Infertility investigations
Your GP may carry out some of the preliminary tests and refer you on to a specialist infertility clinic or gynaecologist at any stage for more thorough investigation.
A physical examination may be the first test you experience, to check for signs of infection as well as any obvious physical abnormalities that may be affecting fertility. Many investigations will then move on to hormone tests for the woman; however, most doctors will insist that the man has a semen sample analysed before the woman goes through any of the more invasive physical tests.
Hormone tests
The levels of most of the hormones known to play a part in fertility can be checked with a simple blood test. For a woman, this test is usually carried out around Day 21 of the cycle, when the levels of hormones can indicate whether ovulation has occurred and also where any problem might lie. Hormone test levels vary and you need to discuss carefully with your doctor not only what each hormone level means on its own, but also in combination, before moving on.
Sometimes the man is tested too, as hormone problems can affect sperm production.
Semen analysis
For this test, a man will need to deliver a sample of his semen into a sterile container. A ‘good’ test will show that he is producing enough seminal fluid, that there are more than 20 million sperm per ml, that more than 40 per cent of these are moving forward and that at least 70 per cent of them are not abnormally shaped. If the sperm count is poor, another test will probably be carried out since sperm counts can vary.
If the sperm seem to ‘clump together’, further tests may be carried out to check for anti-sperm antibodies. Two additional tests may also be used: the ‘swim-up’ test, which allows the percentage of normal sperm to be established, and microscopic photography, which checks the distance the sperm travel.
Post-coital test
In this test, a couple needs to have intercourse around the time of ovulation, when a woman has ‘fertile’ mucus. A sample of cervical fluid is then obtained from the cervix a few hours later and checked under a microscope to see if motile sperm are present. If a large proportion are moving through, it shows that there is no ‘hostile’ reaction taking place.
However, if sperm aren’t getting through, this test may be followed by the sperm invasion test. A sample of the woman’s fertile cervical mucus is mixed with the man’s semen and examined under a microscope to see how far the sperm penetrate into the mucus.
If they clump together and don’t move forward, or if they die off inside the mucus, this may be because one of the couple is producing antibodies to the sperm. In such cases, a ‘crossover’ test may be done, in which the man’s semen is put on a slide with someone else’s mucus and the mucus is put on a slide with someone else’s semen. This can show where the problem might lie.
Cervical mucus can also be analysed to see if it ‘ferns’ under a microscope. Ferning is a characteristic pattern of fertile mucus and shows whether it is as stretchy as it needs to be to let sperm through.
Physical investigations
Sometimes a woman will know that she has had an infection which may have caused damage to her fallopian tubes, sometimes she won’t. Chlamydia, for example, sometimes produces no discernible symptoms, so the fact that it has damaged the tubes may come as a complete surprise. This is why a check on the state of the fallopian tubes is essential in any investigation of infertility, and there are several ways in which this can be done.
Laparoscopy test
In a laparoscopy, carried out under general anaesthetic, a viewing tube is inserted through a small incision in the woman’s abdomen. The abdomen is inflated with carbon dioxide, which makes it easier for the surgeon to check the uterus, ovaries and fallopian tubes for structural abnormalities, endometriosis and adhesions, as well as possibly repair any problems at the same time. Some surgeons also use a laparoscopy to assess whether the fallopian tubes are open: dye is injected through the cervix and should flow out of the ends of the tubes; if it doesn’t, they are blocked.
A laparoscopy is usually carried out as a day procedure, but it carries the small risks and potential side effects of any operation which requires a general anaesthetic. Some women take several days to recover and can suffer soreness as the carbon dioxide tries to escape again. Despite these drawbacks, the procedure can provide a great deal of useful information, and the tiny scar will fade.
X-ray Test (hysterosalpingography)
Another standard test to assess whether the fallopian tubes are open is hysterosalpingography. Dye is injected through the woman’s cervix into the uterus. This dye shows up on X-rays, so a series of X-rays is taken to check how it is flowing through the fallopian tubes and whether there are any blockages.
Any problems show up immediately, which makes this a useful procedure, but it can cause mild to severe cramps. Another advantage of this test is that you avoid having to have a general anaesthetic and surgery; it is usually done in the hospital’s X-ray department and you can go home soon afterwards, though you may need someone to drive you.
