Fertility Tests – there seem to be so many of them, with different terminologies, objectives and levels of importance. You end up asking yourself “Do I need them all? Are they expensive? Why am I only being told I need these tests after a failed round of IVF? Why wasn’t I offered these tests before? Are these just add-ons? I can’t even pronounce Hysterosalpingogram, let alone understand if I need it. Do I need this?”
These are just some of the questions we get asked, about the enormous list of tests out there that are designed to help you achieve pregnancy. With so many that you may not have heard of, to the ones you have but don’t quite understand, we turned to Stavros Natsis, MSc and Evripidis Mantoudis FRCOG from Gennima to explain.
Q: What are the first tests that clinics offer when a patient has their first consultation to explain why they are not conceiving naturally?
A patient’s first fertility consultation is really very important to them and to us. Deciding to seek advice and meet a fertility expert can be a stressful process emotionally. So we don’t only deal with the medical aspects, we also pay attention to the patient’s background. We aim to make them feel comfortable.
Routinely, a fertility ultrasound scan is performed during the first consultation. We focus on the ovaries to check their reserve and to make sure that there aren’t any reasons for concern, such as cysts, PCOS etc. We also check the uterus to make sure that it is healthy and there aren’t any polyps, fibroids etc
The first tests we recommend are the following:
- Hormonal profile (female partner)
- FSH, LH, E2, TSH, PRL on day2-4 of the cycle
- Thyroid test (TSH)
This is a group of blood tests to check the way the ovaries function and that ovulation occurs with no problems. Also, another hormone test (blood test) we recommend is AMH (Anti-Mullerian Hormone). This provides more information on ovarian reserve. Combining the data from all these hormonal tests and the fertility scan, we get a pretty good idea about the female patient’s fertility.
- Sperm analysis (male partner)
This is to check male fertility. A typical sperm test includes measurement of number, mobility and morphology of spermatozoa. On top of this, we recently decided to check for oxidative stress as a routine. This is considered a ‘hidden enemy’ of male fertility and proper treatment may be needed even if all other parameters are normal.
- Salpingogram (female partner)
To check that fallopian tubes are not blocked. The fallopian tube is where the sperm meets the oocyte (egg) and conception takes place. The embryo then moves to the uterus and implants. Blocked tubes mean that the egg cannot meet the sperm therefore conception is not possible.
Q: Can a patient request more detailed tests before they start a round of IVF, such as a thyroid test, a DNA fragmentation test, (if these aren’t on the primary list) even if the consultant hasn’t recommended them at this stage?
Obviously, we talk with our patients and discuss their concerns. If they request a certain test, we would consider it but first it is important to understand why the patient requests this and whether it makes sense for them and their treatment. Taking their medical history into consideration, we can explain whether a certain test would make a difference.
Q: IVF babble’s co founder Tracey Bambrough tried to conceive over many years without success. However, prior to her second and last IVF treatment, she was advised (by her new doctor) to have pre treatment tests, which confirmed she had endometriosis, a thyroid issue, a polyp and a blocked tube . . . ! Once resolved, Tracey went on to have twin daughters!
Why do you think her previous doctor didn’t test for this before? Do clinics wait for a failed round of IVF before exploring more deeply? If yes, what are the ‘phase two’ tests, and why not just do them all before the first round?
Well, actually, I have no idea! Checking for endometriosis or a polyp is part of our ‘phase 1’ tests, if I could borrow your term. The same goes for thyroid function and fallopian tube blockage tests. I am really sorry that Tracey had to go through all this, we certainly do not wish for this kind of fertility journey for any of our patients.
And yes, some fertility specialists will tell you that your first round of IVF is ‘exploratory’, but I totally disagree. At Gennima IVF, 7 out of 10 patients have a positive pregnancy test following their first round of IVF with us (provided they have a normal ovarian reserve). As you see, this means that first we resolve any issues (for example, a polyp) and then we go ahead with treatment. This is how we have such high success rates.
If treatment is unsuccessful and a second round of IVF is needed, then yes, we go ahead with some ‘phase two’ tests, only if it makes sense for that specific patient according to their tailor-made treatment plan and depending on ‘why’ the treatment didn’t work. We strongly believe in individualizing IVF, so ‘phase two’ tests might be different for each patient.
Here is list of common phase two tests and when we recommend them:
- Genetic thrombophilia testing – After a biochemical pregnancy or a miscarriage.
- Karyotype – After a biochemical pregnancy or a miscarriage.
- DFI (DNA fragmentation index) – In case of low fertilisation rate or severe male infertility
- Hysteroscopy – In case of a negative result despite excellent embryo quality
- Microbiome analysis with PCR – Recurrent implantation failures
Q: Why not just do them all before the first round?
It is important to distinguish between screening and testing. These tests are supposed to help patients with certain indications, and are not meant for everyone. Also, they cost a lot of money, some are time-consuming and they definitely add more stress to the treatment.
Q: Can you explain what the following tests do and if they are necessary?
- Mock embryo transfer
This is absolutely necessary for all IVF patients. Some women have cervical adhesions or unusual cervix morphology, so we perform a mock embryo transfer using an empty embryo transfer catheter (not loaded with embryos). This way we make sure that there won’t be any problems when it’s time for the actual embryotransfer.
- ERA test
This is quite a ‘popular’ test lately. It is actually an endometrial biopsy to check the implantation window. It is mostly recommended for frozen embryo transfer, but remains controversial.
- Endometrial scratch test
The idea is to boost implantation of embryos by introducing an endometrial injury. The healing process is supposed to mobilize a healthier endometrial cell population. The procedure is performed on egg retrieval day.
So far, this hasn’t been all that successful, it rather seems we need a hysteroscopy to actually see real benefits. So instead, we recommend a hysteroscopy 1-2 months prior to embryo transfer, either a diagnostic hysteroscopy to check the endometrium or ‘implantation cuts’ if needed. This approach works wonders, especially when patients have good quality embryos but still their pregnancy test is negative.
- Pre-implantation genetic screening (PGS)
This technique is to test the embryos for chromosome abnormalities. Embryos with chromosomal abnormalities (missing or extra chromosomes) cause biochemical pregnancies or miscarriages. This test is quite invasive for the embryos as you need to biopsy them prior to embryo transfer. It is recommended for patients with a certain profile, more specifically for young women with good quality embryos and healthy endometrium, as verified by hysteroscopy, who wish for a single embryo transfer (SET).
PGS does not make sense for all patients as we know now that some embryos with abnormal chromosomes can still repair them later and develop into healthy pregnancies.
- Reproductive immunology tests and treatment
This approach makes sense in the case of a biochemical pregnancy or early miscarriage. We test for several immunological factors that are associated with infertility. The idea is that the patient’s immune system is ‘hostile’ towards the embryo.
Several types of treatment are recommended, for example infusion for immune system suppression (Intralipids), cortisone, blood-thinner injections, progesterone supplementation or vitamin supplementation. I can’t stress enough how important it is to individualise immunological treatment.
Thank you so much to our experts Stavros Natsis, MSc and Evripidis Mantoudis FRCOG from Gennima IVF.
If you have any further questions, please do drop us a line at firstname.lastname@example.org