History, examination and investigations
Before any investigations are carried out it is important that your doctor takes a detailed history and performs an examination.
In the discussions which take place, your doctor will want to establish important facts, such as your ages, how long you have been trying, how often you have intercourse, if there is any problem with normal intercourse (eg. psychosexual, impotence or penetration problems), and whether either of you have had any pregnancies in previous relationships. Irregular periods may suggest that ovulation is not taking place every month or if they are particularly painful and intercourse is uncomfortable, this might suggest endometriosis. Previous pelvic or chlamydia infection may be significant with regards to tubal blockage, as might previous pelvic surgery.
On the male partner's side, it is important to know if there have been any operations or trauma to the testes or a significant infection, such as mumps as an adult, which can be associated with a low sperm count. For both partners documentation of alcohol and smoking habits is important, as both of these are associated with lower fertility.
Examination of the woman will include an internal to check that the uterus & ovaries feel normal and to see if there is any particular tenderness or painful areas. Swabs are sometimes taken to rule out infection. Many men are surprised when asked to be examined in an infertility clinic, but it can be helpful, particularly if the semen analysis turns out to be abnormal.
Essential investigations
Couples will need to undergo the following investigations.
A hysterosalpingogram (HSG). This test is carried out in the x-ray department of the hospital and is a screening test to check if the tubes are blocked. A speculum is passed (like when having a smear test) and a small amount of dye is injected through the cervix. A series of x-rays are taken which show the outline of the uterus and if the tubes are open, dye will be seen flowing through.
Day 2 LH/FSH. This is a blood test that checks whether there is a good reserve of eggs in the ovary and that the hormonal system leading to their release is intact. It is taken on the second day of the cycle (day 1 is the first day of a period). LH and FSH are hormones that stimulate egg development and release. High levels of LH are also found in polycystic ovary syndrome, which is a common cause of anovulatory infertility.
Progesterone test. This will check if ovulation has taken place. It should be taken 7 days before a period, so for a 28-day cycle it is done on day 21. If a period doesn't come 6-8 days after the test, then it will need to be repeated. A level of 30 nmol/l or more suggests ovulation has occurred.
Semen analysis. A sample of semen is needed to check the total count, whether the sperms look normal, and if they are motile. It is important to abstain from sex for a few days before the test and to ensure that the sample is transported to the lab without delay when produced. If the first test is low or borderline a second sample is requested to see if this was a one-off result - was this the best or worst? More details about abnormalities of the semen analysis will be discussed in another section.
Rubella antibody levels. These are checked to see that immunity is present, as this is a good time to repeat the immunisation if not, rather than risk infection during pregnancy, which can cause birth defects.
Other investigations - for special circumstances
Pelvic ultrasound scan - sometimes this is carried out as a part of the initial investigation to check that the uterus appears normal and whether the ovaries have a polycystic appearance. An internal or transvaginal scan is most accurate.
Diagnostic laparoscopy and dye test - if there is a significant degree of pain with intercourse or painful periods then a laparoscopy might be suggested instead of a HSG. This involves a general anaesthetic and small telescope look through the umbilicus into the pelvis to see if there is anything causing the pain (eg. endometriosis). At the same time some dye is injected to check the tubes are open. This is also done if a HSG suggests that there might be a problem with the tubes, as a HSG alone can't give all the information and the 'blockage' may just be due to spasm of the tube or inadequate pressure when injecting the dye.
Post-coital test - this test involves an examination of the mucus around the cervix shortly after intercourse has taken place. It is like having a smear test, and under the microscope interactions between the sperms and cervical mucus are analysed. It is only rarely used now, as studies have found it to be poor at predicting infertility, it often gives inaccurate results and adds little to the information obtained by the above tests.
Hysteroscopy - if the HSG suggests that there is an abnormality of the inside of the womb, a hysteroscopy can be done for a closer look. A fine telescope is passed through the cervix and the uterine cavity visualised. Hysteroscopy can detect fibroids or congenital variations such as a double-womb, bicornuate (heart-shaped) uterus or a uterine septum.
Thyroid function tests and prolactin - If a woman has irregular or infrequent menstrual cycles, or shows other signs of thyroid disease then it is important to exclude this. Prolactin is a hormone that is normally involved in production of breast milk and is released from a gland in the brain called the pituitary. An overactive pituitary gland can cause abnormally high levels of prolactin (hyperprolactinaemia) which prevents ovulation. A blood test for prolactin levels should be done if cycles are infrequent or there is an unusual discharge from the breast.