Semen analysis

While there a number of parameters reported in the analysis, only a few are really important:

• Volume. A typical specimen is 1-4cc. While volume does not play an important role in fertility, a low volume suggests an incomplete collection. Conversely, very large volumes may result in dilution of sperm and may cause considerable leakage after intercourse. Some people believe large volumes are associated with infection, but this is not well-established.
• Count. A normal specimen should contain 20 million sperm/ml, or more. Most low counts go unexplained, but occasionally this can be hormonally related.
• Motility. This is expressed as percent of live sperm. Different labs express this differently, but essentially, about 60% of the sperm should be swimming.
• Morphology. This refers to the shapes of the sperm. Over a decade ago, a new “strict” criteria was introduced. The result is that most men have very low numbers. Fourteen percent of “normal formed sperm” is considered normal. In our lab, as with most labs, we almost never see that result. As the number for normal keeps dropping, the usefulness of the test also decreases. The test is widely misunderstood; it is not a test of fertility or a predictor of having a normal baby. Low morphology has only been associated with low fertilization rates in an IVF lab when natural fertilization is allowed to occur. Many labs also report White Blood Cell numbers (WBC). Elevated levels might be associated with infections like prostatitis. However, WBC’s can look like immature spermatids. Immature spermatids occur more frequently in specimens with low counts, so it is important to make sure the lab has stained the cells specifically for WBC’s. Semen cultures can also clarify the situation. After decades of experience with semen analysis, it is clear that the WBC test is not a perfect predictor of fertility. For this reason, it is inappropriate to ask a man to undergo the test before he has tried to father a child.

Transvaginal Ultrasound Procedure for Infertility Testing

Transvaginal ultrasound is sometimes coupled with transabdominal ultrasound to examine the entire pelvic region. While transabdominal ultrasound is performed externally, the transducer used in transvaginal ultrasound is designed to fit in the vagina. Consequently, the pictures it creates are clearer because the transducer gets closer to the organs. Before the procedure begins, you will be asked to empty your bladder, undress from the waist down and lie on your back on the examining table with your feet in the stirrups, as you would for an internal gynecological exam. The health care provider will cover the transducer with a condom and lubricating gel, place its tip in your vagina and move it within the area. The transducer sends out sound waves that bounce off the pelvic organs. A computer transforms these waves into images, which can be viewed on a video monitor.

What is a hysterosalpingogram?

A hysterosalpingogram, or HSG is an important test of female fertility potential. The HSG test is a radiology procedure usually done in the radiology department of a hospital or outpatient radiology facility.

• Radiographic contrast (dye) is injected into the uterine cavity through the vagina and cervix
• The uterine cavity fills with dye and if the fallopian tubes are open, dye fills the tubes and spills into the abdominal cavity

What else can be seen by a hysterosalpingogram, besides whether the tubes are open?

Other things that can be seen on a hysterosalpingogram include：

• The uterine cavity is evaluated for the presence of congenital uterine anomalies, polyps, fibroid tumors or uterine scar tissue.
• The fallopian tubes are also examined for defects within them, for suggestion of partial blockage, and for evidence of pelvic scar tissue in the abdominal cavity near the tube.

What to expect during a hysterosalpingogram

The hysterosalpingogram study only takes about 5 minutes to perform. However, the test is usually done in the radiology department of a hospital so there is additional time for the woman to register at the facility and fill out a questionnaire and answer questions regarding allergies to medication etc. The way the test is done is the following：

• The woman lies on the table on her back and brings her feet up into a "frog leg" position.
• The doctor places a speculum in the vagina and visualizes the cervix.
• Either a soft, thin catheter is placed through the cervical opening into the uterine cavity or an instrument called a tenaculum is placed on the cervix and then a narrow metal cannula is inserted through the cervical opening.
• Contrast is slowly injected through the cannula or catheter into the uterine cavity. An x-ray picture is taken as the uterine cavity is filling and then additional contrast is injected so that the tubes should fill and begin to spill into the abdominal cavity. More x-ray pictures are taken as this "fill and spill" occurs.
• When both tubes spill dye, the woman is often asked to roll to one side or the other slightly to give a slightly oblique x-ray image which can further delineate the anatomy.
• The procedure is now complete. The instruments are removed from the cervix and vagina.
• The woman usually remains on the table for a few minutes to recover from the cramping caused by injection of the contrast.
• The results of the test can be immediately available. The x-ray pictures can usually be reviewed with the woman several minutes after the procedure is done.

