The Infertility Work-Up: What’s Routine and What’s Not?

Medical contribution by Naveed Khan, M.D.,
of Shady Grove Fertility’s Leesburg, VA, office

Dr. Naveed Khan

Dr. Naveed Khan

When you meet with a fertility specialist for your initial consult, he or she will outline for you a diagnostic plan—or infertility work-up—tailored specifically for you, which will help determine the cause of your infertility. The physician will base the testing schedule on the information provided by your medical history and physical examination. This plan will focus on answering many important questions, including the following:

  • Are you ovulating?
  • Are your fallopian tubes normal?
  • Is your uterus receptive to implantation?
  • Are the sperm normal in number and function?

The diagnostic tests that comprise the standard infertility work-up answer these questions and help determine the cause of your infertility. While we commonly recommend a set of routine prescreening tests at Shady Grove Fertility, there are some tests that do not always make sense at such an early stage, and we would caution patients from moving in that direction unnecessarily.

Infertility Work-Up: Routine Tests

SGF uses the following standard infertility work-up to evaluate the potential fertility of the female and male partner:

Female

Day 3 Bloodwork

A clinician will perform bloodwork on day 3 of your menstrual cycle to test levels of the following:

  • E2 (estrogen): the main female reproductive hormone secreted from the ovary
  • FSH (follicle-stimulating hormone): releases from the brain and stimulates the ovary to mature an egg. High FSH levels can indicate to your physician that the hypothalamus and pituitary glands are working harder than normal due to a decrease in ovarian reserve (egg supply). FSH levels can vary from cycle to cycle.
  • AMH (anti-Müllerian hormone): AMH is the most accurate predictor of a woman’s egg supply. This test can be more accurate than FSH because there is no fluctuation from month to month and the test is not dependent on a woman’s menstrual cycle, which means women can have the test at any point.
  • LH (luteinizing hormone): a hormone that is integral to the final maturation and release of a mature follicle.

Internal Baseline Ultrasound

ultrasoundEmbryos implant in the uterus, which makes it necessary to perform tests to determine if a woman’s uterine cavity is normal. A sonographer or physician will perform an ultrasound of the ovaries between days 2 through 4 of your cycle. We use this test to determine the antral follicle count (AFC), which represents the number of eggs available for pregnancy that month.

HSG

The HSG, or HSGhysterosalpingogram, is an x-ray of the uterus and fallopian tubes to help determine their condition. Physicians rely on this test to see if a patient’s fallopian tubes are open, to assess whether the uterus has normal shape, and to ensure that the cavity is not affected by fibroids, polyps, or scar tissue.

Male

Semen Analysis

spermAndrologists perform a semen analysis to evaluate the sperm’s potential to fertilize the egg. The test results will tell your physician the number of sperm in your semen (your sperm count), whether they are normal (morphology), and how well they swim (motility).

Infectious Disease Testing

Through a simple blood test, a clinician will perform infectious disease testing for both the male and female partner.

  • Male screening includes: HIV; Hepatitis B surface antigen; Hepatitis C antibody; RPR (serology)
  • Female screening includes: Hepatitis B surface antigen; Hepatitis C antibody; HIV; RPR (serology); Rubella titer (one time only); blood group; and RH (one time only). Negative infectious disease results must be documented every 12 months.

Genetic Screening

SGF is an advocate for genetic testinggenetic screening when planning for pregnancy, offering testing for over 100 different diseases and syndromes. While we strongly recommend this screening due to benefits for patients and their future children, patients do have the choice to opt out of testing. For patients who are interested, their physician will review their family history at the initial consultation and select the appropriate testing. Patients are provided with a testing kit and will then arrange to return to our center for both partners to be tested during day 3 bloodwork or at specially-scheduled appointment. The testing kit can be run from DNA obtained through either blood or saliva. Once the sample is obtained, the kit is sent out to the genetic testing laboratory, with results arriving to the patient and physician within 2 to 3 weeks.

Infertility Work-Up: Non-routine Tests

The American Society for Reproductive Medicine (ASRM) recommends consulting with your physician to discuss the risks and benefits for any of the tests described below before making a decision. Your personal diagnosis may necessitate one or more of these tests. This article represents a respected clinical viewpoint, but there can be exceptions.

Laparoscopy for Evaluating Unexplained Infertility

laparoscopyUnless there are suspicions of pelvic conditions based on clinical history, an abnormal pelvic exam, or abnormalities identified through less invasive testing, SGF physicians generally find a routine diagnostic laparoscopy (a surgery that uses a thin, lighted tube inserted into the belly to look at female pelvic organs) unnecessary for patients undergoing an infertility work-up.

