Investigating the Female Partner

Introduction to Fertility Investigations

The urge to reproduce affects most couples and failure to produce a child can be very distressing. Any such failure should not be blamed on either partner. It is always a "team effort".
The recent custom of postponing pregnancy until a career is well established has increased this distress. The human body is at its most efficient in its early twenties and after about 35, many functions start to deteriorate. At their best, a couple can expect to produce a conception once in six months, on average. About six out of seven will be successful in a year. Amongst the remainder, many will have no cause for this found even after extensive investigation

What needs to occur for conception?
  1. The woman has to produce eggs.
  2. The eggs have to burst out of the ovary (ovulation) and pass along the Fallopian tube to the womb.
  3. The Fallopian tube must provide the motive power for this and provide the right environment for fertilisation (combination of egg and sperm).
  4. The man has to produce sperm.
  5. He has to ejaculate in the vagina
  6. The sperm have to be able to swim to the Fallopian tube and penetrate the egg there.
  7. The lining of the womb must be suitable for implantation of the embryo (combined egg and sperm)

How do we check that ovulation has occurred?

The egg develops in a follicle in the ovary. The hormone LH (or Luteinising Hormone) is produced in a surge which causes the final development of the egg, the swelling and bursting of the follicle to release the egg. Ovulation prediction tests measure this hormone but cannot tell if ovulation results from the instruction. Then the follicle changes into a corpus luteum which produces as well as estrogen, the hormone Progesterone. This hormone can be measured by a blood test which can confirm ovulation. Alternatively, we can use one of the effects of progesterone to recognise its presence. To do this we can chart the woman's Basal Body Temperature (BBT Chart). This of course does not involve needles.
Sometimes we use ultrasound to measure growth of the follicle (follicle tracking). When it disappears, we can deduce that it has released the egg. This is an expensive investigation and not usually used unless there is a risk of multiple ovulation.

How do we check that the Fallopian Tubes are open?

Years ago we would try to blow some gas through the cervix and listen for the bubbles with a stethoscope on the tummy. A newer version of this test uses a fluid containing many tiny glass spheres which can be "seen" flowing through the tubes by ultrasound scanning.
In general these days, we use one of two techniques:

Hystero-Salpingo-Gram (HSG) is an X-Ray, performed as an Outpatient. A clear fluid which is opaque to X-Rays is injected into the cervix. It outlines the endometrial cavity and the inside of the Fallopian Tubes. Hopefully, we can see wisps of the fluid around bowel showing that it has flowed out of the tube on either side. Sometimes, there are little collections (loculations) suggesting adhesions. This examination gives practically no information about the pelvis around the womb and the tubes.

A better examination of this area can be made at Laparoscopy (Laparoscopy and Dye Studies, Lap'n'dye). To see that the Fallopian Tubes are open, we pass a BLUE dye through them and often take photographs to show it spilling out of the tubes. The dye is absorbed into the blood stream without harm and excreted through the kidneys. Your urine might, therefore, turn GREEN for a while. Laparoscopy enables us to see the extent of adhesions or diagnose endometriosis, which none of the other techniques will do.

Can we check the rest of the functions of the Fallopian Tubes?

No. We do not have the ability to see inside the tube at present, though there are experimental micro-cameras which might enable this in future. Nor can we sample the fluid inside the tube.

How do we check the lining of the womb?

If you are having an hysteroscopy or laparoscopy (and dye studies) at a time when we expect that ovulation has occurred, a scraping from the womb can be examined to see that the correct changes due to progesterone have occurred. A view of the endometrial cavity (inside of the womb) at hysteroscopy enables us to find abnormalities which might prevent implantation (e.g. polyps)

How do we check the Male factor?

Problems with erection or ejaculation should be apparent to the couple. Such problems should be mentioned to your doctor as there are treatments available for some of the causes. They may be a side effect of certain medications and another therapy may be as good without that effect.
The mainstay of our investigation is the Semen Analysis (also called sperm count or Male Fertility Testing). A sample of semen is produced by the man and it is tested for:    Numbers of Sperm, the movement of the sperm and the shape and structure of the sperm.

