California IVF Fertility Center | 2590 Venture Oaks Way Ste 103, Sacramento CA 95833 | 530-771-0177

Before deciding on an appropriate form of treatment, diagnostic testing to evaluate for the various causes of infertility is usually the first step.  In some cases there may be more than one cause of infertility.  A comprehensive evaluation can then be used to direct fertility treatments.  In some cases, correctable abnormalities may be found and fertility treatments may not be necessary.

Ovulation and Ovarian Reserve – establishing a regular menstrual pattern will often suffice as a means of establishing the presence of eggs.  Predictable menstrual cycles serve as an indicator of regular ovulation, however, regular menstrual cycles will not tell us about ovarian reserve or egg quality.  AMH testing has essentially replaced the Clomiphene Citrate Challenge Test (CCCT).  The levels of anti-mullerian hormone (AMH) will provide an indicator of ovarian reserve.  Ovarian reserve testing will give an idea of the pool of remaining eggs.  During an ultrasound, an antral follicle count (AFC) can also provide information about ovarian reserve.  A woman with low ovarian reserve will be less likely to produce larger numbers of eggs when fertility medications are used.  There are some implications that egg quality may also decline as ovarian reserve declines.  A low AMH level and a low AFC predict lower ovarian reserve.  Historically, women with an abnormal CCCT would be less likely to conceive.   Age is one of the biggest factors that affect ovarian reserve.  Chemotherapy, endometriosis, and certain types of ovarian cysts may also diminish ovarian reserve.  Fertility preservation is used to protect against a decline in ovarian reserve due to age or medical treatments.

Semen analysis – this is the main test of the male fertility evaluation.  A normal semen analysis does not guarantee a pregnancy but reduces the likelihood that fertilization issues are due to problems with the sperm.  An abnormal semen analysis may repeated to confirm the result.  30-40% of infertility is due to male factors.  When combined with female factors, male factor infertility may contribute to more than 50% of infertility.  Medications and supplements are usually not effective in improving sperm function.  When semen parameters are significantly abnormal, injection of the sperm into the egg, or ICSI, is usually recommended.  For more information on male infertility click the link.

Pelvic ultrasound – Our clinic uses transvaginal ultrasound to evaluate the uterus, tubes, and ovaries.  By using a vaginal probe instead of an abdominal probe we are able to obtain images that are very clear and show very small details.  Things that can be detected on transvaginal ultrasound include uterine fibroids, endometrial polyps, retained pregnancy tissue, or scar tissue.  Outside the uterus, things such as ovarian cysts, including endometriomas, fluid in the fallopian tube known as a hydrosalpinx, as well as other abnormalities which may require further evaluation and treatment.  Frequently things identified on a pelvic ultrasound will require fertility surgery.   Transvaginal ultrasound is also used to monitor responses to medications.  A monitoring ultrasound is one used in combination with treatment while a baseline ultrasound is one used before medications are started.  Ultrasound is also very useful in viewing pregnancies as early as 6 weeks from last menses (4 weeks from conception).  By this time a heartbeat is usually detectable by ultrasound.

One thing commonly seen on a pelvic ultrasound is an ovarian cyst.  Ovarian cysts are misunderstood and extremely common.  Women who are ovulating regularly will form a follicle during her menstrual cycle.  This follicle contains an egg, or oocyte.  This follicle may become as large as 2.5 cm in diameter.  This follicle and the structure that forms after ovulation, known as the corpus luteum (secretes progesterone to support the uterine lining for a pregnancy), are functional cysts.  Sometimes these cysts do not regress on their own and are called functional cysts.  There are multiple other types of cysts, including ones that are malignant, hemorrhagic cysts from bleeding into a follicle after ovulation, but by far the most common type of cyst is the functional cyst.  Observation is the most common form of treatment.

Saline Contrast sonography: This is a special ultrasound where fluid is put inside the uterine cavity to allow for better visualization of the inside of the uterus. This can detect small abnormalities inside the lining of the uterus which can decrease fertility and lead to a higher rate of miscarriages.  Polyps, fibroids, and other uterine abnormalities can be seen.  Other names used are saline hydrosonography, saline infusion heterography, or SCUS.  

