What’s involved in a fertility assessment?
When is the right time to take a closer look at your fertility?
If you’ve been trying to fall pregnant for 12 months and you are less than 35 years old, or six months and you are 35 or older, seeing your GP for a fertility assessment is a good first step.
There are also instances when you may seek a review earlier than these recommended times frames, including, but not limited to;
● You have irregular periods.
● Your periods are painful or very heavy.
● Spotting occurs before your period starts.
● You experience painful sex or pelvic pain at any time of your cycle.
● You have a family history of endometriosis or premature menopause.
● You have a history of recurrent (2 or more) miscarriages.
● You and your partner are having difficulties with intercourse.
Around 30% of fertility problems experienced by heterosexual Australian couples are due to male factor infertility, so I encourage both partners of couples struggling to conceive to be involved in an assessment from the outset.
Fertility assessments start with chatting to your GP about your medical, surgical and family history, medications, lifestyle, gynaecological, obstetric and sexual history.
Sometimes, all that is needed is some reassurance that you’re on the right track, lifestyle advice or some guidance on when or how often you should be having intercourse.
Depending on your individual circumstances, the following fertility testing may recommended;
Blood tests to assess hormones such as testosterone or thyroid function: additional hormone screening might be needed for example if your periods are irregular or there is suspicion of PCOS.
Sometimes, an AMH test may be done to check the woman’s ovarian reserve or ‘egg count’. This test has limitations and appropriate pre and post-test counselling is very important — see more on AMH below
An internal pelvic ultrasound — see below for more detail.
A special ultrasound called a ‘HyCoSy’ (Hysterosalpingo-contrast-sonography) sometimes referred to as ‘flushing the tubes.’ This can check to make sure your fallopian tubes are open, to allow a fertilised egg to reach your uterus. If there is a history of untreated STIs or suspected endometriosis, this may be especially important.
A “day 21 progesterone” blood test to check for ovulation: this is a blood measure of your progesterone levels approximately seven days before your next period.
If there are any suspicions about endometriosis, you may be referred to a specialist to discuss whether additional investigations (e.g keyhole surgery) are appropriate.
Semen analysis for the male partner – looking at quantity, shape and swimming ability of the sperm.
What happens in a pelvic ultrasound?
In a transvaginal pelvic ultrasound, an ultrasound probe is inserted gently into the vagina so that a more detailed image of the reproductive tract can be obtained. The ultrasound can assess your ovaries, including performing an ‘antral follicle count’ - which, as the name suggests, is a physical count of a type of immature follicle (egg containing sac) on your ovaries. An antral follicle count gives us an idea of your ovarian reserve (i.e., how many eggs you have left) and it’s also a way of screening for polycystic ovaries.
The ultrasound can also look at the lining of your uterus (called the endometrium), and check for polyps, fibroids and even sometimes pick up signs of endometriosis.
Important point - The information that can gleaned by ultrasound can be operator dependent, so, if possible, go to a specialised women’s health and obstetrics imaging practice. (Ask your GP to recommend one of these close to you)
What is AMH?
AMH stands for Anti-Mullerian Hormone. It is hormone released by cells in the follicles of your ovaries and can be detected in your blood.
An AMH test may be included in a fertility work-up and while it gives us some information, please keep in mind that it is only one piece of the puzzle.
AMH testing done in the wrong context without the appropriate counselling has the potential to cause both unnecessary anxiety and false reassurance. The test is used as one way of assessing your ovarian (egg) reserve. If your AMH is below the normal range, it may possibly indicate you have a condition that predisposes you to premature menopause.
If your AMH is significantly higher than the normal range, it may indicate another condition like Polycystic Ovary Syndrome (PCOS). The normal range of AMH changes based on your age. This is because females are born with all the eggs they will ever have, and this number naturally decreases over time - so when you are older, the AMH range is lower.
Something that the AMH test does not give is any information on the quality of your eggs, your actual likelihood of getting pregnant, or “how long you can wait’ – in fact there is no test that can do this! There is no way to test your egg quality. The strongest predictor of egg quality is age.
If any abnormalities are found on preliminary investigations or if further testing is needed, your GP may refer you on to a fertility doctor for specialist advice. It’s important to know that a referral to a fertility specialist does not necessarily mean IVF is needed. There are many less invasive reproductive technologies that may be offered, depending on your specific situation. Sometimes, continuing to try naturally is also encouraged.
Read more about reproductive health and fertility: https://www.yourfertility.org.au
This post was written by Dr Ali with Monique Cormack, twin mum and Australian nutritionist specialising in women’s health and fertility: https://moniquecormack.com/blog/fertility-testing
