Fertility Testing
Testing for Women
The main causes of female infertility are ovulation dysfunction or anatomic factors including fallopian tube disease, pelvic adhesions (scar tissue), fibroids and endometriosis. Age and ovarian reserve (egg age) also have significant impacts on the ability of a woman to conceive. Fertility testing of the woman is designed to detect abnormalities which might be corrected. Following is a brief description of each area of testing.
Ovulation Testing. If a woman does not release eggs (anovulation), she will not get pregnant. If she releases eggs infrequently (oligo-ovulation), her chances of getting pregnant are reduced. Most women who have menstrual periods every 24-35 days do release eggs (ovulate); however, regular menses do not guarantee ovulation.
It is important to know if and when ovulation occurs. Women should ovulate approximately 14 days prior to expected menses. Women who have fewer than 13 days between ovulation and menses have short luteal phases and may have reduced fertility. Tests of ovulatory function include: basal body temperature charting, ovulation predictor kits and timed serum progesterone levels. We recommend against performing tests on salivary and cervical secretions as these tests have not proven reliable.
Basal Body Temperature (BBT) Testing measures subtle changes in a woman’s body temperature which occur due to ovulation. After ovulation, the ovary produces progesterone, which causes a woman’s temperature to increase by about ½ of a degree on the Fahrenheit scale. When a special BBT thermometer is used on a daily basis, one can determine both if a woman ovulates and how long her luteal phase lasts. Proper technique is essential in order for your physician to interpret the results.
Basal Body Temperature Charting Technique
- Obtain a BBT thermometer, available at your drug store.
- Place the thermometer at your bedside.
- The day after your menses begin, start recording your temperature.
- Each morning, upon waking and before rising and before drinking anything, take your temperature.
- Record the temperature on a BBT graph.
- Keep recording on a daily basis until your next menses begins.
- The temperature should remain elevated for at least 11 days.
- If you do not get a temperature rise, or if the rise does not last 11 days, consult your doctor.
(BBT Chart Showing Ovulation with Adequate Duration of the Luteal Phase.)
(BBT Chart Showing Short (10 day) Luteal Phase)
(BBT Chart Showing No Evidence of Ovulation)
An Ovulation Predictor Kit (OPK) is another test that patients can do at home, functioning similarly to a home urine pregnancy test. OPKs measure the level of luteinizing hormone (LH), the hormone which triggers ovulation. Typically, LH levels rise rapidly in the 24 hours prior to ovulation. OPKs detect this rise, and are useful in helping couples know when to optimally time intercourse. The optimal time for intercourse is the day following the positive test. If menses occur within 12 days of the positive OPK result, the luteal phase is likely too short to sustain a pregnancy, and a patient should consult their physician.
Optimizing your OPK test:
- If you have regular, predictable menses, begin testing 17 days prior to the day your period is likely to start.
- Testing should occur around the same time each day. Most test kits will instruct individuals to test with the 2nd urination of the day. However, the LH rise is most likely to be detected if testing occurs in the mid afternoon, between 3-7 pm.
- While fluid restriction is not necessary, excessive fluid intake causing very dilute urine may limit the ability to detect LH in the urine.
- Ovulation is likely to occur within 12 – 36 hours after a positive test.
- The best time to have intercourse is the day after a positive test.
Serum Progesterone measurements are a reliable way to document ovulation. The human body produces very little progesterone, except during the luteal phase (two week period between ovulation and menses). Ideally, progesterone is measured at its peak – usually 7 days prior to expected menses. Thus in a 28 day cycle, we would measure on day 21. In a 35 day cycle, we’d measure on day 28.
Some physicians equate a progesterone level greater than 10 ng/ml as evidence of a high-quality ovulation. However, progesterone is secreted in a pulsatile fashion in women, meaning values fluctuate throughout the day during the luteal phase. Therefore, it is quite possible that values less than 10ng/ml may be adequate to support an early pregnancy. Any level greater than 3ng/ml is evidence of ovulation. If your progesterone is less than 10ng/ml, consult your doctor.
Ovulation tests we do not advise: microscopes used to detect for changes in saliva and in cervical mucus are generally not reliable enough to be useful. They will even predict ovulation in men and in women who do not ovulate.
