Dr. Nezhat diagnoses infertility by performing what is commonly referred to as an infertility workup. A series of tests are conducted to check for ovulatory irregularities or abnormalities in the uterus or fallopian tubes. Hormone levels, including FSH, LH, prolactin, and progesterone, are also checked.
A basic workup is usually done within one or two menstrual cycles. Several specialized lab tests are also conducted to check for any male factors that may be contributing to the difficulties the couple has been experiencing with fertility. Some of the most basic include sperm motility and male hormone tests. (See the section below called Not all sperm motility tests are the same for important information about this test).
DIAGNOSTICS: INITIAL EVALUATION
Initial evaluation is advised for the following groups even if it’s been less than 6 months:
- Women 40 years or older
- Women with oligomenorrhea (infrequent periods)/amenorrhea (no periods)
- Women with a history of chemotherapy and/or radiation
- Advanced-stage endometriosis
- Known or suspected uterus/tubal disease
- Women whose male partner has had previous testicular or groin surgery, impotence, chemotherapy and/or radiation, or a history of sub-fertility with another partner.
NOT ALL SPERM MOTILITY TESTS ARE THE SAME
We have seen countless cases of couples who were told that the sperm tests were normal, only to find that there were in fact abnormalities that went undetected. This misdiagnosis of sperm motility abnormalities occurs because some laboratories still use old instrumentation and old techniques that are not sensitive enough to detect subtle abnormalities, including sperm head anomalies. Sperm head abnormalities can make it impossible for the sperm to penetrate inside the egg. This means that the egg would not become fertilized and pregnancy would not be possible.
This is why Dr. Nezhat always performs sperm motility tests using the most advanced instrumentation and methods currently available.
DIAGNOSTICS: IN-OFFICE PELVIC EXAM
A basic pelvic exam performed in the doctor’s office can help determine a preliminary diagnosis. While not infallible, nevertheless in-office pelvic exams can often uncover conditions such as reproductive tract anomalies, fibroids, and endometriosis with a surprisingly high degree of accuracy.
DIAGNOSTICS: BLOOD TESTS & HORMONE ANALYSIS
Monthly and mid-cycle blood tests are performed to evaluate monthly fluctuation of hormones. (Men undergo similar analyses). These tests may help reveal ovulatory dysfunction. Others tests include:
- Ovarian Reserve Testing
(follicular-stimulating hormone (FSH) and luteinizing hormone (LH)
- Measuring Estradiol
- Measuring Progesterone
- Measuring Inhibin-B
- Clomiphene Citrate Challenge Test
- GnRh Agonist Stimulation Test
- Hypothalamic activity
Before (photo 1) and after injection (photo 2) of sterile saline into the uterine cavity. This patient had a normal result.
DIAGNOSTICS: TRANSVAGINAL ULTRASOUND (SONOGRAM), SONOHYSTEROGRAM
Transvaginal ultrasound (also sonogram)
Transvaginal ultrasound is a type of pelvic ultrasound, also called a sonogram. Transvaginal means across or through the vagina. A probe called a transducer is covered with a condom and gel and then placed inside of the vagina. Once inside of the body, the transducer sends out high-frequency sound waves. These sound waves help reveal the shape of the uterine cavity, ovaries, cervix, and vagina by reflecting off of the body’s structures.
The information is then sent back to the attached computer, which uses the data to create an image, like the one shown on the left. The doctor can immediately see the picture on the attached TV monitor. Conditions such as ovarian cysts, uterine fibroids, and adenomyosis can usually be easily detected. Conditions such as endometriosis are more difficult to distinguish in this manner. However, endometriomas (endometriosis of the ovaries) can sometimes be detected using this technology.
A sonohysterography, also called saline infusion sonography (SIS) or hysterosonography, may be needed to obtain more detailed images. This test is essentially identical to the transvaginal ultrasound, except that it requires saline (sterile salt water) to be placed into the uterus beforehand. The saline is used because it distends the cavity of the uterus, which allows better visualization of the inside lining of the uterus. Distended in this manner, uterine septums, submucosal fibroids and endometrial polyps can be more easily detected.
DIAGNOSTICS: HYSTEROSALPINGOGRAPHY (HSG)
A hysterosalpingogram (HSG) is an X-ray of the uterus and fallopian tubes. An instrument called a fluoroscope is gently passed into the canal of the cervix and a special contrast solution (radio- opaque dye) is injected into the uterus. Because this test requires the use of x-ray technologies, it must be performed in the radiology department by a radiologist.
The dye shows up on an X-ray screen, which the doctor can see filling the uterus and then passing along both tubes to enter the cavity of the abdomen. If the dye fails to enter the tubes this may indicate an obstruction of the tubes. However, sometimes this failure to enter the tubes is the result of a temporary spasm of the tubes, which can cause a temporary, reversible obstruction.
The HSG test can pinpoint the exact site of any tubal obstruction and can also show the presence of any irregularity in the shape of the cavity of the uterus. However, this test cannot identify the existence of pelvic adhesions, which may be enveloping the ovaries and preventing eggs from gaining access to the tubes. ( Videolaparoscopy is best for diagnosing such fertility-obstructing adhesions).
While it doesn’t technically require any general anesthetic, many women do experience some discomfort and pain. Therefore, if you would like to take any medicine prior to this test to reduce any discomfort, please just ask our staff.
A hysteroscope is a thin, telescope-like instrument that is inserted into the uterus through the vagina and cervix. This tool often helps a physician diagnose or treat a uterine problem. Hysteroscopy is considered minor surgery, which can be performed either in your physician’s office or in a hospital setting. It can be performed with local, regional, or general anesthesia. For most women, there is little risk involved with this procedure. However, for those who have distorted anatomies due to adhesions or other conditions, extra care must be taken to avoid complications, such as perforating the uterus.
When is hysteroscopy indicated?
Hysteroscopy is used to diagnose some uterine abnormalities and may also be used to confirm the results of other tests, such as
hysterosalpingography (HSG). Other instruments or techniques, such as dilation and curettage (D&C) and laparoscopy are sometimes used in conjunction with hysteroscopy. Diagnostic hysteroscopy can be used to diagnose certain conditions such as abnormal uterine bleeding, infertility, recurrent miscarriages, uterine adhesions, fibroids, or polyps.
Hysteroscopy should not be performed on women who are pregnant
Hysteroscopy should not be performed on women who are pregnant. Prior to performing hysteroscopy, all patients undergo a urine, clinical, and visual test to check for pregnancy.
In cases of suspected endometriosis and unexplained infertility, videolaparoscopy is one of the most accurate and useful diagnostic tools available. Ultrasound and other tests are simply not advanced enough to detect all of the potential abnormalities that may exist inside of the body. Videolaparoscopy is a surgical procedure where a camera is placed inside the abdomen allowing the surgeon to see inside the entire abdomen and pelvis through a small incision.
Dr. Camran Nezhat invented this technology and is the world’s expert in videolaparoscopy.