The fertility work-up

Many of us assume starting a family will be as easy as pitching the pills or ditching the diaphragm, but for an estimated eight percent of Canadian couples, the pathway to pregnancy is a bit more challenging. After a year of unprotected intercourse, that’s how many people find their dream of having a baby is still just that.

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Nancy and Randy Johnston’s hopes for a houseful of kids seemed to be out of reach, when, after their eldest child was born, they found themselves unable to conceive a second time. Finally, the London, Ont., couple decided to try and find out what was standing in the way of adding to their family.

So if you’re still waiting for the stork to arrive, what’s the next step?

Joint Venture Typically, the first stop is your family doctor’s office. She should be able to conduct the initial workup and direct you to more specialized help if required. Experts emphasize that ideally, a couple should be investigated together. Why? “Male factor infertility will be implicated as the sole cause, or a contributing cause, in half the cases,” explains Ellen Greenblatt, clinical director of the fertility and IVF Clinic at Mount Sinai Hospital in Toronto. (That’s when a reason can be found at all—up to 30 percent of couples who experience difficulty conceiving are diagnosed with “unexplained” infertility.)

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David Mortimer, president of Oozoa Biomedical Inc. and an expert on diagnostic andrology testing (sperm testing, to you and me), makes the case this way. “If he’s got a bit of a problem, and she’s got a bit of problem, then between them, they’ve got a bigger problem.” If both partners aren’t adequately investigated, he adds, “people may be pushed into treatment that might not be appropriate, or receive treatment that is foredoomed to failure.” So what does the male half of a fertility investigation entail?

Male Work-up

History The most important part doesn’t involve needles or bodily fluids, but something some men dislike as heartily as a prostate exam — talking about intimate issues. A detailed medical and sexual history is the cornerstone of the fertility work-up. A man can expect to be queried about matters such as: whether he’s ever undergone genital or prostate surgery; what he does for a living and whether it involves exposure to hazardous chemicals (pesticides, heavy metals); if he suffers from any chronic health problems; and whether he has any difficulty achieving an erection.

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What’s the point of these probing personal questions? For starters, it’s possible to modify certain factors that impair fertility—say, by quitting smoking, losing excess weight or switching from one prescription medication to an alternative — and your physician may be able to help. Your doctor is also looking for clues that could guide further testing and eventual treatment. For example, in some men with diabetes, the muscle responsible for keeping semen from detouring into the bladder stops working properly—something that can be diagnosed with a simple urine test.

Sharing certain nitty-gritty details of your sex life is also important. For instance, if you only make love during the fertile period, you’re unwittingly sabotaging your chances of becoming parents. “‘Saving up’ doesn’t enhance fertility,” stresses Margaretha Rebel, an associate professor of obstetrics and gynaecology at the University of Western Ontario’s Schulich School of Medicine and Dentistry. “The numbers (of sperm) may increase—but the motility (movement) decreases.” Two to three ejaculations a week make for the best-quality sperm, according to Rebel.

Physical Stage two of the male workup is a physical exam of the genitals and prostate to check for any abnormalities that could impede sperm production or release. One common problem that can turn up during the physical is a varicocele. Basically a varicose vein in the testicle, a varicocele impedes normal circulation, which may prevent blood in the area from cooling properly: Since even a slight rise in temperature can cripple or kill sperm, this can impair fertility.

Blood tests If you and your partner haven’t concieved after a year or more of trying, some specialists recommend running blood tests to screen for conditions that can affect fertility, such as disorders of the thyroid and pituitary glands.

Semen analysis Don’t dismiss this test as a simple sperm count. Sure, it involves measuring the volume of fluid and counting sperm, but it should also include a check for infection (an easily remedied cause of infertility), and an estimate of how many of the tadpole-like cells are the correct size and shape (which is linked to their ability to fertilize an egg) and strong swimmers.

This initial screening should be performed at least twice, stresses Keith Jarvi, head of urology at Mount Sinai Hospital. “There’s quite a bit of variability week to week and month to month in a man’s sperm counts, so we usually do two sperm tests a couple of weeks apart. If the two are different, we get a tiebreaker.”

Mortimer also recommends checking for the presence of antibodies that signal a man’s immune system is attacking his own sperm—a test some labs don’t run routinely. While relatively uncommon, this problem dooms certain fertility treatments to failure—something you should know before proceeding any further.

