Fertility investigations are something I advocate starting as soon as clients come to clinic, but there is a hierarchy of testing, there is often no need to carry out everything from the outset, results from each inform us where to go next. Here’s a summary
- Sperm analysis test – this is a baseline test for men and is available on the NHS if you have been accepted for fertility treatment, or privately for about £270 (because yes they really do have to count sperm!). It looks at sperm count, mobility, progressive motility, morphology, liquefaction, white blood cells, pH and gives a good idea of the health of the sperm. If some of the parameters are looking poor then the next step up is the Sperm DNA Fragmentation Test.
- Sperm DNA Fragmentation test looks at the amount of DNA damage at the head of the sperm. DNA fragmentation significantly increases implantation failure, but it does not appear to effect fertilisation, but it is associated with early pregnancy loss.
- Ultra sound on the testes will detect any issues with varicoceles (varicose veins in scrotum which can diminish blood flow and can cause fertility problems. This usually follows a specific set of symptoms and an examination.
- Hormone profile via blood test checks for syndromes and infections. Women have testosterone in their system and likewise follicle stimulating hormone is found in men.
- There is another test worth mentioning which measures reactive oxygen species but this is not a routine test.
- The starting block is the female hormone blood profile taken between day 1-4 of the menstrual cycle, and something I recommend in my clinic. The hormones measured are FSH, LH, Oestrodiol, Prolactin, Testosterone, SHGB and FAI. This can give a lot of good information on ovarian reserve, likelihood of PCOS, and general hormone health. This is paired with an ovulation Progesterone test, 7 days post ovulation which will give a good indication as to whether ovulation has occurred for that cycle.
- Thyroid function issues can also have an impact on both conception and pregnancy and is another easy test to employ at the start. TSH (Thyroid Stimulating Hormone) and free T4 (thyroxine) is the basic starting point to determine whether there is enough thyroxine in the system. Important to note though that “normal” range for absence of disease is not the same as the ideal if you are trying to conceive. GP’s may read a test as within normal range when in fact it is sub clinical for conception and pregnancy. A follow up of FT3 and thyroid antibodies may be necessary based on results.
- The next layer of investigations test for anatomical issues, one of the best of these is the trans vaginal ultra-sound scan – not only can it show anatomy of the uterus, antral follicle count, but also information on the thickness of the endometrium, presence of polyps, fibroids, health of the ovaries.
- If there is a concern about the health of the fallopian tubes, either because of an ectopic pregnancy, a long period of time with no conception, a HyCosy is often performed this is one of the first tests the NHS will do after referral to a fertility consultant. Hysteroscopy is another way of investigating the uterine cavity (womb) for structural abnormalities and a biopsy of endometrial tissue can be taken for testing – see next bullet.
- Testing the endometrium (womb lining itself) is becoming more popular when there is a suspicion that implantation is a problem. ERA is usually used in IVF because it detects the best time for the embryo to be transferred, ALICE looks for pathogenic bacteria and EMMA looks at the endometrial microbiome. Currently these tests are usually considered when there has been recurrent miscarriage or failure to achieve a pregnancy.
- Karyotyping is a blood test for male and female and it checks for abnormal chromosomes making sure the egg and sperm have the correct complement of chromosomes, where there is a genetic defect this will exist in all the cells i.e. all the eggs or all the sperm. Every embryo produced will carry the same genetic defect in all its cells. I have never come across a couple with this issue, private fertility clinics will do this test and it is quite expensive, but not one to do straight away.
- Blood clotting factors (sometimes comes under reproductive immunology) known as Thrombophilia Screening coagulation profile – there are a lot of different blood clotting issues and tests and all have the same end treatment – anticoagulant. If blood clots occur in the blood vessels of the placenta the blood flow to the baby is decreased leading to either miscarriage or complications, but there can be complications during implantation also. Inherited Thrombophilia also results in compromised placental blood flow. Again these tests are usually done after up to 2 miscarriages.
- Reproductive immunology is still quite controversial with some consultants doubting their importance, although they are not first line tests, they can have an important part to play in couples ability to become parents. These are blood tests again and the two most popular are
- NK (natural killer) cells – elevated NK cells can sabotage the implantation process
- TH1 and TH2 cytokine ratio – a measure of the balance of the immune system – women with a high ratio are more likely to suffer decreased fertility and recurrent miscarriage