Reproduction and Fertility

Infertility evaluation and counseling

Ovulatory function evaluation

Ovulation of the growing follicle occurs usually 14 days prior to menstruation, which means mid cycle for a 28 day cycle. During ovulation the follicle ruptures and releases the oocyte (egg) along with follicular fluid in the abdominal cavity.

But who tells the growing follicle to ovulate?    There is an intricate cascade of hormones which involves the hypothalamus, hypophysis and ovaries that results in the abrupt release of LH (Luteinizing Hormone), called “LH peak”. This happens usually when the size of the follicle is 17-20mm and gives the signal for ovulation to occur 32-36hrs later.

There are several ways to predict when someone will ovulate and if that actually happens:

BBT ( Basal Body Temperature)
Daily oral temperature measurements in the morning before getting out of bed. A rise of 0.2 degrees Celsius compared to the previous 6d indicates that you are close to ovulation. You are most fertile on the day of temperature rise and the few preceding days.

Now days there are several smart phone applications that can help you calculate your fertile days.

Ovulation prediction kits
Over the counter kits that detect the “LH peak” in the urine and can predict the ovulation period.

Sonographic evaluation 
Follow up of the growing follicle with sonography. When the follicle(s) reaches 18-20 mm in diameter, we know that it will ovulate in the next 2 days approximately. Also confirmation of ovulation can be done by witnessing the ruptured follicle which is transformed to corpus luteum.

Serum progesterone levels.
Testing for serum Progesterone level on Day 21 of your cycle will tell if the ovulation has already occurred when the levels are above >3ng/ml.

Uterine evaluation

The uterus and especially the endometrial cavity with its lining, the endometrium, must be normal for the embryo to implant.  We can evaluate the uterus and the endometrium with ultrasound, Hysterosalpingography (HSG), hysterosonography, hysteroscopy and occasionally with endometrial biopsy. This way we can identify problems like fibroids, endometrial polyps, adhesions and uterine malformations.

Transvaginal ultrasound is a good screening test (a test that might identify a problem before proceeding to a confirmatory test) and is usually done routinely in infertility evaluation.

Tubal evaluation

The patency, normal function and anatomy of the salpinges (tubes) are of the uttermost importance for natural conception to occur.

The tubes must be patent and functional in order for the spermatozoa to reach the oocyte and for the resulting embryo to be transferred back to the uterus.

The fallopian tubes can be examined with Hysterosalipngogram (HSG), sono-hysterosalpingography and chromotubation during laparoscopy. HSG is still considered the golden standard for tubal evaluation.

HSG is an X ray test. It looks at the inside of the uterus and the salpinges by instilling contrast material in the uterine cavity via the cervix.

Hormonal evaluation

The hormones of various endocrine glands must be functioning correctly in order to have normal ovulation and endometrial receptivity. A baseline panel of hormones, like Prolactin, TSH and others, must be ordered to properly investigate infertility causes.

Ovarian Reserve testing:

Every woman is born with a certain amount of oocytes (primordial follicles) around 1million and enters her reproductive age at the beginning of her menstruation with approx. 300.000 oocytes, there is a continuous decline in the number of oocytes over the ages until she reaches menopause. There is no production of “new” oocytes every month, instead they are selected from the pool of remainig oocytes in each ovary. The amount of oocytes remaining in the ovaries is called ovarian reserve.

There is an accelerated loss in fertility rates after the age of 37.

In women above the age of the 35 that are trying to conceive it is a good idea to test for their ovarian reserve. Also in cases with family history of premature menopause or exposure to gonadotoxic substances, like in cancer patients, ovarian reserve testing is recommended at an earlier stage.

There are several ways to estimate the ovarian reserve of a woman. Most doctors use blood tests like Day 2 or 3 of the cycle  FSH combined with Estradiol and independently of the cycle with AMH (Anti Mullerian Hormone). There are also ways to estimate the ovarian reserve of a woman sonographically, like the AFC (Antral Follicle Count) and the size of the ovaries.

Male partner evaluation

Semen analysis is usually the first step in male partner investigation.

If a problem is identified then more detailed investigation may be needed:
– thorough history of past diseases and gonadotoxin exposure
– endocrine evaluation
– genetic testing
– physical examination
– testicular ultrasound