Why Screen?

Many women do not realize that a significant decline in fertility really begins in the early 30's, not in the late 30's or early 40's as many people believe. In fact, for many successful fertility treatments, the biggest predictor of pregnancy outcome is the age of the female partner. The significant impact that age has on fertility is related to both the quality and quantity of a woman's eggs.
In contrast to healthy men whose sperm cells continuously divide and renew themselves well into later life, healthy women are born with all the eggs that they will ever have. In fact, by the time a female infant is born, still many years away from reproductive potential, the number of eggs in her ovaries has already declined by 80% from their peak numbers. The numbers are even smaller by the time a girl enters puberty and begins to have menstrual cycles.
In addition to this decrease in the number of eggs that women can experience, some women may have poor quality eggs that reduce the likelihood that a given fertility treatment will result in a healthy pregnancy. Ovarian reserve screening is one mechanism by which fertility specialists can partially predict the reproductive potential of a specific patient as well as the potential of her eggs to result in a healthy pregnancy. This information can be used to help couples decide which therapies may be emotionally and financially sound to pursue.

Screening Tests

There are essentially 4 different screening tests for ovarian reserve. Three of them are hormonal blood tests, and the third is an ultrasound examination. Follicle stimulating hormone (FSH) is the hormone from the pituitary area in the brain that drives the follicles (or maturing egg sacs) in the ovaries to develop an egg (or oocyte) that is ready to be released (ovulated) and fertilized. How hard a woman's brain has to work at the beginning of the cycle to get the eggs in the ovaries to respond to the appropriate signals is a reflection of both the number and quality of the eggs that remain in the ovary. This process is reflected by circulating levels of FSH that can be measured, usually on the 3rd day of a woman's menstrual cycle. We call this test a Day 3 FSH level. In general, FSH levels rise as the egg supply decreases. Elevated levels indicate that response in that patient to a particular treatment may be less likely to result in a healthy pregnancy compared to other patients.

Another type of ovarian reserve testing is the Clomiphene citrate challenge test. This test relies on the same principle that the brain and the ovary communicate with each other through FSH (as modulated by other hormones like inhibin and activin). This test involves measuring the Day 3 FSH and then administering clomiphene citrate (Clomid or Serophene) at a dosage of 2 tablets per day, for days 5-9. The serum FSH levels are then measured again on Day 10. The idea behind this test is to give the ovaries a push in the right direction by stimulating them with the drug before rechecking the FSH. An abnormal result on this screening test may indicate that a woman's chances of taking home a baby after a specific fertility treatment like IVF may be significantly reduced.

Finally, some investigators are also using antral follicle counts to help determine cycle outcomes. Many fertility treatments rely on stimulating the ovaries to mature more than one fertilizable egg per month. An ultrasound measurement of the antral follicles, or small follicles available to be stimulated that month, may help predict the response of an individual woman to fertility drugs.
The newest and most accurate test available is AMH (antimullerian hormone). AMH is produced by small follicles in the ovary. AMH reflects the pool of active follicles. It can be checked at any point of the menstrual cycle. It can also be checked if someone is on birth control pills. Because AMH does not fluctuate as much as FSH it is a more convenient predictor of ovarian reserve.
AMH is measured in nanograms per milliliter (ng/ml). The following reflects our experience with the LabCorp AMH assay. We have found that other labs give considerably different results.

normal AMH	>1 ng/ml
Increased (freq PCOD)	>3
lownomral	0.7-0.9
low	0.2-0.6
extremely low	<0.2

It is important to know that low AMH does not mean that it is impossible to get pregnant just low sperm count. It does mean that it is harder and that we need to get the ball going because things will not improve over time. AMH is an extremely important test today. It will probably replace all FSH testing in the future for fertility purposes. To some extent it predicts the number and quality of eggs collected with IVF.

Who should be screened?

Different programs have different approaches to their screening protocols. In general, most women over 35 years of age should be screened before pursuing any type of fertility therapy. Most programs will screen all women regardless of age undergoing therapy with the assisted reproductive technologies like IVF. However, it is less clear what abnormal values may indicate in women who are younger than 32 years of age. Many times it is valuable to screen women less than 35 if they may be at an increased risk of diminished ovarian reserve (e.g. following surgery for ovarian cysts or removal of endometriosis from the ovary).

