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Eeyore

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Thursday, May 10th 2007, 11:01am

INFO: A ROUGH GUIDE TO INITIAL FERTILITY TESTS

A common misconception is that getting pregnant is a simple task. In reality, trying to conceive can be a long and difficult road for some couples. When you and your partner decide it's time to expand your family, how long should you realistically expect to try before you get pregnant? And at what point is it worthwhile seeing a fertility expert?


How Long Should it Take to Get Pregnant?

Some couples are content to stop their contraception and just see what happens; others find themselves in a monthly cycle of expectation and disappointment. Most GP’s won’t start fertility investigations or refer you to a specialist until 12 months of trying. The reason for this can be understood when we look at how efficient normal fertility actually is.


Normal Conception Rates

Even for a healthy, fertile couple, the 'per month' success rate is around 15-20%, so it is not at all uncommon for it to take some months to conceive. Overall, around 70% of couples will have conceived by 6 months, 85% by 12 months and 95% will be pregnant after 2 years of trying.

Although for a normally fertile couple, the 'per month' rate is around 20%, as you might expect for couples where there actually is a problem, the pregnancy rate is lower. It is useful to know the overall background rate of pregnancy after any given duration of trying, particularly to make sense of success claims of any treatment.

'Infertility' is really a poor term to use, because this implies that there is no chance of getting pregnant. For most couples who are referred for further investigations, it would be best described as 'subfertility', meaning reduced fertility, as there is usually a background pregnancy rate - it's just taking longer than they would wish. Of course couples will want to exclude an insurmountable problem, or one which will definitely require some form of treatment to succeed.

Causes of Infertility

For conception to occur, adequate numbers of actively swimming (motile) sperms need to enter the cervix, work their way up the uterus and into the fallopian tubes. At the same time, an egg must be released from the ovary and be able to make its way down the tube to meet the sperm. The egg and sperm combine at fertilisation and the dividing egg makes it way back down to the uterus to implant into the thickened lining of the womb. Any problem along the way may result in problems falling pregnant.

The causes of infertility can be considered as follows:

Ovulation problems 10-15%
Tubal blockage or endometriosis 30-40%
Male (sperm) problems 30-40%
Unexplained 15-20%

These rates are variable for any given population, and are only a guide. Each of these factors is given consideration, in the discussion before, during the examination and in the investigations subsequently arranged.


Are you and your partner havinig troubles conceiving? If so, you may be considering going for infertility testing. But what can you expect dring your appointment and what types of tests might you have to do? Gain a better understanding of the infertility testing process with this article.


History, Examinations and Testing

Before any testing is carried out it is important that your doctor takes a detailed history and performs an examination.

In the discussions which take place, your doctor will want to establish important facts, such as your ages, how long you have been trying, how often you have intercourse, if there is any problem with normal intercourse (eg. psychosexual, impotence or penetration problems), and whether either of you have had any pregnancies in previous relationships. Irregular periods may suggest that ovulation is not taking place every month or if they are particularly painful and intercourse is uncomfortable, this might suggest endometriosis. Previous pelvic (PID) or chalmydia infection may be significant with regards to tubal blockage, as might previous pelvic surgery.

On the male partner's side, it is important to know if there have been any operations or trauma to the testes or a significant infection, such as mumps as an adult, which can be associated with a low sperm count. For both partners documentation of alcohol and smoking habits is important, as both of these are associated with reduced fertility.

Examination of the woman will include an internal to check that the uterus & ovaries feel normal and to see if there is any particular tenderness or painful areas. Swabs are sometimes taken to rule out infection. Many men are surprised when asked to be examined in an infertility clinic, but it can be helpful. Most clinics, however, do not routinely examine the male partner unless the semen analysis turns out to be abnormal.


Essential Examinations


All couples will need to undergo the following testing:


Hysterosalpingogram (HSG): This test is carried out in the x-ray department of the hospital and is a screening test to check if the tubes are blocked. A speculum is passed (like when having a smear test) and a small amount of dye is injected through the cervix. A series of x-rays are taken which show the outline of the uterus and if the tubes are open, dye will be seen flowing through.

