Diagnosis And Causes Of Infertility In Women

Infertility Diagnosis

There are a number of diagnostic tools available to help pinpoint the cause of infertility. After a couple has undergone evaluation through a comprehensive physical exam and medical history, a fertility doctor will recommend specific diagnostic tests.

To diagnose infertility, doctors generally check the following areas: the female hormone system and ovarian reserve, the female pelvis, the vagina and cervix, and the semen.

Endocrine System Tests

The endocrine system includes all the hormone-producing glands in the body that regulate the body’s growth, metabolism and sexual development. Sometimes infertility is due to problems in the endocrine system, and the fertility specialist may perform various tests, which include:

1) Basal Body Temperature Charting (BBT)

BBT charts help predict the time of ovulation. They can also indicate whether or not there are problems with ovulation. Higher levels of progesterone cause the body temperature to increase slightly (about 0.5F to 1F). To create a BBT chart, a woman must record her temperature every morning before getting out of bed.

  • A normal BBT includes a slight increase in temperature between days 10 through 21 of the ovulation cycle.
  • BBT that shows a relatively constant temperature indicates an absence of ovulation.

There are many tests that help identify the timing of ovulation, such as Ovulation Predictor Kits (OPK) which are usually Urinary Luteinizing Hormone (uLH) tests. As a result, BBT charts are much less commonly used today than OPKs.

2) Endometrial Biopsy

A specialist takes a sample of the cells lining the uterus (endometrium) after ovulation occurs. They then test the sample to look for signs of inflammation, changes in the endometrium (due to ovulation), and a change in hormones. This test is usually performed about 7 to 12 days after ovulation. Today, this procedure is much less commonly performed, because it has limited ability to help with infertility diagnosis and treatment.

3) Testing for Luteinizing Hormone

Ovulation Predictor Kits (OPKs) detect the ovulation-triggering hormone, lutenizing hormone (LH), in the urine. Levels of LH reflect the presence or absence of ovulation. It can help a specialist time diagnostic procedures and inseminations and intercourse. OPKs are generally effective about 90% or more of the time.

4) Ultrasonography

Ultrasonography uses sound waves to image and closely examine the uterus, ovaries, endometrium and ovarian follicles. The imaging test can be performed via the woman’s abdomen or vagina. The specialist can also use ultrasonography to look for signs of ovulation, which include:

  • Smaller follicle size
  • Loss of clear follicles
  • Fluid in the follicle sac
  • Sufficient thickness of the endometrium

The presence of multiple small follicles may be signs of polycystic ovarian disease.

5) Testing the Health of the Ovaries

Fertility doctors may use a combination of the following tests to check the health of a woman’s ovaries and the ‘supply’ of eggs (ovarian reserve):

  • Follicle Stimulating Hormone (FSH) test, a hormone made inside the pituitary gland. Levels of FSH increase as the number of eggs decreases. Thus, FSH levels increases with age. Levels are checked between days 2 and 4 of the woman’s menstrual cycle. FSH levels below the range 10 IU/L are considered normal. FSH levels above 15 IU/L are linked with lower pregnancy rates.
  • Estradiol test, a hormone produced by the ovary. Levels are checked between days 2 and 4 of the woman’s menstrual cycle. Levels less than 85picograms/mL is considered healthy. While higher levels can indicate problems in ovulation, many women with a slightly abnormal result will still be able to get pregnant.
  • Anti-Mullerian Hormone (AMH) test, which is made inside the follicles, can be tested at any time in the menstrual cycle. AMH levels decrease with age since the number of follicles decrease. Levels above 0.9 nanograms/mL is generally considered normal.
  • Clomiphene Citrate Challenge Test (CCCT): A more sensitive test in which the doctor checks both FSH and estradiol levels between days 2 and 4 of the menstrual cycle. Between days 5 and 9, the woman is then given a 100mg dose of the fertility drug, clomiphene citrate. FSH levels are also checked, which should be below 10mIU/mL. The CCCT is more sensitive in picking up decreased ovarian reserve than only testing for FSH and estradiol levels alone. It is only indicated in a few patients.
  • Ultrasound to determine the number of antral follicles (small follicles) in the ovaries and help diagnose decreased ovarian reserve (DOR). Usually, a woman shows signs of DOR if she has less than 8 antral follicles and the ovaries are less than 3ml in volume.

It is important to remember that even women who experience a slightly abnormal result will often still be able to get pregnant.

When is Ovarian Testing Performed?

These tests are usually performed if a woman is about 33 years of age or older, or if she has other risk factors, such as:

  • a cigarette smoker
  • family history of early menopause
  • ovarian or extensive pelvic surgery
  • signs of premature ovarian failure
  • recurrent pregnancy loss

6) Laparoscopy

Laparoscopy is a surgical procedure that uses a thin, lighted tube (a laparoscope) to see and closely examine the uterus, fallopian tubes, ovaries and pelvic surfaces. A common sign of ovulation is the appearance of follicular cysts, which are non-harmful, fluid-filled sacs that appear on the ovaries. Follicular cysts suggest that ovulation is occurring. Laparoscopy can be very helpful in diagnosing infertility in women.