Fluctuating levels of FSH

Many times when a Day 3 FSH test comes back unexpectedly high, a physician may choose to repeat this test or a patient may request that it be repeated. Despite the relative simplicity of the test, levels may fluctuate or vary considerably in the same woman from month to month and cycle to cycle. Initially fertility specialists thought it made sense to monitor these levels on a regular basis and only perform advanced therapies such as IVF on months when the FSH levels looked normal. Unfortunately, even when using later cycles with normal FSH levels, pregnancy rates were still largely poor in women who had a previously elevated Day 3 FSH level. It now seems clear that a single abnormally high FSH test predicts a markedly reduced chance for healthy pregnancy using a woman's own eggs, even when the most advanced fertility treatments are utilized. Many of these women may still achieve pregnancy rates of 60-70% using donated eggs or oocytes.

Using the information wisely and to your advantage

Ovarian reserve screening should be viewed as one more piece of knowledge in your fertility work-up. Just as other hormone levels, a semen analysis, or an x-ray test of the uterus and tubes may help guide your treatment options, ovarian reserve screening is one more piece of information that you and your physician can use to jointly decide what roads may lead to your dreams of creating a healthy family.

Hysteroscopy

Hysteroscopy is performed approximately half the time for the diagnosis of infertility. It is generally best performed in the postmenstrual proliferative phase. Different locations for hysteroscopy include the office, surgery center, or hospital operating room. Different media include CO2 gas, Sorbitol, glycine, Mannitol/Sorbitol mixture, 5% dextrose in water, or 32% Dextran-70. Endoscopes can range from 2 mm in size to 6.5 mm in size. The choice of location, medium, and instrumentation depends on the availability of facilities and resources, the anticipated diagnosis, and the surgical plan. The optimum approach involves one which has a high probability of resolving the clinical issue at hand, with the major difference in approach depending on whether or not operative intervention will be required, safety, and cost. Adjunctive procedures such as hysterosalpingography and sonohysterography can be of significant help in identifying the patient who requires hysteroscopy, and the best hysteroscopic approach for that patient given the clinical conditions.

Carbon dioxide gas has the advantage of excellent clarity, and it is very safe. Disadvantages are that CO2 gas bubbles can form and blood can quickly obscure the view. CO2 hysteroscopy is diagnostic only, and there is a small potential for systemic absorption resulting in acidosis, arrhythmias, and even fatal complications. Five percent dextrose in water has the advantage of good clarity and being safe, but disadvantage of being primarily diagnostic. However, recently developed instrumentation which will allow the use of bipolar electrosurgery in normal saline may dramatically improve the utility of the use of normal saline for operative hysteroscopy. Sorbitol, glycine, and Mannitol/Sorbitol can be very effectively used especially with the resectoscope for treatment of large intrauterine lesions, such as myomas. Nevertheless, there are potential serious complications including pulmonary edema, fluid overload with electrolyte imbalance, cardiovascular collapse, neurologic toxicity, and anaphylaxis.

23% Dextran-70 has the advantage of providing good clarity and it is miscible with blood, which is very advantageous for operative procedures. Disadvantages include potential allergic reactions, noncardiogenic pulmonary edema, and potential coagulation defects. In addition, the material is more difficulty to work with because of its stickiness for the surgeon, operating room personnel, and equipment. While most gynecologists have their favorite medium, it is usually advantageous to have familiarity and be able to use different media depending on the surgical procedure.

The choice of instrumentation will often depend on the choice of medium. Larger instruments tend to be used for operative intervention, and tend to require more anesthesia. Anesthesia may range from simple reassurance, nonsteroidal anti-inflammatory drugs, and anxiolytics, through conscious sedation with intravenous medication, epidural anesthesia, or general anesthesia. Again, the least interventional, yet effective and safe, anesthetic should be chosen for the particular situation.

Contraindications to hysteroscopy include an absolute contraindication for pelvic infection or endometrial cancer, and relative contraindication in the case of pregnancy, excessive bleeding, cardiovascular disease, or severe vaginitis.

Complications of hysteroscopy are reported in 1 to 3% of cases. These include cervical laceration, uterine perforation, bleeding, reactions to the distention media, or anesthesia. Potential long-term complications include femoral injury resulting in intrauterine scarring or tubal obstruction, as well as injury to contiguous organs.