Day 2 LH/FSH: This is a blood test that checks whether there is a good reserve of eggs in the ovary and that the hormonal system leading to their release is intact. It is taken on the second day of the cycle (day 1 is the first day of a period). LH and FSH are hormones that stimulate egg development and release. High levels of LH are also found in polycystic ovary syndrome, which is a common cause of anovulatory infertility.

Progesterone Test: This will check if ovulation has taken place. It should be taken 7 days before a period, so for a 28-day cycle it is done on day 21. If a period doesn't come 6-8 days after the test, then it will need to be repeated. A level of 30 nmol/l or more suggests ovulation has occurred.

Semen Analysis: A sample of semen is needed to check the total count, whether the sperms look normal, and if they are motile. It is important to abstain from sex for a few days before the test and to ensure that the sample is transported to the lab without delay when produced. If the first test is low or borderline, a second sample is requested to see if this was a one-off result - was this the best or worst? More details about abnormalities of the semen analysis are discussed in Male Infertility.

Rubella antibody levels: These are checked to see that immunity is present, as this is a good time to repeat the immunisation if not, rather than risk infection during pregnancy, which can cause fetal defects.


Other Examinations: For Special Circumstances

If the standard battery of tests come back abnormal in some way, further tests may be carried out. These tests can include:

Pelvic Ultrasound Scan: Many units now carry this out as a part of the initial examination process to check that the uterus appears normal and whether the ovaries have a polycystic appearance. An internal or transvaginal scan is most accurate.

Diagnostic Laparoscopy and Dye Test: If there is a significant degree of pain with intercourse or painful periods then a laparoscopy might be suggested instead of an HSG. This involves a general anaesthetic and small telescope look through the umbilicus into the pelvis to see if there is anything causing the pain, such as endometriosis. At the same time some dye is injected to check the patency of the tubes. This is also done if an HSG suggests that there might be a problem with the tubes, as an HSG alone can't give all the information and the 'blockage' may just be due to spasm of the tube or inadequate pressure when injecting the dye when you are awake.

Post-Coital Test: This test involves an examination of the mucus around the cervix shortly after intercourse has taken place. It is like having a smear test, and under the microscope interactions between the sperms and cervical mucus are analysed. It is only rarely used now in the UK, as studies have found it to be poor at predicting infertility, it often gives inaccurate results and adds little to the information obtained by the above tests.

Hysteroscopy: If the HSG suggests that there is an abnormality of the inside of the womb, a hysteroscopy can be done for a closer look. A fine telescope is passed through the cervix and the uterine cavity visualised. Hysteroscopy can detect fibroids or congenital variations such as a double-womb, bicornuate (heart-shaped) uterus or a uterine septum.

Thyroid Function Tests and Prolactin: If a woman has irregular or infrequent menstrual cycles, or shows other signs of thyroid disease then it is important to exclude this. Prolactin is a hormone that is normally involved in the production of breast milk and is released from a gland in the brain called the pituitary. An overactive pituitary gland can cause abnormally high levels of prolactin (hyperprolactinaemia) which prevents ovulation. A blood test for prolactin levels should be done if cycles are infrequent or there is an unusual discharge from the breast.

Eeyore

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Wednesday, August 8th 2007, 8:22am



Hysteroscopy

A hysteroscopy is a test that allows your doctor to look inside your womb using a narrow tube-like telescope called a hysteroscope. This instrument is very slim (about three to five millimetres in diameter). It's carefully passed through the vagina and cervix, and into your womb.

Why have a hysteroscopy?
A hysteroscopy can help find out what is causing symptoms such as unusual vaginal bleeding, or as a check-up for certain gynaecological conditions such as fibroids, heavy periods or early signs of womb cancer, and can also be used to deliver treatment.

