Fertility Testing

The Start of the Fertility Journey

We say fertility testing is the beginning of “The Fertility Journey,” and it is. However, it’s more like Phase Two of the beginning of The Fertility Journey. The first phase begins when a couple looks at one another in consternation, recognizing all those negative pregnancy tests, or returned periods, are starting to feel a little scary.

If you are reading this, you have discovered conception does not always happen overnight. Per the American Society of Reproductive Medicine, your highest chances of success occur during the first three months of trying, and the clear majority of couples will conceive within one to two full years of trying – 80% and 90%, respectively.

When to Schedule Your First Visit with a Fertility Specialist

Age is probably the most important factor to consider. Women over 35, and men over 50, are more likely to have a difficult time trying to conceive. In most cases we recommend:

Women under the age of 35 years visit a fertility specialist after trying to conceive for 12 consecutive months without pregnancy. Women age of 35-39 years visit a fertility specialist after trying to conceive for 6 consecutive months without getting pregnant. Women 40 years and over visit a fertility specialist proactively or after trying to conceive for 3 – 6 months consecutive months without success. It is always best for both partners attend the first visit with a fertility specialist – even if the woman has a known fertility issue such as PCOS or endometriosis. Firstly, it ensures you are both on the same page, hearing the same information, at the same time. Secondly, male infertility factors are equally as common as female infertility factors, thus it’s best that both partners are evaluated so your doctor can select the best method of treatment right from the beginning.

Fertility Tests – the Basics

Once the preliminary physical stats and medical histories are noted and discussed, your fertility specialist will begin to evaluate five separate factors that affect your chances of conceiving:

  1. The Eggs
  2. The Sperm
  3. The Uterus
  4. The Fallopian Tubes
  5. The Cervix

When it comes to eggs, we consider two primary elements: egg quantity and egg quality.

Egg Quantity: To determine egg quantity, we consider:

—Do you ovulate regularly? If you do not ovulate each month, it makes it much more difficult to conceive because the sperm have fewer chances to make contact with and fertilize a viable egg. If you do not have regular periods each month, you are not ovulating every month.

—Are you over 35? By age 35, you are considered to be of an “advanced maternal age.” By this point in your childbearing years, the viable egg population has decreased considerably. Chances of conceiving naturally decrease, while the chances of a miscarriage increase. The chances to have a child with birth defects increases as well, although not all that notably (we will cover that in the Egg Quality section below).

Egg quantity testing is important for all women with infertility, but especially for those over 35 years old. Since no single test is perfect, we prefer to gather as much information as possible by obtaining both a blood test (either AMH or FSH, see below) and an antral follicle count (done by ultrasound). The medical term for low egg quantity is Diminished Ovarian Reserve (DOR).

Anti-Mullerian Hormone (AMH) test – higher is better: An AMH level is one of the important blood tests for egg quantity. AMH is a hormone produced by cells that surround the eggs, called granulosa cells. The more eggs you have in your ovaries, the more AMH producing cells you have, which results in a higher level of AMH in your blood. Thus, an AMH test is used to check your “ovarian reserve,” or the potential number of eggs you have left in your ovaries. Women with PCOS often have very high levels of AMH. The test is convenient because it can be done on any day of your menstrual cycle.

AMH > 2 ng/mL is Good.

AMH = 1 – 2 ng/mL is OK.

AMH = 0.3 – 1 ng/mL is Concerning (your biological clock is ticking fast).

AMH < 0.3 ng/mL is Poor and means there are very few eggs remaining (it may be too late).

Follicle Stimulating Hormone (FSH)/estradiol test – lower is better: The FSH level is the other blood test. FSH is actually produced in the pituitary gland, located at the base of your brain and should be low while you are on your period. Think of Follicle Stimulating Hormone as Egg Stimulating Hormone, so when there are not many eggs remaining in your ovaries the brain has to work harder by pumping out extra FSH in order to stimulate egg production. When it comes to FSH levels, lower is better, which is opposite of AMH levels (there are uncommon exceptions when FSH levels are too low). An FSH level < 10 mIU/mL is considered normal; whereas, an FSH level above 10 mIU/mL indicates diminished ovarian reserve and levels above 20 mIU/mL suggest early- or regular menopause. This test is done on day two or three of your cycle and must be validated by an estradiol blood level drawn at the same time.

Antral Follicle Count (AFC): Most fertility clinics also use an ultrasound – which we always include as part of the first visit evaluation– to perform an antral follicle count. The doctor will perform a vaginal ultrasound (using a wand that is inserted into your vagina, as opposed to the type that is used over your belly) to count the number of antral, or primordial (“sleeping”) follicles in both ovaries. Each antral follicle represents a potential egg. A low count indicates diminished ovarian reserve, and a high count indicates a better chance of producing more eggs for whatever treatment may be needed. An antral follicle count can be done at any point in your menstrual cycle.

Egg Quality: Unfortunately, at this point in time, there is no good way to test for egg quality. However, your body is pretty amazing. It has the ability to recognize when an egg isn’t good enough quality to produce a healthy baby. Poor egg quality is often the result of chromosome or DNA abnormalities. If the egg has a defect, your body will usually recognize a problem and will either prevent fertilization/conception altogether, or if the abnormal egg fertilizes and does attach to the uterus your body will trigger a miscarriage. This is why, while the rate of babies born with birth defects does go up for older women – the result of poor egg quality – babies born with birth defects are still very uncommon. There are actually tests for embryo quality (after the sperm fertilizes the egg) with a test called Preimplantation Genetic Screening (PGS).

