Investigations for Women
A) Frequent Tests
1. Hormonal Profile
Hormonal profile check levels of ovulatory hormones, hormones that are produced by the ovaries, the pituitary hormones that control reproductive processes and thyroid hormones that can affect the implantation of the embryo.
2. AMH
Anti-Müllerian hormone (AMH) plasma levels reflect the continuous non-cyclic growth of the very small follicles (non-selected). Thereby mirroring the number of the resting primordial follicle pool and thus acting as a useful marker of ovarian reserve. The level of AMH is an indication and not a proof of the remaining egg supply and under no circumstances should be used as a predictor of the fertility treatment outcome.
3. Hysterosalpingography (HSG)
Hysterosalpingography evaluates the condition mainly of the fallopian tubes and secondarily of the uterus, as it looks for tubal blockages or other problems like uterine polyps, submucosal fibroids or uterine shape abnormalities. It’s accuracy for tubal evaluation is very high, while for uterine evaluation is moderate and in this case usually additional investigations are needed. During the procedure of the HSG, X-ray contrast is injected into the uterus, through a catheter. Then an X-ray is taken to determine if the uterine cavity is normal and the most important to see if the fluid spills out of the fallopian tubes. If the fluid can pass through the fallopian tubes then the tubes are patent, if not then the tubes are characterized as blocked.
HSG is also the most useful investigation for the diagnosis of a condition called hydrosalpinx. In this case the tubes the full of a fluid which can be toxic for implantation.
4. Pelvic Transvaginal ultrasound
The transvaginal ultrasound is very useful to evaluate the uterine cavity and the ovaries. Uterine polyps, fibroids and other uterine abnormalities can be easily seen with the ultrasound. It is a very useful tool as well to determine ovarian reserve as the very small follicles (AFC) that are present in the ovaries mirroring the egg supply. Therefore, AFC in combination with the serum AMH is a quite accurate marker for the evaluation of the ovarian reserve. A more advanced type of the traditional pelvic transvaginal ultrasound is the 3D transvaginal scan which allow a more thorough view of the endometrial cavity and the shape of the uterus.
5. Saline Infusion Sonography (AquaScan)
The AquaScan is a procedure in which sterile water is injected through the cervix into the uterus. A catheter is placed in the neck of the womb and the sterile water is passing through the catheter to the endometrial cavity. The procedure is painless and very useful in order to examine the lining of the womb for any abnormalities such as polyps or fibroids which may prevent a pregnancy from implanting.
B) Other Tests
1. Hysteroscopy
This is a surgical procedure and it is performed under sedation. During the procedure, a thin, lighted device including a camera is inserted through the cervix into the uterine cavity to view any potential abnormalities and to treat them at the same time. Hysteroscopy is the gold standard for uterine investigation as it offers a direct view into the uterine cavity.
When it comes to the comparison between the Hysteroscopy and Aqua Scan, the Hysteroscopy is unquestionably more accurate, however the combination of the Aqua Scan along with the 3D Scan is a respected alternative option for patients with no strong indication for Hysteroscopy
2. Laparoscopy
This minimally invasive surgery is performed under general anaesthesia. The procedure involves making a small incision beneath the navel and inserting a thin viewing device (camera) to examine the fallopian tubes, the ovaries and the uterus. Any findings can be treated the very same time and the recovery costs no more than 2-3 days.
3. Special Tests
Rarely and depending on the medical history, the reason of infertility and the results of the above mentioned investigations, may some other tests be required such as:
– NK cells
– Thrombophilia Screen
– Microbiota test
– Immunology Tests
– Endometrial Receptivity Array (ERA test).
– Karyotype,etc
Investigations for Men
A) Frequent Tests
1. Semen Analysis
The typical semen analysis is the first step for investigation of male fertility before starting the fertility treatment. Semen is generally obtained by masturbating or by interrupting intercourse and ejaculating your semen into a clean container.