Advanced Sperm Function Testing

ASRM found that advanced sperm function testing in the initial work-up—such as sperm penetration or hemizona assays—to generally be unnecessary, as variability exists in these tests with very little correlation between results and outcomes. They are also not cost-effective and can lead to more expensive treatments.

Postcoital Test (PCT)

The postcoital test (PCT) is not easily reproduced and its prediction of pregnancy is “no better than chance,” according to ASRM. Utilizing this test often leads to more tests and treatments, but it does not yield any difference in pregnancy rates.

Blood Clotting Evaluation

blood cellsPerforming thrombophilia tests is of no benefit to patients who do not have any history of bleeding or abnormal clotting, or in the absence of family history. We do not recommend this test as part of the routine infertility work-up.

Immunological Testing

As mentioned above, an infertility evaluation investigates factors affecting ovulation, the fallopian tubes, and sperm, based on clinical history. While immunological factors may influence early embryo implantation, routine immunological testing of couples with infertility is expensive and does not predict pregnancy outcomes.

Prescribe Testosterone or Testosterone Products to Male Partner

Testosterone therapy is widely used for sexual dysfunction, but researchers have found it decreases sperm production, sperm count, and causes infertility. These therapies are not always reversible, even after removing the additional testosterone, so we strongly advise against it if a man is attempting to conceive with his partner.

FSH Level Screening in Women in their 40s

Menstrual cycles for women over 40 are less predictable due to the normal menopausal transition. During this time, FSH levels can vary from woman to woman and from day to day in the same woman. The FSH level will not predict when a woman will transition to menopause or diagnose that it has begun. If there are no other causes of irregular or abnormal bleeding, fertility treatment for women over 40 will not change based on the FSH level.

Endometrial Biopsy

The endometrium is the tissue lining the uterus. This tissue responds to the production of ovarian hormones and allows implantation of the placenta during pregnancy. During menstruation, the upper layers of the endometrium are shed. An endometrial biopsy (removing a sample of this tissue), will not predict the likelihood of pregnancy in general and it is not associated with improved live birth rates in assisted reproductive technology (ART) cycles. Physicians at SGF do not utilize biopsy in the routine evaluation of infertility.

Prolactin Testing in Women with Regular Menstrual Cycles

Prolactin levels are routinely checked during the infertility work-up by many centers. According to ASRM, though, there is no reason to expect that a woman would exhibit significant, elevated prolactin levels when she has normal menstrual cycles and no discharge from her breasts. Therefore, testing prolactin levels in a woman with a normal menstrual cycle provides no benefits and would not impact clinical planning.

Infertility Work-Up: The Bottom Line

When it comes to testing your fertility in the initial work-up, your Shady Grove Fertility physician has your best interests at heart. Day 3 bloodwork, the ultrasound, the HSG, and the semen analysis all provide your physician with important data regarding your reproductive health. Do your hormone levels show a decreased egg supply? Are your fallopian tubes blocked? Does your uterine cavity have a normal shape? Does the male partner have sperm? These are all valid questions that can we can answer from the work-up to help put you on a treatment path that will ultimately lead to parenthood.

If you would like to learn more about the infertility work-up or are ready to schedule an appointment, please speak with one of our New Patient Liaisons at 877-971-7755.

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Patient Resources: Egg Freezing Medications

A topic of concern for many women who Smiling Young Female Doctor In Hospitalconsider egg freezing is a fear that is not abnormal or uncommon. In fact, the thought of giving yourself injectible egg freezing medications is a fear and concern of many of our infertility and egg donor patients, as well. But let us set your mind at ease. These medications have been carefully developed to replicate the hormones your body naturally produces each month to create and release one egg. During an egg freezing or IVF cycle, your body requires higher doses of these natural hormones in order to produce more than one egg.

Common concerns shared by many of our patients include: What are the side-effects? What if I get confused when trying to follow the instructions? Can a nurse help me? Do you offer at-home assistance? Do these medications have late effects such as cancer? Rest assured, these concerns are perfectly normal and we are here to assist you every step of the way.

Side-Effects of Egg Freezing Medications

The hormone injections you’ll be taking are very similar  to the hormones that your body naturally produces. Most women don’t experience any significant side effects directly from the medication, while some women report mild symptoms similar to premenstrual syndrome (PMS). To date, there’s no evidence to support that the medications used during the egg freezing process cause undesirable late effects such as cancer. Tenderness may also occur around the injection site. In this case, we recommend ice and light massage to ease the tenderness.