During the procedure your doctor may take a biopsy (a small sample of tissue) for examination in a laboratory, and/or treat the inside of your womb. It's also possible to remove polyps (small lumps of tissue) that may be found on the womb lining, as well as scar tissue and intra-uterine contraceptive devices (IUCDs) or "coils" that have become lost or stuck.

What are the alternatives?
Depending on your symptoms and circumstances, it may be possible to examine your womb using ultrasound (an imaging technique using sound waves). For some women, a simpler procedure called endometrial aspiration may be an alternative to a hysteroscopy. This involves passing a narrow tube through the cervix and into your womb, and using suction to remove samples of the womb lining.

For most women, however, a hysteroscopy is the best option to help diagnose or treat the problem. Unlike other tests, it enables your doctor to see directly into your womb.

Preparing for the procedure
Hysteroscopy is routinely performed as an out-patient or day case

Hysteroscopy can be performed with or without a local anaesthetic, especially if it's only being used for a check-up (a diagnostic hysteroscopy). Sometimes, it's done under general anaesthesia (an operative hysteroscopy). This means you will be asleep during the procedure.

If the procedure is planned under general anaesthesia, your hospital may send you a pre-admission questionnaire. Your answers help hospital staff to plan your care by taking into account your medical history and any previous experience of hospital treatment. You will be asked to fill in this questionnaire and return it to your hospital.

If you are having the procedure under a local anaesthetic, you will be asked some questions -about your health, experience of surgery, allergies and the medicines you are taking - when you arrive for your examination.

If you normally take medication (eg tablets for blood pressure), continue to take this as usual, unless your doctor specifically tells you not to. If you are unsure about taking your medication, please contact the hospital.

Before you go for your examination, you will be asked to follow some instructions.

Have a bath or shower at home.
Remove any make-up, nail varnish and jewellery.
Bring some sanitary towels with you.
You must follow the fasting instructions in your admission letter. These will vary depending on the type of anaesthesia you are having. Typically, if you are having a local anaesthetic there is no need to go without food or drink. If you are having general anaesthesia you must not eat or drink for six hours before the procedure.

About the procedure
Your doctor may use a speculum to gently open your cervix (similar to having a smear test). The vagina and cervix are cleaned with an antiseptic solution. Your doctor will then pass the hysteroscope through the cervix and into your womb.

Gas or fluid is then usually pumped into your womb to make it expand and the womb lining easier to see.

A camera lens at the end of the hysteroscope sends pictures from the inside of your womb to a video screen. Your doctor will look at these images and if necessary take a biopsy, remove polyps, and/or deliver treatment. This is done using special instruments passed inside the hysteroscope, and is quick and painless.

When the examination is finished, the hysteroscope is gently taken out. The procedure usually takes about 10 to 20 minutes to complete.

What to expect afterwards

If you have a biopsy or polyps removed, you may need to wear a sanitary towel to absorb any vaginal bleeding.

If the procedure is done under a local anaesthetic, you will usually be able to go home after a short rest.

If you have general anaesthesia, you will need to rest on your bed until the effects of the anaesthetic have passed. You will need to arrange for someone to drive you home and stay with you for the first 24 hours.

General anaesthesia can temporarily affect your co-ordination and reasoning skills, so you should not drive, drink alcohol, operate machinery or sign legal documents for 48 hours afterwards. If you are in any doubt about driving, please contact your motor insurer so that you are aware of their recommendations, and always follow your doctor's advice.

As the anaesthetic wears off, you may have period-like cramps, and may need painkillers.

Results
If you have a biopsy or polyps removed, the results will be ready several days later and will usually be sent in a report to the doctor who recommended your test. Other findings may be discussed before you leave the hospital. If you have general anaesthesia, it's a good idea to have someone with you if the results are being discussed immediately after the procedure, as you may not remember the details clearly.

After you return home
If you need them, continue taking painkillers as advised by your doctor.