Since performing these analyses properly requires specific expertise, picking the right lab is critical, says Mortimer. He cites a study in which semen samples were split up and sent to several different laboratories: the sperm counts that came back differed as much as a hundred-fold! “People need to know that they’re going to labs that specialize in looking at sperm,” Mortimer emphasizes. True, when your doctor writes the order for the test, typically she’ll suggest where to have it done—but not all physicians recognize the importance of selecting the right lab, and those who do may not have time to do the necessary homework. That means it’s probably worth doing some checking yourself, before you make a choice.

So how do you find a suitable lab? An integrated fertility service (one that doesn’t specialize in IVF) or a urologist specializing in male fertility should be able to refer you to an appropriate facility. Or you can call prospective labs and ask a few questions — for example, does it follow World Health Organization methods and participate in external quality assurance programs on sperm analysis?

Once you’ve chosen a lab, follow the instructions on collecting the specimen. (Stop smirking, this is serious stuff—ignoring the instructions can throw off the results. For example, most lubricants can kill sperm.) Men are advised to avoid ejaculating for a set period, usually between 48 and 72 hours, before depositing a masturbated semen sample into a container. (Where this is done depends on the lab’s policy and how close by you live — the specimen must be delivered to the lab within an hour. Many facilities have a private room for, er, command performances.) Awkward and embarrassing? Sure. But keep in mind it’s still less invasive than some tests women may undergo.

Female Work-up

History Just as a long Q & A session is the first step in the male partner’s fertility workup, history is a huge part of the female investigation. Expect to answer questions about your medical, menstrual and sexual history, including if you’ve ever conceived before; whether your menstrual cycles are regular; if you’ve ever had abdominal surgery; and whether you’ve ever had pelvic inflammatory disease.

This information can point the way for further testing: For example, if you’re under 35 and your periods arrive like clockwork, that’s a good indication you are ovulating, so you may not need to have certain hormone levels checked.

Other answers may alert your physician to the need for certain tests. For instance, if you have symptoms that suggest endometriosis (killer menstrual cramps or pain during intercourse, to name two) or you’ve had a sexually transmitted disease in the past, your doctor will likely recommend a test to determine whether your Fallopian tubes are open, or “patent.” Endometriosis, abdominal surgery or certain sexually transmitted diseases can create scarring that seals off the pathway between ovary and uterus, thus preventing sperm from reaching the egg.

Physical Step two is the physical exam. Your doctor will look for certain characteristics, such as excess hair growth, that might herald hormonal abnormalities like those caused by polycystic ovarian syndrome or PCOS, which interfere with ovulation. The physician will also examine your breasts and may squeeze your nipples to see whether they leak fluid — an indicator of high levels of prolactin, a hormone that suppresses fertility. And, of course, she’ll do a thorough pelvic exam. “That’s to make sure that there isn’t a lot of scarring, tenderness, nodularity (lumpiness) or masses (fibroids) that might be associated with endometriosis,” Greenblatt explains.

Blood tests Often, a fertility assessment involves tests to check for anemia and thyroid gland function. If you’re uncertain of your vaccination status, your doctor may also run a test to see whether you need a booster against rubella, since it can cause problems for the baby if you contract this illness during pregnancy. Your doctor may also recommend one or both of the following:

Day three assessment A hormone assessment is done between day two and day four of your period. If there’s any question about whether you’re ovulating (say you have very irregular cycles), this cluster of tests will include checking levels of thyroid hormone, prolactin and certain reproductive hormones.

But the main reason for doing the test at this point in your cycle is to try and determine how fast your biological clock is ticking, by measuring the amounts of estradriol (a form of estrogen) and follicle stimulating hormone (FSH) in your blood. While the quantity and quality of a woman’s eggs—and thus, her chances of conceiving — typically start falling quickly after age 35, every woman’s reproductive system ages at a different rate. If your body is producing extra FSH to spur the ovaries into action, that’s an indication your remaining eggs are—pardon the expression—past their “best before” date. This information is important because it helps estimate the likelihood that any treatments will succeed.

“Women over 35 with FSH levels over 10 have a markedly decreased prognosis for pregnancy,” Rebel notes—they stand about half the chance of conceiving, compared to other women the same age. That’s something couples need to consider when deciding about further intervention.

Mid-luteal progesterone level If the results of the day three assessment are normal, but there are still lingering doubts about whether you’re ovulating, your physician will send you for an additional blood test to measure progesterone levels. “We do that in the luteal phase — the second half of the menstrual cycle, between day 21 to 23,” notes Rebel

Other Investigations If neither egg nor sperm production appears to be the problem, it’s possible the sperm are running into a roadblock in the Fallopian tube. There are three different types of tests that can be used to determine if this is the case. Each has its pluses and minuses — your doctor’s recommendation will depend on a number of factors, including your age, and your preferences.