Ultrasound tests (hysterosalpingo-contrast sonography)
A relatively new test for assessing whether the fallopian tubes are open is hysterosalpingo-contrast sonography. A contrast solution is injected through the cervix and ultrasound scanning allows its flow along the tubes to be traced. The procedure takes between 15 and 30 minutes and you can go home straight afterwards. However, it is not suitable for everyone and a laparoscopy may also be recommended for a full assessment of your pelvic cavity.
Ultrasound scanning
Ultrasound scanning is also sometimes used as a diagnostic test. Abdominal ultrasound can give a picture of a woman’s uterus and ovaries and show any fibroids, uterine abnormalities or polycystic ovaries. Ultrasound can also monitor whether eggs are developing and being released from the ovaries. One uncomfortable aspect of abdominal ultrasound is that a full bladder is necessary to allow the ovaries to be seen more clearly. Sometimes transvaginal ultrasound is used and a full bladder is then not needed.
For a man, ultrasound can show whether the sperm are being stored and passed on through the system as they should be.
Endometrial biopsy
If there is doubt whether a woman’s endometrium (lining of the womb) is thickening as it should be in preparation for a developing embryo, an endometrial biopsy can be undertaken. A catheter is inserted through the cervix and a small sample (biopsy) of the uterine lining removed. If the endometrium has not developed as expected for that phase of your cycle, this can indicate a problem with hormone levels. The test can also be used to check for infection and if this is discovered a D&C (dilatation and curettage of the endometrium under general anaesthetic) may be needed.
Surgical exploration of the testes
This is done if no other reason can be found for a man’s infertility. It can check for blockages or infections, and a biopsy may be taken to check whether sperm are being produced and are maturing properly. If the sperm-producing tubules and the sperm in them are normal but a semen analysis shows no sperm, the problem is likely to be a blockage. A vasogram may be performed to pinpoint the blockage: dye is injected and X-rays will outline the ducts and pinpoint any obstructions.
What next?
After one, two or several of the tests, you will be told one of three things:
- There is definitely something wrong (for example the man is producing no sperm). You won’t be able to get pregnant without treatment which will try to cure or get round the problem. You can then decide whether you want to go ahead with treatment.
- Something is having a mild effect on your fertility (like irregular ovulation or endometriosis) but you could still get pregnant without intervention, although it may take a little longer. In this case, the process of weighing up the costs and benefits of possible treatments is more difficult.
- Your infertility is ‘unexplained’ - there is no apparent physical or hormonal cause. You could still conceive, but you may not. If you have unexplained infertility it doesn’t mean there isn’t a reason why you’re not conceiving, just that doctors haven’t been able to identify it yet. This sort of infertility can often be treated successfully through techniques such as IVF, which may bypass whatever the hidden problem is.
Different causes of infertility require different approaches and you need to decide whether you want to go ahead with treatment at all and, if so, consider which treatments are available on the NHS and which treatments you could access as private patients.
NHS or private?
What will be available to you on the NHS depends on where you live. Many health authorities make no funding available for infertility treatment. In other areas, what is available will be strictly rationed; for example, drug treatment may be available but nothing else or, if your health authority does fund IVF, it may only be available to married couples under 35. Your Community Health Council will have a list of the criteria for treatment in your area.
However, even if your health authority considers you eligible for treatment, there are financial implications, including the hidden costs of taking time off work and travel expenses (you may need to make very many journeys to the clinic). You also need to remember that waiting several months for an appointment is not unusual.
One of the main advantages of private treatment is that, if you have the ability to pay, you can by-pass NHS waiting lists as long as you conform to the clinic’s own eligibility criteria. If your GP will agree to fund the costs of the drugs you will need, this can mean the difference between being able to go ahead or not. It is worth asking if your GP will do this, as many will. If you have a private health scheme, ask if your insurance will fund any part of the investigations or treatment.
It is important to take time out as a couple once you know the results of the initial tests to consider the emotional and the financial implications of treatment. Your GP can put you in touch with a counsellor if you want to talk things through, and you will be offered counselling if you’ve been referred for IVF or treatment involving donor eggs or sperm. Whether you decide to go ahead with treatment or not must ultimately be your own decision.
If you want to find out more about what is offered in your area, the Human Fertilisation and Embryology Authority (HFEA) publishes a Patients’ Guide to all the clinics in the UK which offer IVF and donor insemination (DI) treatments. The guide contains a comprehensive section on factors for couples to consider when choosing a clinic and before undergoing treatment. It is available free by calling the HFEA, or can be downloaded from the HFEA website at http://www.hfea.gov.uk