Testing the Anatomy
Pelvic adhesions (scar tissue), endometriosis, fibroids, uterine polyps and blocked fallopian tubes can all contribute to infertility. A thorough evaluation includes a pelvic examination and some form of imaging study. No single imaging study is perfect at detecting all conditions; therefore, in some cases more than one test needs to be performed to thoroughly understand a woman’s anatomy.
Hysterosalpingogram: This is one of the most common studies performed to assess a woman’s anatomy. Translated it means, picture (-gram) of the uterus (hysto-) and fallopian tubes (-salpingo-).
The test is performed in a radiology suite. A speculum is placed into the vagina and a small catheter is introduced through the cervix and into the uterus. X-ray contrast media is then pushed through the catheter to fill the uterus and tubes. The resulting image shows the inside of the uterus (not the walls) and whether the tubes are open.
Uterus with HSG catheter:
X-ray image:
Sometimes an HSG can show whether the tubes are blocked, or if fibroids are present in the uterus. It is a good screening test for uterine malformations. It can also indicate whether a patient is at increased risk for conditions like endometriosis. One limitation of the HSG is that it does not show the walls of the uterus or the ovaries directly.
The HSG image is essentially a shadow of the woman’s anatomy, and there are times when these shadows can be incomplete. In these cases, other tests may be necessary.
The HSG can cause uterine cramping and, in very rare cases, lead to tubal scarring or pelvic infection. Anti-inflamatory medicine such as Ibuprofen are typically recommended prior to the test. Antibiotics are prescribed if a patient is at increased risk for tubal infection.
Ultrasound is the most frequently employed test used by fertility specialists and gynecologists. Ultrasound generally provides an excellent view of the uterus and ovaries, and can be instrumental in diagnosing a wide range of conditions from fibroids, polyps, polycystic ovary syndrome and endometriosis. One limitation of the ultrasound is that it generally does not allow visualization of the fallopian tubes.
Saline Sonography is a test that combines ultrasound with the HSG technique. A catheter is inserted through the cervix. The uterus is filled with sterile fluid and the ultrasound is then performed. Aside from looking into the uterus directly with a hysteroscope, saline sonography is the most sensitive test to detect uterine polyps and fibroids. Frequently, saline sonography is used to complement the HSG test.
Ovarian Reserve
Among fertility specialists, ovarian reserve is the equivalent of a “biological clock.” Most people are aware that women have a biological clock for fertility, a limited time to complete childbearing, after which having a baby becomes unlikely. What most patients are not aware of is that the biologic clock is not the same for every woman. With age, a woman’s fertility decreases and her miscarriage rate and chance of having a baby with a genetic abnormality increases.
Why do some women lose their fertility sooner than others?
- Women are born with all the eggs they will every have – approximately 2 million.
- Everyday, including through childhood, women lose eggs. No matter if she is on birth control, if she is pregnant, or not even menstruating, she is losing eggs.
- Additionally, as a woman ages, the cells around the eggs and the eggs themselves can accumulate damage which is never repaired.
- Therefore, as a woman ages, not only does she have fewer eggs, but a higher percentage of her eggs are abnormal. If she ovulates an abnormal egg, her chances of pregnancy are lower, and her chances of miscarriage and having a baby with an abnormality are higher.
- Women with diminished ovarian reserve were either born with fewer eggs than average, lost them more quickly than average, or over time the eggs accumulated more damage than average.
With time, eggs are lost and more become abnormal.
While many cases of diminished ovarian reserve are never explained, common causes are:
- Age >35
- Smoking
- Genetic Abnormalities (Fragile X Premutation, or X chromosome abnormality)
- Cancer treatments with radiation and certain chemotherapy agents
- The surgical removal of part or all of an ovary
With ovarian reserve testing your physician can estimate whether your eggs have the fertility potential of most women your age, or if your ovaries demonstrate accelerated aging. In practical terms, ovarian reserve is a measure of the number and quality of eggs a woman has in her ovaries.
In cases where a woman has poor quality eggs, or few eggs, she may have a much more difficult time conceiving and she is said to have “diminished ovarian reserve.”
There is no cure for diminished ovarian reserve and generally, a woman’s diminished fertility potential is predicted by any abnormal ovarian reserve test (meaning that while repeating the test may yield a normal result, any prior abnormal result predicts significant difficulty conceiving either spontaneously or with aggressive treatments including IVF). However, it is very important to understand that even a significantly abnormal test result CAN NOT exclude the possibility of pregnancy. Ovarian reserve testing best predicts outcomes with IVF.