Injection Training and At-Home Resources for Egg Freezing Medications

We understand that administering injections, mixing medications, and dealing with needles is not something the majority of our patients have ever experienced before. While the medication portion is inevitable, at Shady Grove Fertility, we will do everything possible to assist you through the process. We hope that you will take advantage of the following resources our patients have found to be helpful in alleviating the stress and anxiety that can often accompany taking medications.

  • Injection Training Classes: SGF offers its patients hands-on injection training classes at local offices throughout the region. At these sessions, our nurse educators will discuss medication protocols and patients will have the opportunity to practice and ask questions. To register for a class, please ask your nurse for more information.
  • Online Video Training: Through one of our partners, Freedom Fertility Pharmacy, free online training videos are available for a variety of different medications. Patients often use these videos for guidance after receiving their medications.
  • Private Injection Services: As a courtesy, we are happy to provide our patients with a list of Registered Nurses who offer injection services (injection classes, administration of injections), independent from SGF, and outside of normal business hours. For a small fee, a nurse will come to your home and teach you how to do the injections, as well as administer them for you if you wish. Women and couples who are nervous about giving themselves the medications throughout their cycle and/or the trigger shot have found this service to be immensely helpful. If you are interested in this service, please contact Pamela Collins, RN, at 571-263-2110 or visit their website for more information.

Even though egg freezing medications can seem intimidating, we hope that you will find that with the guidance these resources can provide, along with the personalized coaching from your nurse, you can make it through this portion of your cycle.

 “At first I was nervous and felt ill-equipped to do this on my own, but with the thorough instruction and guidance from my nurse, it soon became second nature.” – Sara, Egg Freezing Patient

If you’re interested in learning more about our unique Egg Freezing Program or you’d like to schedule an appointment to discuss your options and egg freezing potential, please fill out this brief form, or call 1-877-411-9292. To learn more about egg freezing, join us for one of our upcoming Wine & Freeze egg freezing seminars.

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New Woodbridge Fertility Center Means Easier Access for Patients

new woodbridge fertility centerShady Grove Fertility’s Woodbridge, Virginia office will be moving to a new location as of June 1, 2015. This new Woodbridge fertility center will give patients greater convenience and access than ever before, as the office is located right off of I-95. All appointments will now be located at 13580 Groupe Drive, Suite 105, Woodbridge, VA 22192.

New Woodbridge Fertility Center Provides Greater Access to Care for Virginia Patients

The new Woodbridge location will make it easier for current and new patients from the surrounding areas, such as Stafford, Fredericksburg, and Richmond, to get convenient access to care. Woodbridge is one of four Shady Grove Fertility offices serving the Virginia community:

Shruti Malik, M.D., to Join the Woodbridge Fertility Center Team

Shruti Malik, M.D.

Shruti Malik, M.D.

Shruti Malik, M.D., who practices currently at SGF’s Fair Oaks office, will also begin seeing patients at the new Woodbridge location. Dr. Malik finished her residency in Obstetrics and Gynecology at Summa Health System and completed a three-year fellowship in Reproductive Endocrinology and Infertility at Magee-Womens Hospital at the University of Pittsburgh Medical Center. She is board certified in Obstetrics and Gynecology and has expertise in the diagnosis and treatment of polycystic ovary syndrome (PCOS), male factor infertility, ovarian aging, and elective egg freezing.

Dr. Malik has received several honors, including the University of Pittsburgh Medical Center Physician Services Division Scholarship, the Society of Laparoscopic Surgery Outstanding Surgeon Resident Award, and the Cleveland Society of OB/GYN Women’s Health Service and Leadership Award. She has presented her research on fertility preservation and sexual dysfunction at several national meetings. An advocate in the reproductive endocrinology field, Dr. Malik has held a variety of leadership roles with the American Medical Student Association and the American Congress of Obstetricians and Gynecologists. Dr. Malik has been with SGF since late 2014.

“I look forward to joining the incredible team at the Woodbridge office as we make this next step towards providing the best care for our patients,” says Dr. Malik.

Rachana V. Garde, M.D.

Rachana V. Garde, M.D.

Dr. Malik will be joining Rachana V. Garde, M.D., who practices primarily in the Woodbridge and Annandale locations. Dr. Garde performed her residency in Obstetrics and Gynecology at Barnes Hospital, Washington School of Medicine in St. Louis, MO, and completed her fellowship in Reproductive Endocrinology and Infertility at Duke University Medical Center. She is the recipient of numerous academic awards and is a member of the American College of Obstetrics and Gynecologists and the American Society for Reproductive Medicine. Dr. Garde was named a Top Doctor by Northern Virginia Magazine.

To schedule a new patient appointment at the Woodbridge fertility center or another Shady Grove Fertility location, please call our New Patient Center at 888-761-1967.

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