Semen analysis usually includes the evaluation of both macroscopic and microscopic parameters:
– Macroscopic parameters: sperm volume, liquefaction, viscosity, pH
– Microscopic parameters: sperm number and concentration, motility, normal and abnormal morphology, coagulations, vitality, cell types.
Based on the results of the semen analysis may some other tests be requested and the proposed fertilization technique will be decided (IVF vs ICSI).
2. Sperm DNA Fragmentation Test
Sperm DNA integrity is vital for achieving and maintaining of a pregnancy as well as for the birth of healthy offspring. Nowadays, increasing evidence indicates that sperm DNA fragmentation a marker of damaged chromatin, has a pivotal role in male infertility and reproductive success. In simple words DNA fragmentation test is a marker of the quality of the sperm. Sperm of poor quality can be the cause of failure of natural conception and can lead to multiple unexpected effects during the fertility treatment such as fertilization failure, poor quality of embryos and recurrent implantation failure. Also, there are strong evidence that high DNA fragmentation rate could be a cause of recurrent miscarriages. The good news are that with the suitable treatment (called sperm improving protocol) the parameters of the sperm including the high DNA fragmentation rate can be improved.
3. Semen Culture
Semen culture is an integral step of sperm evaluation. It looks for the presence of aerobic and anaerobic microorganisms which may be the cause of an acute or chronic infection responsible for infertility. Quite often, the chronic infection can be the cause of the high DNA fragmentation rate. After the identification of the microorganisms, antibiotic sensitivity testing is also performed in order to determine the appropriate antibiotic for a successful treatment.
4. Sperm Oxidative Stress Test
Sperm produce small amounts of free oxygen radicals (ROS) which are essential for their normal function. However, the level of ROS should be remain low, and for this reason there are antioxidants in the sperm environment that remove these free radicals as soon as they have performed their function. Therefore, a balanced level of ROS in semen is needed for sperm’s normal function and successful oocyte fertilization. On the contrary, excess ROS level is the underlying cause of sperm DNA damage. It has such a harmful effect on sperm plasma membrane that can significantly affect the sperm motility and vitality. High oxidative stress, impairs fertilization, embryo development, reduces the pregnancy rates and it may also increase the risk of miscarriage. The treatment includes antioxidant supplements, changes in lifestyle, treatment of underlying infections and maybe surgical varicocele repair.
B) Other Tests
1. Hormone Testing
This is a blood test to determine the level of testosterone and other male hormones. It is useful in cases of sperm disorders associated with the total number and concentration of the sperm (oligospermia, azoospermia).
2. Karyotype – Y deletion test
Genetic testing will be performed in cases of severe oligospermia and azoospermia to determine if there is a genetic defect causing infertility.
3. Testicular Ultrasound
Imaging test is useful to evaluate anatomical abnormalities responsible for sperm problems. In this case surgical repair of anatomical abnormality may be beneficial and may increase the chances for both natural conception and successful fertility treatment.
4. Testicular Biopsy (PESA/TESE)
In selected cases with azoospermia (total absence of ejaculated sperm) testicular biopsy may be performed to retrieve sperm from epididymis (PESA) or testis (TESE) for fertility treatment. This is a routine surgical procedure under sedation and the recovery is usually painless and fast.
5. Anti-Sperm Antibody Test
An antisperm antibody test looks for abnormal presence of special proteins called antibodies in the seminal plasma. These antibodies bind to antigens on the surface of spermatozoa and can cause an immune system response in either the man’s or woman’s body as they can damage or kill sperm. The sperm becomes unable to fertilize the egg and the couple has difficulties to become pregnant. This is called immunologic infertility.
Normally the sperm is kept away from the rest of the body and the immune system by testicular mechanisms. However, testicular injuries, surgeries, or even infections can disturb the testicular function and the sperm can come into contact with the immune system creating antibodies. Also, a women can have a kind of allergic reaction to her partner’s sperm and this can also create sperm antibodies, causing infertility.