7) Other Female Endocrinology Tests

Testing the levels of other endocrine hormones can help indicate the causes of infertility. These may include checking the levels of:

  • Thyroid Stimulating Hormone, to help determine diseases of the thyroid gland
  • Serum Prolactin (PRL), a hormone normally produced in large amounts during pregnancy but which can interfere with normal ovulation in a woman who is not pregnant
  • Androgen hormones, particularly testosterone, which can help detect polycystic ovarian disease, a disorder in which the ovaries become enlarged and contain numerous cysts

Tests for Pelvic Disorders

Your fertility doctor may suspect a problem within the pelvis or the tissue that lines the abdomen, uterus, bladder and rectum (peritoneum). One or more of the following diagnostic tests are likely to be used:

1) Ultrasonography and Sonohysterography

Ultrasonography is an ultrasound-based imaging technique that helps doctors visualize the structure of organs. It is useful in detecting abnormalities in the pelvic region often associated with infertility. For example, ultrasonography can diagnose a condition called hydrosalpinges, in which the fallopian tubes are blocked by scarring (often due to previous pelvic infection). Problems in the pelvis and ovaries can also be detected using a similar technique called sonohysterography, which is a special ultrasound technique to check the inside of the uterus for abnormalities such as scar tissue, fibroids or polyps (growths attached to the inner wall of the uterus).

2) Hysterosalpingogram

Hysterosalpingogram is a radiology procedure that examines the health of the uterus and fallopian tubes. A radio-opaque fluid is injected into the uterus and fallopian tubes and photographed via x-rays to check the shape of the uterus for fibroids, and scar tissue, and whether the tubes are blocked. It is relatively safe, simple, inexpensive and reliable test. It can cause cramping in some women.

3) Hysteroscopy

Hysteroscopy is a minimally invasive procedure in which a fiberoptic ‘telescope’ is passed through the vagina into the uterus to examine and check for abnormalities. It can be used to find polyps, fibroids, scar tissue or other abnormalities inside the uterus.

4) Magnetic Resonance Imaging (MRI)

Magnetic resonance imaging is an imaging technique that uses a magnetic field and radio waves to develop pictures of organs inside the body. MRIs can be helpful in some situations, such as identifying lesions or rare abnormalities inside the pelvis and uterus.

5) Laparoscopy

Laparoscopy is an out-patient surgical procedure that uses a thin, lighted tube (a laparoscope). It can also be used to look for abnormalities inside the pelvis. It is generally accurate in diagnosing infertility. It can be used to treat problems that cause infertility such as scar tissue, endometriosis, ovarian cysts, fibroids and endometriosis, a condition in which uterine lining tissue grows outside the uterus.

Tests Related to the Cervix

Very occasionally infertility in women is related to difficulty the sperm  has getting from the vagina to the inside of the uterus and fallopian tubes. This can occur because the woman’s cervical mucus (which is a sticky fluid made by the endocervical canal that connects the vagina to the inside of the uterus) may not function normally as a result of surgery or other problem, or that not enough sperm are deposited at the cervix by intercourse at the right time to get pregnant. To determine if there is a problem with the cervical factor as this is called, a fertility doctor may run the following procedures or tests:

1) History of Sexual Intercourse

Your fertility specialist will talk to you about your sexual history with your partner. Questions such as the frequency and timing of intercourse are critical. Intercourse should occur every 1.5 to 2.5 days, starting about 3 to 4 days before expected ovulation. Additional factors such as the type of lubricants that can interfere with sperm, ejaculatory problems and other issues that can affect the delivery of sperm to the cervix at the right time will be explored. This sexual history will also look carefully at your medical history, including: abnormal Pap smears, cervical or vaginal operations, and other surgeries. The lack of high quality mucus can mean the cervix has problems producing mucus or it may reflect poor timing (of sexual intercourse). Prior surgery of the cervix can also affect cervical mucus production.

2) Tests for Sexually Transmitted Disease

Doctors will test for sexually transmitted diseases, such as HIV1, Hepatitis B and Hepatitis C, Syphilis, Chlamydia and Gonorrhea. These tests are mandatory in some States before a fertility doctor can perform Intrauterine Insemination (IUI).

3) Post-Coital Test

A post-coital test analyzes cervical mucus within a few hours of sexual intercourse to inspect the interaction between sperm and cervical mucus. However, in recent years, fertility doctors have stopped using the test. Many studies show it cannot help predict pregnancy. In some situations, the test can at least confirm that the sperm is near the cervix after intercourse.

4) Antisperm Antibody Tests

Sometimes, the woman’s immune system may produce proteins that attack sperm (antisperm antibodies). Doctors can test for these proteins in the man’s sperm. They can also check to see if the partner’s sperm can move through a woman’s cervical mucus to reach the fallopian tubes. However, these tests are now rarely performed because they do not help predict pregnancy. Fertility doctors may run this test if a male has previously undergone a vasectomy.

 Semen Analysis

In addition to taking the male’s medical history and physical examination, the specialist will also test the semen. Semen analysis is the single most important diagnostic test for male infertility. Abnormally shaped sperm are usually sperm with defects. The most advanced fertility practices offer semen diagnostic tests that closely examine the sperm based on strict criteria for sperm shape.