It's important to take it easy for the rest of the day. Some women feel ready to return to normal activities and work the day after the procedure; others may need to take two or three days off. Follow your doctor's advice about contraception, and starting to exercise again and having sexual intercourse.

Most women experience no problems after the procedure. However, please contact your doctor if you develop any of the following symptoms:

prolonged heavy bleeding
vaginal discharge that is dark or smells unpleasant
severe pain
pain that lasts for more than 48 hours
high temperature
You shouldn't use tampons for at least one month after your hysteroscopy to help reduce the risk of infection.

You may find that your first period following the hysteroscopy is heavier or more prolonged than usual and that your periods are irregular for a couple of months.

Deciding to have a hysteroscopy
Hysteroscopy is a commonly performed and generally safe procedure. For most women, the benefits in terms of having a clear diagnosis, or quick and effective treatment, are much greater than any disadvantages. However, as with all medical procedures, a hysteroscopy carries an element of risk. In order to make an informed decision and give your consent, you need to be aware of the possible side-effects and the risk of complications.

Side-effects are the unwanted but mostly temporary effects of a successful procedure. After having a hysteroscopy you may:

have slight period-like cramps and may need painkillers
feel some pain in the tip of your shoulders caused by the gas or fluid used to inflate the womb but this should clear-up within 48 hours
have some vaginal bleeding for a few days - in some cases bleeding and discharge continue for up to a month
Complications are unexpected problems that can occur during or after the procedure. Most women are not affected. The possible complications of any surgery include bleeding during or very soon after the procedure, infection and an unexpected reaction to the anaesthetic. It's also possible to develop a blood clot in a vein in one of the legs (deep vein thrombosis or DVT).

Specific complications of hysteroscopy are uncommon but it's possible to:

develop a pelvic infection afterwards, needing treatment with antibiotics
damage or perforate the womb during the procedure - this can lead to bleeding and infection, which may require further surgery or, in very rare cases, a hysterectomy
Your doctor will be experienced at performing hysteroscopies, but even so a few are not successfully completed and may need to be repeated.

Ask your doctor to explain how these risks apply to you. The exact risks will differ for every woman. This is one of the reasons why we have not included statistics here.

Eeyore

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Tuesday, April 22nd 2008, 7:59am

Postcoital Test

A postcoital test checks a woman's cervical mucus after sex to see whether sperm are present and moving normally. Not all fertility clinics carry out this test.

The test is done 1 to 2 days before ovulation when the cervical mucus is thin and stretchy and sperm can easily move through it into the uterus. Within 2 to 8 hours after you have sex, your doctor collects and looks at a cervical mucus sample.

The postcoital test may be done if you are not able to become pregnant and:
You are ovulating, your fallopian tubes are not blocked, and your partner's sperm are normal. A problem with your cervical mucus may be causing infertility.
Immune system problems, such as sperm antibodies, may be a cause of infertility.
Your male partner does not want to be tested.

The postcoital test must be done within 1 to 2 days of ovulation. Follow your doctor's instructions for checking your basal body temperature, cervical mucus, and the level of luteinizing hormone (LH) in your urine. When you check your LH level, do the urine test in the mid- to late morning, and do not drink any fluids that morning until you have done the test. If your test shows that you are ovulating, call for a doctor's visit for the next day.

Have sex about 2 to 8 hours before your visit. Do not use lubricants during sex. Do not douche or take a bath after sex, but you may take a shower.

Results

A postcoital test checks a woman's cervical mucus after sex to see whether sperm are present and moving normally. Results of the postcoital test may be shared with you right after the test.

Normal:

Normal amounts of sperm are seen in the sample.
Sperm are moving forward through the cervical mucus.
The mucus stretches at least 2 in..
The mucus dries in a fernlike pattern.

Abnormal:

Mucus does not stretch 2 in..
Mucus does not dry in a fernlike pattern.
No sperm or a large number of dead sperm are seen in the sample.
Sperm are clumped together and not moving normally.


