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.
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:
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.
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:
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 than 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).
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 egg remaining (it may be too late).
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 do 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.
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 blockages, often the result of things like prior infections, endometriosis, or scar tissue from a previous surgery or injury.
An HSG also shows the contours of the inside of the uterus, called the endometrial cavity. Some patients have congenital abnormalities (birth defects) that affect the uterus’s shape, or you may have polyps, fibroid tumors or uterine scar tissue. This makes it near impossible for the embryo to implant and thrive after conception.
Sometimes, tubal or uterine infertility factors can be treated using surgery and sometimes they can’t. It depends on the cause, the severity of the scar tissue or blockage and your body’s response to a potential treatment.
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.
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.