[more information about saline contrast sonography, saline infustion hysterography, or saline contrast ultrasound]

Hysterosalpingogram (HSG): The HSG is a procedure done with contrast dye injected through the cervix into the uterus while observing with fluoroscopy (moving x-rays).  This procedure is performed in a radiology suite.  The HSG’s should be scheduled for the week immediately after your menses, ideally between cycle days 5-12.  The HSG procedure will be performed by a radiology physician who will also briefly review the results with you after the procedure.  Patients may be advised to take 600-800mg of ibuprofen one hour before the procedure.  If you cannot take ibuprofen, then 500mg of Tylenol may be helpful to reduce cramping during the procedure. [HSG Procedure]

Diagnostic hysteroscopy and diagnostic laparoscopy – these are surgical procedures that use instruments to look inside the abdomen (laparoscopy) and uterus (Hysteroscopy).  These procedures will have to be scheduled through the surgery coordinator and will usually require pre-authorization with insurance.  Hysteroscopy (H-scope) can often be performed in the office but, laparoscopy (L-scope) is usually performed under deeper sedation or general anesthesia in a hospital setting. [Fertility Surgery Information]

Hormone Evaluations

The pituitary is located at the floor of the brain just above the mouth and nasal passages. It is responsible for secreting hormones to the rest of the body. These hormones regulate body functions such as thyroid hormone balance and ovulation.

Thyroid Stimulating Hormone (TSH):  TSH testing may uncover a thyroid abnormality that may have an impact on fertility.  TSH is released from the pituitary gland and stimulates the thyroid gland to make thyroid hormone.  An elevated level means the gland is not making enough hormone in the case in hypothyroidism.  Low levels indicate problems with TSH production or increased thyroid hormone production (hyperthyroidism).  Additional tests may be necessary to determine the exact cause of the abnormality.  Fertility patients and pregnant women may need tighter control of their thyroid hormones than patients having routine health screening.

Prolactin is another hormone of the endocrine system that is released from the pituitary gland.  Prolactin is responsible for the production of milk. Prolactin levels can be elevated without causing galactorrhea (discharge of milk in a non-pregnant woman).  Prolactin can hormonally interfere with the normal function of the hormones that govern follicular development and the menstrual cycle.  Prolactin tumors may also cause the pituitary to stop producing other hormones, namely FSH and LH, which will also have an impact on normal reproductive function.

Androgens are a group of hormones usually thought of as male hormones; such as testosterone.  These hormones are also present in females.  There are several disorders in which the androgens are abnormally elevated in a female patient.  Physical findings usually include abnormal hair growth, acne, and deepening of the voice.  One of the most common scenarios in which increased effects of androgens are seen is in polycystic ovarian syndrome.

Infectious testing: Infectious disease testing is important to prevent the transmission of infectious agents to patients and newborns.  Examples of infectious agents commonly assessed include:

  • HIV – Human Immunodeficiency Virus which is responsible for AIDS
  • Hepatitis B & C
  • Syphilis
  • Cytomegalovirus (CMV)
  • HTLV – Human T-Cell Lymphocyte Virus types 1 & 2
  • Rubella Immunity
  • Gonorrhea & Chlamydia

There are state and federal regulations governing infectious disease testing.  Fertility clinics in California fall under state tissue bank regulations.  These regulations require that infectious disease testing be completed on patients undergoing certain treatments.  The US Food and Drug Administration (FDA) has regulatory oversight of donor tissues.  This includes donor sperm, donor eggs, and donor embryos.  The FDA regulations also pertain to gestational carrier treatment cycles.  The FDA requires specific types of blood tests, physical exams, and history questionnaires.  In many cases, the testing performed as part of your fertility evaluation can be used by your OB doctor as part of your pregnancy care.