What Affects the Test
A postcoital test may not be normal if you do not know the exact day of ovulation. If the test is done at another time in your cycle, the sperm cannot move through your cervical mucus.

Eeyore

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Thursday, February 5th 2009, 8:23pm

AMH TESTING

http://www.fertilityzone.co.uk/wcf/js/ww…tion-online.org

In the years preceding menopause, fertility already decreases and the menstrual cycle becomes irregular. Chronological age is a poor indicator of reproductive aging, and thus of the ovarian reserve.

To assess an individual’s ovarian reserve, FSH, inhibin B and estradiol can be measured but these factors are not independent of each other and so cannot give an accurate result in all cases. In recent years, new data indicate that anti-Müllerian hormone (AMH) may fulfill this role.

AMH expression is strongest in small antral follicles (less than 4 mm). AMH expression disappears in follicles of increasing size and is almost lost in follicles larger than 8 mm. This expression pattern suggests that AMH may play a role in initial recruitment and in the selection of the dominant follicle.

Changes in serum AMH levels are thought to occur relatively early in the sequence of events associated with ovarian aging. Substantially elevated serum levels of FSH are not found until cycles have already become irregular. Therefore, a marker that already shows a considerable change when menstrual cycles are still normal would better identify women with declining fertility.

In women undergoing treatment for infertility, ovarian aging is characterized by a decreased ability of the ovaries to respond to injected gonadotropins (such as Gonal F, Menopur, Puregon etc) and poor pregnancy outcome. Correct identification of poor responders by assessment of their ovarian reserve before starting IVF is important as it can help clinicians to determine which dose to start a cycle on.

Several studies have shown that AMH is an excellent marker to determine ovarian responsiveness in an IVF program. AMH levels are lower in patients with poor ovarian response than in women with normal response, with ovarian responsiveness being defined as the number of eggs retrieved, or as cancellation due to impaired or absent follicular growth. AMH blood levels were shown to be highly correlated with the number of antral follicles before treatment and number of eggs retrieved upon ovarian stimulation.

Blood of PCOS women contains increased AMH levels because of the increased number of small antral follicles. In PCOS women, AMH levels were correlated with antral follicle number.

AMH levels decrease with age in premenopausal women. In addition, levels of AMH correlate strongly with the number of antral follicles, suggesting that AMH levels reflect the size of the primordial follicle pool. Assessment of the ovarian reserve is particularly important in the IVF clinic, where AMH may be useful as a predictor of poor response. Since a considerable proportion of subfertility is due to postponement of childbearing, measurement of AMH levels to assess the ovarian reserve may also be of interest in women in general. Assessment of the ovarian reserve, at least of the size of the ovarian follicle pool, may provide insight into the number of fertile years a woman has left.

http://www.gcrm.co.uk/index.htm

http://www.gcrm.co.uk/downloads/INF-Clin…MH%20&%20OA.pdf


http://www.tdlpathology.com/index.php?op…d=201&Itemid=73

http://www.gcrm.co.uk/downloads/INF-Clin…MH%20&%20OA.pdf

you will see that the UK guide is;

pmol/l
< 1.0
Negligible responses to ovulation drugs.
Treatment with own eggs rarely recommended

1.0-4.9
Reduced responses to ovulation drugs.Expected yields of 1 to 6 eggs (normal average = 10 eggs)

5.0-19.9

A normal response to drugs expected
Low risk of ovarian hyperstimulation syndrome
Low risk of cycle cancellation
Good pregnancy potential

> 20

High responses to ovulation drugs expected
risk of ovarian hyperstimulation syndrome
high pregnancy potential





GCRM AMH WORSHOP 2010 - SUMMARY

-------------------------------------

AMH Levels

Low AMH level

AMH Levels

AMH -way off scale, help!!

low AMH - any hope without IVF

rise and then fall in AMH

Low AMH levels

Low AMH - Confused

normal AMH.FSH yet poor response...anyone?

I've just had my AMH back and devastated

Low AMH - Please help me!




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