Blood tests

In order to evaluate the ovarian function in a menstrual cycle, blood tests are used.  We will tend to measure:

Follicle Stimulating Hormone (FSH).  As its name suggests, this stimulates the follicle to produce eggs.  A very high level shows that the body is finding it difficult to get the ovary to react.  This test is usually done on day 2 or 3 of a menstrual cycle.
In men, the same hormone stimulates sperm production.
Luteinising Hormone (LH).  The other hormone regulating ovulation is normally released by the pituitary gland in a short burst around day 12 of a menstrual cycle.  It causes the last bit of maturation of the follicle, its bursting and the release of the egg.  In PCOS, it will tend to be high all month and so we might check twice. 
In men, LH stimulates testosterone production.
Estradiol (oestradiol, E2).    This is produced by the ovarian follicles.  It is usuarry measured in the same sample as the FSH to see the response to that stimulation.
Progesterone.   Progesterone is produced by the follicle (now called a corpus luteum) after the egg has been released (ovulation).  People talk of “day 21 serum Progesterone”.  This is the time to do the test ONLY if the menstrual cycles are of 28 days duration.  If longer or shorter, one should try to do it a week before the next expected period.  This may take more than one test.  The basal temperature chart gives the same information (whether ovulation has occurred).
Prolactin.   This is the hormone which stimulates the breasts to produce milk.  It also inhibits ovulation.  It is really only relevant if the woman has no periods.  Stress can cause release of prolactin and so high levels ca often be found which have no clinical relevance whatsoever.
Testosterone.  This is sometimes measured in women.  It tends to be high in PCOS.
Anti Mullerian Hormone.   This has been found to correlate well with Follicular Reserve or the remaining supply of follicles in a woman’s ovaries.  See “How long do I have left to have a baby”.

How Long Do I Have Left To Have A Baby? Ovarian Ageing and Fertility

Many couples, these days, wish to postpone having a family until after a career has been established. This causes anxiety about declining fertility.

Ovarian Ageing and Fertility
The media have recently reported a new test that will (of course) "revolutionise" fertility treatment.
They tell us that it will predict how long you have got before your ovaries will cease to produce eggs.

Anti-Mullerian Hormones (AMH), a Marker of Ovarian Reserve

As a marker for Ovarian Age, AMH levels correlate with the number of ovarian follicles (the tiny cystic structures in the ovary, each of which could produce an egg).
That is, the AMH levels decline in premenopausal women as the number and quality of ovarian follicles decline with age. The test cannot measure the total number of oocytes (cells that can develop into eggs) but the levels strongly correlate with the size of the follicle pool. It cannot predict the date of your menopause. It can only suggest how you are at the time of the test.
If it suggests a smaller follicle pool, that is fewer left than expected, it would suggest that you would run out earlier than expected and experience an earlier menopause. A low level relates to poor outcomes with IVF.
In Polycystic Ovarian Syndrome (PCOS) there are more follicles developing than normal but few reach maturity. This produces higher than normal AMH levels.

Anti-Mullerian Hormone Results

  • Optimal Fertility: 28.6 pmol/l - 48.5 pmol/l
  • Satisfactory Fertility: 15.7 pmol/l - 28.6 pmol/l
  • Very Low Fertility: 0.0 pmol/l - 2.2 pmol/l
Ilse A L van Rooij et al., Fertil Steril. 83 (4): 979 - 987. (ISSN: 1556 - 5653)

N.B. This test is new and not fully evaluated in this country. It is therefore not available in NHS practice in our area. For private testing, please contact 0845 6861540

Stop Press: This test has recently been used with good success to predict ovarian function after chemotherapy for cancer, thus enabling measures to be taken to preserve fertility after treatment.

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