Tests for ovarian reserve include: cycle day 3 FSH (follicle stimulating hormone) and estrogen levels, antral follicle counts, clomiphene citrate challenge tests and antimullerian hormone levels.
Day 3 FSH and Estrogen Levels
This is the most common test of ovarian reserve. It is performed on the 2nd or 3rd day of menstrual flow (cycle day 2 or 3). A simple way of understanding this test is to think about FSH as the gas pedal to the ovary. If the ovary is working well, it should not require a lot of FSH to function. If the FSH is high, the ovary probably isn’t working efficiently and the patient has diminished ovarian reserve.
The estrogen (estradiol) level is important for several reasons. For the sake of simplicity, think about estrogen as a way to validate the FSH level. A high estrogen level will lower the FSH and bring an abnormally high FSH into the normal range. Therefore, if both FSH and estrogen are in the normal range, this is reassuring.
How the test is performed:
- Using the first day of menstrual flow as cycle day 1 (CD1), a woman comes to clinic on CD3 ideally (or, alternatively, on CD2 or CD4) to have her FSH and estrogen measured.
- An abnormal test is an indication that the ovarian reserve is diminished.
- An FSH > 10 mIU/ml or an estrogen > 75 pg/ml are considered abnormal.
If your test is abnormal, your physician will have to put this into context, considering your entire evaluation.
Day 3 Antral Follicle Count
This test is performed on the same day as your day 3 labs and measures the number of eggs which are trying to grow in a given month.
Each egg is contained within a follicle (a collection of cells which nurture the egg). If the follicle survives to a certain size, it begins to collect fluid around the egg. This fluid is visible on ultrasound and looks like a small black circle on the ovary.
If we see a large number of follicles on cycle day 3 (CD3), this indicates that the ovary has an ample number of eggs still in hibernation. If we see few follicles, this means that the ovary is more depleted of eggs.
How the test is performed:
- On the same day as your FSH and estrogen are measured, you will empty your bladder and have a vaginal ultrasound.
- The follicles on each ovary are counted.
- If fewer than 10 follicles are seen (on both ovaries combined) you are deemed to have diminished ovarian reserve.
Normal: > 10 follicles seen on two ovaries combined
Abnormal: < 10 follicles seen on two ovaries combined
As with Day 3 Labs, an abnormal test must be put into context by your physician.
Clomiphene Citrate Challenge Test (CCCT)
Some women have normal day 3 labs, but still have diminished ovarian reserve.
The clomiphene (clomid) citrate challenge test (CCCT) detects about 10% more cases of diminished ovarian reserve than does checking labs on CD3 alone.
How the test works:
- The test is based on the premise that a woman with normal ovarian function should respond to fertility drugs.
- CD3 labs are obtained, then 100mg of clomiphene citrate is taken daily for 5 days.
- Clomid temporarily raises FSH and therefore stimulates egg development and estrogen production.
- One or two days after finishing the tablets, FSH is measured again.
- A woman with normal ovarian function will produce a lot of estrogen and inhibin in response to clomid and this will cause her FSH to decrease to normal levels.
- A woman with poor ovarian reserve will not respond to the clomid and will not have increased estrogen and inhibin production. In this case, the FSH will stay high.
- FSH levels less than 10 mIU/ml are considered normal, levels from 10 – 15 mIU/ml are considered mildly elevated and abnormal, and levels greater than 15 mIU/ml are significantly elevated.
If the woman has an elevated day 3 FSH or estrogen, or a high FSH after clomiphene, then she has diminished ovarian reserve.
Antimullerian Hormone (AMH) and Inhibin
AMH and Inhibin are two hormones produced by the ovary and generally reflect the numbers of eggs which are emerging from hibernation. We do not routinely test these hormone levels, as they do not add any additional information over the tests listed above.
Home Urinary FSH Kits
There is now a commercially available kit which allows a woman to measure her FSH at home. The kit measures the amount of FSH in the urine and can reliably tell her if her FSH is > 10 mIU/ml. We do not recommend this test. First, the test is fairly expensive. Second, and more importantly, this is only helpful if it is abnormal. You should not be reassured by a normal result, and here's why:
Because FSH levels are affected by estrogen levels, and because this urine test does not assess estrogen levels, an individual has no way of knowing whether a normal test is valid.