Tests for Female Infertility
Written by Dr.M.D.Mazumdar, MD
The Basic Infertility Workup includes physical examinations and medical and sexual histories of both partners. A thorough infertility workup of the couple should be done before any tests are carried out. Tests may be both invasive and non-invasive.
The couple should be asked about their age, previous pregnancies, if any, frequency of intercourse, pain during intercourse and whether they use any lubricants during sex. Use of birth control methods, menstrual history, current and past sexual practices, surgical history and other health issues should be discussed. The history may sometimes suggest the cause of the infertility.
Details about any relevant medical diseases that they may suffer from (like diabetes, thyroid hormone deficiency) and whether they take any medicines, either as recreational drugs or for any diseases should be enquired about.
The most important factors controlling pregnancy in a woman are patency of the reproductive tract, mainly the tubes, and regular ovulation or anovulation.
Tubal Patency Tests
Hysterosalpingograhpy (HSG)This is the most widely used and also the most informative test for tubal patency in the investigation for female infertility. A non-irritant radio-opaque dye is injected through the cervix into the uterus. X-rays are taken of the movement of the dye through the uterus, the tubes and then the spillage into the abdominal cavity through the fimbrial end of the tubes. Any block in the passage is shown up in the X-rays.
The advantage of an HSG is that not only does it reveal whether a block is present or not, it also reveals the position of the block in the reproductive tract, and also the presence of adhesions around the tubes.
LaparoscopyDye injected into the cervix during a laparoscopy procedure can be observed spilling out of the tube if patent. This is a most reliable test as it is directly visualized. Advantage of the test is that any adhesions seen during the procedure can be corrected on the spot. Disadvantages are that it is an operative procedure and requires the patient to be admitted to the hospital for at least one day. It may also not reveal the position of the block inside the tubes.
HysteroscopyBy this method, the inside of the uterus as well as the inner opening of the tube can be directly visualised. Hysteroscopy is usually done with laparoscopy in the same sitting for a better chance of occurance of a pregnancy .
Assessment for Ovulation
Ultrasonography (USG)USG is used for real-time visualization of the gradual growth of the graafian follicles, the number and size of the follicles and the corpus luteum after rupture of the dominant follicle. It is the most commonly used method for diagnosis of ovulation.
Basal Body temperature (BBT)The body temperature is raised by progesterone and is thus higher in the luteal phase of the menstrual cycle than in the follicular phase since the progesteone levels increase after ovulation. The difference in temperature may be between 0.5 - 1 degree. This change is temperature can be recorded on a temperature chart (shown below) and gives a fair indication of ovulation.
The temperature is recorded from the 1st day of the menstrual cycle. The oral temperature should be taken first thing in the morning while the woman is still in bed, before taking any food or even rinsing the mouth. There may be a sharp drop of about 0.5 degrees just at the time of ovulation. Then the temperature rises and stays more than 1 degree above the pre-ovulation temperature. If pregnancy occurs, it continues to remain high throughout pregnancy. But if pregnancy does not occur, it begins to drop again 2-3 days before the start of the next menstrual cycle.
The BBT can be altered by lack of sleep, stress or fever. It is not very reliable in women with irregular cycles. But its advantage is that it can be done by the couple themselves in the privacy of their home.
The BBT is the basis of the rhythm method of birth control.
- Cervical Mucous: At the time of ovulation the cervical mucous changes from a thick consistency to a thin, watery consistency. It can be drawn out into threads more than 10-15 cms long. This is called the Spinnbarkeit test. If the mucus is spread out thickly on a glass slide and allowed to dry, it shows a typical 'fern pattern' under the microscope (See cervical mucous changes for images). Both these tests indicate a level of oestrogen adequate to cause ovulation.
- Ovulation Kits: Ovulation kits are freely available in the market to test for ovulation. These kits test for the LH surge just before ovulation. Sexual intercourse within 36 hours of the positive ovulation test (LH surge) is necessary for pregnancy.
- Endometrial Biopsy: A sample of endometrium is curetted out on the 21- 23rd day of the menstrual cycle. Secretory endometrium means that the patient has ovulated in that cycle.
- Hormone levels: If ovulation occurs, the serum progesterone level in the blood on the 5-8th day after ovulation (approximately 21st day of the menstrual cycle) becomes high, around 10-60 nmol/litre.
Other Tests for Female Infertility
- Sims-Huhner test: In this test, a drop of mucous is removed from the cervix not later than 12 hours (preferably within 2 hours) after coitus. The mucus is examined under a microscope for sperm and their motility, if any. The test is said to be positive, if there are at least 5 motile sperms found in the cervical mucous.
- Kremer Test : A drop of mucous at the time of ovulation is collected and placed on a glass slide. A drop of the husband's semen is placed near it. Invasion of the mucous by the sperm is examined under a microscope. Donor semen with the wife's mucous and donor mucous with the husband's semen can also be used for differential diagnosis.
Hormone assays: Tests for TSH, T3, T4, prolactin level, insulin level and androgen level should be done. Conditions like hypothyroidism, hyperprolactinemia, and PCOS can cause infertility by interfering with normal ovulation.
Blood tests: VDRL test, ESR for any infections, blood glucose test.
- Post pill loss of Periods.
- Genital Herpes and other Sexually Transmitted Diseases.
- Vaginal Discharge with Itching .
- Female Genital Anatomy - Vulva, Vagina, Clitoris, G-spot etc..