Hystersalpingogram (HSG) This is an X-ray study that’s conducted between the end of your period and ovulation (somewhere around day nine to 12 of your cycle). It’s a little like undergoing a PAP test — a speculum is inserted into the vagina, and a tiny tube is threaded into the cervix. Then, a special dye is slowly injected into the tube, and the fluid is tracked with a sort of moving X-ray (fluoroscopy). If there are no obstructions, the dye will travel through the uterus, spilling out through the ends of the Fallopian tubes into the pelvis, where it will be absorbed by the body. (Since the procedure can cause period-like cramping, you may want to take a dose of Ibuprofen or acetaminophen about half an hour beforehand.) In addition to helping determine whether the coast is clear, so to speak, HSG can establish whether size and shape of the uterine cavity is normal, and hint at the presence of polyps or fibroids (benign tumours in the muscle of the uterus) that could interfere with the implantation of a fertilized egg.

So what are the advantages and disadvantages of HSG? Since it’s non-surgical and doesn’t require any anaesthesia, it’s very low risk. On the other hand, HSG is only about 85 percent accurate (it misses some blockages and sometimes suggests a problem where none exists). And if the results do hint at an abnormality, you’ll probably have to undergo a second procedure to pinpoint the location and extent of the obstruction. Consequently, if you’re over 35, some doctors will suggest skipping the first step and proceeding directly to laparoscopy to save time.

Sonohystogram (Sono HSG/SHSG) This test is very similar to an HSG—the main difference being it’s done using ultrasound rather than X-ray. Otherwise, it has the same drawbacks as its older counterpart—namely, it’s not as accurate as laparoscopy and can’t be used to both diagnose and treat problems.

Diagnostic laparoscopy This procedure, done under a general anaesthetic, is considered the gold standard for evaluating the pelvis, says Rebel. An incision is made near the belly button, and a slender instrument called a laparoscope (a combination light source/fibre optic camera) is inserted into the abdomen. Next, carbon dioxide is released into the cavity, making it easier for the surgeon to view the area. The doctor then examines the ovaries, tubes and surrounding tissue. Finally, the gas is removed, and the incision closed. (If your doctor decides a closer look inside the uterus is also needed, a separate laparoscope can also be slipped into the cervix via the vagina—a procedure called hysteroscopy.)

While laparoscopy is safe in experienced hands, any kind of surgery carries risks. For example, approximately one woman in 10,000 will experience an adverse reaction to general anaesthetic, and there’s a one or two in 1,000 chance an instrument will nick a blood vessel or an organ like the bowel or bladder during this type of operation. On the upside, laparoscopy provides the most accurate possible picture of the pelvis and, if it reveals problems, treatment can sometimes be performed at the same time. For instance, if scar tissue is surrounding one of the tubes, the surgeon may be able to clear it away.

While fertility testing can’t guarantee a happy ending, it often uncovers problems that can be overcome. Nancy Johnson discovered her hormone levels were out of sync, which was corrected with medication. Today, she and her husband have three children. “Have faith that if you seek the answers, then you can make intelligent decisions,” she concludes.

Clomid This first-line medication for ovulation problems is a pill you take for five days in the early part of your menstrual cycle.

Intrauterine insemination (IUI) This technique involves placing sperm directly into the uterus. IUI is often combined with ovarian hyperstimulation (using drugs to induce the release of several eggs.)

In vitro fertilization (IVF) Typically, the woman takes injectable medications that override her menstrual cycle, plus ovary-stimulating drugs. Mature eggs are retrieved using a needle before being mixed with “washed” sperm. After the fertilized eggs develop to a certain point, some of them are placed into the woman’s uterus. The cost of one IVF cycle can range from $5,000 to $8,000.

Diagnostic Laparoscopy A “keyhole” operation that can take off scar tissue surrounding fallopian tubes.

Varicocele correction This type of varicose vein can be tied off either with surgery or embolization (injecting a substance into the vein via a fine tube).

When to seek help, sooner If you’re a woman over age 35, or you or your partner have a history of health problems that could interfere with conceiving—such as testicular cancer, sexually transmitted disease, or previous genital or, for women, abdominal surgery—consult your doctor after trying for six months