can cause problems with either conception or miscarriage. Other problems of the uterus can develop over time, such as polyps, fibroids, or scar tissue. Polyps and fibroids are benign growths of the inner lining of the uterine cavity or muscle cells within the walls of the uterus, respectively. Scar tissue within the uterine cavity can develop from prior infections or surgeries in the uterus, such as a D&C. The HSG test or saline ultrasound (sonohysterogram) is used to reveal structural abnormalities of the uterus.
Failure of implantation is another cause of infertility in a small percentage of patients. Implantation can be impaired when there are structural problems of the uterus, but some patients appear to have a problem with the function of the uterine lining, and a less hospitable environment for implantation of an embryo. The Endometrial Receptivity Analysis (ERA) test evaluates the endometrium (uterine lining) to see if it is receptive for embryo implantation.
When the Results Are In
Sometimes a couple tests “normal” for their fertility evaluations, yet still experiences difficulty conceiving or sustaining a pregnancy. A completely normal workup results in the diagnosis of unexplained infertility. When this is the case, we consider looking for more answers from: