About 10% to 15% of any reproductive population are generally diagnosed with infertility. This is after trying for natural conception with regular, unprotected intercourse for 12 consecutive months or about 6 months if the woman is over 35 years old.
Here are the most common reasons why you may need to have your fertility tested:
- You are older than 35.
- You have irregular or scanty periods.
- You have a preexisting condition affecting your tubes, ovaries, or uterus.
- You have a sub-fertile partner.
- You are generally concerned about your chances of having a baby.
- You want to freeze your eggs to delay having a baby.
- You have been diagnosed with cancer and want to save your eggs before undergoing treatment.
Due to career and financial commitments, far more couples are choosing a later age for the first pregnancy, which increases the need for testing due to age-related decline in fertility.
Diagnosing fertility status: What do they look for and why?
Fertility testing checks different aspects that contribute to conception.
In the case of men, doctors run a semen analysis. When the results are abnormal, the care provider needs to look further.
With women, a reproductive medicine specialist would evaluate the following:
- ability to ovulate
- ability to transport a mature egg through the fallopian tube and carry a fertilized egg through to the uterus
- ability of the uterus to house a pregnancy and of the cervix (the neck of the uterus) to transport sperm toward the uterus
- any other genetic, medical, and endocrine factors
How fertility tests for women are carried out
1. Evaluating ovulation
There are direct and indirect ways to determine if a woman’s ovaries are ovulating normally.
- Indirect indicators include regularity of menstrual cycles, cervical mucus changes, symptoms of mid-cycle pain, or an elevation of body temperature during the cycle.
- Direct indicators are provided by checking for biochemical changes in blood or urine, directly sampling endometrium, or documenting ovulation via serial ultrasound that can show ovulation has occurred and when.
Generally, it can be assumed that you’re ovulating if you have fairly regular cycles and tend to experience certain changes during each phase of your cycle, like acne, mood swings, premenstrual symptoms, or cervical mucus that changes with your cycle.
Provided that you have fairly regular cycles, your cervical mucus will look watery, stringy, and thread-like. The appearance of such mucus could begin around the 10th day and continue till about the 16th, depending on your exact date of ovulation. It indicates that you’re in your fertile period.
Home fertility tests basically work on these principles. You can use them if you’re planning to conceive and are within the first year of trying unprotected intercourse to get pregnant. They are also an option if your doctor has recommended timed intercourse, which is essentially heeding the natural fertile window. This works for women with regular menstrual cycles.
Commercially available ovulation predictor kits allow you to detect a surge in your urinary LH (luteinizing hormone). Knowing when this surge happens lets you time your intercourse around the time of ovulation and increase your chances of conception. Ovulation generally occurs about 36 hours after the LH surge and is capable of fertilization for 24 hours, after which it dies out.
Your fertility doctor may advise you to take some blood tests, like serum progesterone, around the 21st day. Occasionally, they may order endometrial biopsies to check the phase of the glands in response to the hormones and whether it’s in or out of sync with the phase of the menstrual cycle.
2. Testing for ovarian reserve
The average female has about 2 million primary oocytes (immature ovum) in her ovaries at birth. Throughout childhood, the number of oocytes falls as they deteriorate and disappear. By the onset of puberty, there are only about 300,000-500,000 primary oocytes left. During a woman’s reproductive life, 400-500 eggs will be selected to ovulate, with only one destined to ripen into a mature egg at each cycle.
Ovarian reserve testing doesn’t just reveal the current status of the ovaries, but also the reserve pool of eggs available for fertilization for the rest of a woman’s life.
The best ways currently used to do ovarian reserve testing aim:
- To determine the levels of serum anti-Müllerian hormone (AMH), which is produced by the cells of the ovaries; this is done via a blood test anytime during the menstrual cycle.
- To do an antral follicle count (AFC) via ultrasound, which visually counts the number of egg-containing follicles in both ovaries. These results vary from month to month and are generally reflective of the ovarian reserve. The follicles can be measured and counted on cycle days 2, 3, and 5.
The reasons for variation in serum AMH values may include:
- lifestyle choices
- chronic stress
- pelvic diseases like endometriosis (tissue similar to the tissue that forms the lining of your uterus grows outside of your uterine cavity)
- family history of premature or early menopause
Having a low AMH level indicates that the reserve pool of eggs is shrinking and egg quality is reduced. It means you may need to seek help to conceive immediately as your fertility is declining with each passing menstrual cycle.
Having a high AMH level means you could have polycystic ovary syndrome (PCOS) and may need assistance to conceive after careful evaluation of clinical parameters by a trained professional.
3. Testing for tubal function
The fallopian tubes normally connect the ovary to the uterus and act as a conduit for the mature egg to pass until it meets sperm. Fertilization generally occurs within this apparatus, and the fertilised ovum then implants within the uterus. Tube tests basically check the patency (lack of blockage) of the fallopian tubes.
If there is any pelvic disease affecting the fallopian tubes, it hinders the transportation of the mature egg to the uterus.
These tests involve pushing a dye via the cervix to see if there’s a spill into the peritoneal cavity (the abdomen), which is possible only if the fallopian tubes are open.
4. Testing for the structure of the uterus and cervix
An internal examination followed by pelvic ultrasound, an HSG test, and occasionally laparoscopy allows a full understanding of the structure of the uterus and cervix with regard to conception.
A pelvic ultrasound is used to diagnose:
- structural abnormalities of the uterus, like a fibroid
- some adhesions between the walls of the uterus
- adenomyosis (cells from the uterus lining or endometrium grow into the muscular wall of the uterus)
- uterine polyps (soft fleshy outgrowths from the lining of the womb)
- follicular studies done serially to monitor the growth of the follicle either during a natural or assisted conception cycle
In addition to revealing tubal abnormalities, the HSG test also picks up any uterine and cervical abnormalities such as:
- existence of a fibroid
- absent or partially absent uterus
- a congenital malformation of the uterus, which may alter, the shape, or size, or function
Laparoscopy is the gold standard in diagnosing with finality and may serve as an early line of investigation if your basic tests show an abnormality or your age is advanced.
5. Testing for other causes of infertility
Other reasons for having difficulty with conception could be:
- thyroid hormone imbalance
- an elevated level of prolactin (a hormone produced by the anterior pituitary gland)
- problem with endometrial receptivity
- ability of the uterine lining to house the growing fetus
- auto immune or genetic disorders
What to expect at your fertility appointment
When you approach your doctor to evaluate your fertility, they would take your history and do a general examination. An internal examination and ultrasound would follow to rule out these conditions.
At the very least, your doctor would do a serum AMH and an antral follicular count with transvaginal ultrasound. Depending on your specific condition, they may suggest other tests. Once the status of your fertility is clear, they would likely propose ways of moving forward.
Options to assist reproduction include:
- artificial stimulation of egg development or intrauterine insemination
- in cases of egg freezing or advanced conditions where fertility is in question, an IVF procedure would be necessary
- a combination of such techniques
Being educated can help you make an informed choice
Rather than relying on anecdotal evidence from friends and family, you could make an educated choice about the timing of conception if you know the stats related to your reproductive potential. If you aren’t ready for a child now, you could save your eggs in time.