Pre-conceptual testing: In addition to infectious disease tests and hormone testing, other initial tests may include screens for genetic disorders. Examples of these tests include cystic fibrosis testing, sickle cell screening, and other inherited disorders such as spinal muscular atrophy and Fragile X.  When a patient tests positive for an inherited genetic disorder, they are considered a carrier for that specific genetic disorder.  For most genetic diseases, a carrier with one copy of a genetic mutation is not affected by the disease.  If the partner is also a carrier of the same genetic disorder, there is a risk that the baby can be affected by the genetic disorder.  When both partners are carriers for a specific genetic disorder, pre-implantation genetic diagnosis can be used to screen the embryos before implantation.  This allows carriers of a genetic disorder to have a child without the genetic disease.  Genetic testing is optional and in some cases is covered by insurance.

Recurrent Pregnancy Loss Testing:  Patients that have had multiple pregnancy losses may have special testing designed to test for potential causes of recurrent pregnancy loss.  These tests typically look at blood clotting factors, genetic disorders, and limited autoimmune disorders.  Additionally, structural abnormalities of the uterus are evaluated using an HSG or Saline Contrast Ultrasound.  While pregnancy losses are common, the tests do not frequently identify a cause.  The guidelines for recurrent pregnancy loss testing has been revised.  The American Society for Reproductive Medicine recommends the following tests for recurrent pregnancy loss.

  • HSG or Sonohysterography
  • Anticardiolipin Antibody (ACA)  IgG and IgM
  • Lupus Anticoagulant (or equivalent aPTT, Kaolin, dRussel VV)
  • Anti-beta2 Glycoprotein I
  • Female Karyotype
  • Male Karyotype

Screening for inherited thrombophilias (condition causing abnormal clotting) is performed only when there is a history of venous thromboembolism or a first-degree relative with a known or suspected high-risk thrombophilia.

  • Factor V Leiden mutation
  • Activated Protein C resistance
  • Protein S deficiency
  • Prothrombin G20210A mutation screening

Most miscarriages are considered sporadic events related to genetic mistakes in the embryo.  The frequency of these genetic mistakes increases with maternal age.  One of the most frequent risk factors for a miscarriage is advancing maternal age and the impact of age on infertility.  Genetic testing of embryos has been used to reduce miscarriage.  The impact of genetic testing on reducing the rate of pregnancy losses has been questioned.  Without genetic testing, IVF will not avoid the risk of a pregnancy loss but can usually shorten the time to conception.  Embryos left over from IVF treatments can be frozen and stored as a means of fertility preservation.  As women age, the frozen embryos will retain their ability to bring about a pregnancy independent of the woman’s age when she decides to use the embryos.

Autoimmune testing and Natural Killer Cells:  Testing for antiphospholipid antibodies and other markers of autoimmune imbalance such as natural killer cells (NK cells) has been used for years.  Autoimmune testing with antiphospholipid antibodies and natural killer (NK) cells has not been proven to be of use in the evaluation of recurrent pregnancy loss evaluation.  There are several websites that promote autoimmune testing and evaluation for elevated natural killer cells.  There are treatments for these abnormalities involving the use of intralipids and intravenous immune globulin (IVIG).  The accepted guidelines used by most fertility specialists and insurance companies do not recommend testing for anitphospholipid antibodies or natural killer cells.  The American Society for Reproductive Medicine (ASRM) has issued an opinion advising against regular use of IVIG outside of investigational studies.  Patients seeking answers for recurrent pregnancy loss are usually very anxious to find answers.  Due to the lack of strong evidence supporting antiphospholipid antibody testing, NK cells, and intra-lipids, and IVIG, women with recurrent pregnancy loss should be very careful trying to evaluate potential treatments that could be very expensive.  Therapy can add between $5,000 to $15,000, despite limited data supporting these treatments.

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The physicians at California IVF Fertility Center are board certified specialists with years of training and experience.  We will use evidence based medicine to evaluate for a variety of causes of infertility and recurrent pregnancy loss and advise you appropriately.  While there are many possible tests available, having the correct testing for each individual situation is important.  Improper testing and treatment can lead to significant delays in treating abnormalities and subsequent delaying the time it takes to become pregnant.  California IVF has the expertise you need to help you become pregnant.