The next thing we want to evaluate is the number of normal, moving sperm. Sperm are the key players in male fertility, so even if we were to determine that a woman has low ovarian reserve or some other infertility diagnosis, we still want to evaluate the sperm to know exactly what we’re working with.

When a man submits a sperm sample it is evaluated for:

Normal sperm parameters (in order decreasing order of importance):

Concentration > 15 million sperm/mL

Motility > 40% moving fast.

Morphology > 4% normal shape sperm.

Volume > 1.5 mL of ejaculated fluid.

White blood cells: Few or none.

Agglutination: None.

Sperm Concentration: Also called sperm count, this is determined by the number of sperm present in a milliliter of semen. A “normal” sperm concentration is more than 15 million sperm per milliliter of semen.

Sperm Motility: This term refers to the percentage of sperm that are moving fast. Obviously, the goal is to swim quickly and efficiently in order to get to the egg within the relatively small fertility window (24-hours or less), keeping in mind that super sperm can live inside the female reproductive tract for 4 to 7 days. More than 40% of the sperm should be motile.

Sperm Morphology: This refers to the sperm’s shape. Misshapen sperm will not swim well and have abnormalities that prevent them from fertilizing the egg and/or producing a viable embryo. Using the most up to date “strict Kruger” criteria more than 4% of sperm should have a normal morphology.

Seminal Volume: If there is too little fluid in the ejaculate then the sperm may not be able to come in contact with the cervix. If the sperm cannot reach the cervix then the sperm will never be able to swim to the egg.

White Blood Cells (WBC): A high level of WBC reported in the semen analysis usually indicates an infection. The infection can be from either a virus or a bacteria and the infection can either temporary or chronic. Some infections can be treated with antibiotics. A note of CAUTION when looking at WBC on the semen analysis report. Far too many labs confuse ROUND CELLS for WBC when performing a semen analysis. WBC and immature sperm cells both look like ROUND CELLS under the microscope. A special stain is necessary to differentiate WBC from immature sperm cells on the semen analysis. If the sperm concentration is normal then a high level of immature sperm cells is no big deal.

Agglutination: This means the sperm are sticking together and cannot swim free to find the egg. Severe agglutination can occur after a vasectomy and vasectomy reversal or other surgeries involving the testicles.

Sometimes, patients come in for their first visit saying, “we’ve already had our sperm analyzed via a sample taken at our OB/GYN or General Practitioner’s office and were given the green light!” Unfortunately, these analyses are not as good as the ones performed by lab technicians who work for a fertility clinic. The typical lab technician is trained to examine blood and urine but not necessarily factors pertaining to fertility. For example, it takes a well-trained eye from a lab technician to accurately evaluate sperm morphology/shape.

We’ll combine Fertility Factors 3 and 4 in this overview because they are typically tested in the same way during the initial evaluation.

The primary cause for infertility as the result of the uterus or fallopian tubes is an anatomical abnormality of some kind. Fibroid tumors, endometriosis, prior pelvic infections or surgery and other issues can change the shape of the uterus or block the fallopian tubes making them inhospitable to the fertilization process, or making it difficult for a fertilized embryo to attach and thrive inside the uterine wall.

To get a good look at these reproductive organs, fertility specialists use a hysterosalpingogram, or HSG test. This is a special type of x-ray, performed by a radiologist. It uses a dye (radiological contrast), via a catheter that is inserted into and cervix after a speculum has been placed in the vagina (like a Pap smear). This dye (contrast) moves through the reproductive tract, making it easier to visualize the contours of the fallopian tubes and uterus in combination with x-ray technology. By following the dye, the radiologist can observe tubal blo

Your cervix has two major jobs to perform. First, it allows sperm to pass through during ovulation to reach the egg so fertilization can take place. Once you are pregnant, the second job of the cervix is to seal itself off and not open until your pregnancy reaches full-term.

Sometimes, however, the cervix just doesn’t do what it’s supposed to. Cervical mucous may refuse to thin – or can even become thicker – preventing sperm from getting inside. The chemical make-up of your cervical mucous may be “hostile” and have anti-sperm antibodies that kill the sperm before they can get to the egg.

In any case, there is no acceptable test for cervical infertility factor. Rather, if your fertility doctor can’t find a specific diagnosis as the result of evaluating egg reserves, male fertility factors, and the anatomy of your uterus and fallopian tubes, he or she will recommend using intrauterine insemination (IUI) as a first fertility treatment. If the IUI results in pregnancy, odds are you have what is called “hostile cervical mucous” or an “inhospitable cervix,” (terrible terms, aren’t they?) that simply isn’t conception friendly. The good news is, you have an easy fertility treatment alternative for future pregnancies.

The Sooner the Better – Realistically Speaking

When it comes to fertility, there are three realities to contend with. The first is that most couples are NOT infertile. The second is that about 1 in 8 couples (roughly 12% of married women) have trouble conceiving or carrying a baby to full-term, so you’re not alone (2006-2010 National Survey of Family Growth, CDC). Finally, there is the age issue to contend with: the older you are after age 34, the longer it can take and the more difficult it is to conceive.

Once you’ve crossed one of the relevant failing-to-get-pregnant-without assistance- thresholds we referenced at the beginning (12 months after trying to conceive for women 34 years and younger, 4-6 months after trying to conceive for women 35 and older), it’s a good idea to schedule an appointment with a fertility specialist sooner, rather than later. The longer you wait, the longer it can take to find the appropriate treatment for your infertility diagnosis, and time is of the essence if age and/or egg quantity is at all a factor.