by Dr. Agilan Arjunan, Fertility Specialist & Gynaecologist, evelyn Fertility Centre, Petaling Jaya ( Malaysia)

Infertility remains a major global health challenge. The infertility rate is in an upward trend worldwide despite advancements in fertility treatment. A couple’s fertility journey starts when they undergo a series of fertility tests. These fertility tests should help the couple to make an informed decision regarding their choice of fertility treatment. To achieve this, the couple should take time to understand what the fertility test results tell them about their fertility status. These are the common tests done for couples and the interpretation of the results.

Semen Analysis

In my practice, semen analysis is one of the first tests I ask the couple to do. The reason is that semen analysis is the easiest test. Furthermore, male infertility has been shown to cause up to 50% of infertility. In my opinion, male fertility should be assessed first before subjecting the woman to a series of tests as described below. So, what does a semen analysis tell you?

Semen analysis is a test of ‘male infertility’ based on the appearance and behaviour of the sperm cells under a microscope. It will tell you about sperm concentration, how well a sperm moves, and how normal it look.

If the semen analysis is reported as ‘normal,’ does that mean everything is fine with the male partner. The answer is no. Semen analysis will not be able to predict accurately the reproductive capability of the sperm cells. Let me elaborate further. Even if a sperm cell looks perfect externally and is able to swim forward with ease, it could still carry a defective genetic material in it. If this sperm passes the defective genetic material into a female egg during fertilisation, the chances are high that the resulting embryo will be abnormal, genetically speaking, and will not result in a successful pregnancy. This phenomenon will lead to a miscarriage. Fortunately, most results with a ‘normal’ semen analysis report do result in a reasonable pregnancy rate, especially for an IVF treatment.

You may ask why not in that case we perform a specific DNA fragmentation test for the sperm cells? This test has been performed on the sperm cells for many years. However, there is no clear evidence suggesting its utilization will increase the overall pregnancy rate.

Egg Reserve Test

Egg reserve test is the most important test for female fertility. This test is done either by performing an ultrasound scan, typically a transvaginal scan. During the scan the ‘resting eggs’ or antral follicles can be counted. Another method would be to do a blood test called Anti-Mullerian Hormone (AMH). More often than not, these two methods are used in combination to assess a woman’s egg reserve.

Why the egg reserve test is important? The egg reserve of a woman has a direct association with her chances of getting pregnant, especially with an IVF treatment. Furthermore, the knowledge about egg reserve will help the couple to plan their fertility treatment timeline. If low egg reserve, the best approach would be to hasten the planned fertility treatments.

The egg reserve test only tells you about your egg number, it has no predictive value for your egg quality. Unfortunately, there is no available test for egg quality.

This scenario is best illustrated in a patient with PCOS. The egg reserve is always high in a woman with PCOS. For PCOS women who undergo an IVF treatment, some of them do not make good quality embryos even with a high egg reserve.

Fallopian Tube Test

Fallopian tube test is commonly known as HSG (hysterosalpingography). This test is done to assess whether your Fallopian tubes are patent or blocked. This test is important especially if the couple is considering fertility treatment other than an IVF. HSG test can also indirectly identify possibility of pelvic adhesions, which might help your fertility treatment planning. Does a normal HSG indicate a normally functioning tube? The answer is no. The HSG test does not evaluate the tube’s ciliary function and motility, which are important to move the egg and sperm within the tube. There are no clinically available tests for tube functions.

Fertility Ultrasound Scan

A fertility ultrasound scan looks for any structural abnormalities in the womb, the womb lining and the ovaries. Typical structural abnormalities that can be found are fibroids, endometrial polyp, adenomyosis and ovarian cyst including endometriosis. Rarely, conditions like bicornuate uterus (double uterus) or an incompletely formed womb are diagnosed. Some conditions are amenable to surgery, while some are not.

However, pelvic ultrasound scans does not measure the functionality of the womb, that is can the womb accept an embryo for implantation. Even after a surgery to correct the above-mentioned structural abnormalities, there is no guarantee that the womb will be able to implant an embryo successfully. A normal endometrial lining thickness does not rule out any underlying molecular-level issues that might impair embryo implantation.

Hormonal Blood Tests

Traditionally, there are many blood tests done during the initial fertility work-up. However, with the advancement in fertility science and laboratory tests, you can do fewer tests. For women, as mentioned earlier the most important test would be Anti-Mullerian Hormone (AMH) to assess her egg reserve. More traditional tests such as Day 2 FSH, LH, oestradiol and Day 21 progesterone level are not necessarily done anymore. For example, Day 21 Progetsreone level is not needed to assess ovulation function for a women with a regular period cycle. Day 2 FSH and LH tests that were used previously as a marker for egg reserve are replaced by AMH test.

Any other additional blood tests done will depend on your general health screening and fertility history.

Hysteroscopy

Hysteroscopy is a surgical procedure to assess the cavity of the womb. This is done if a structural problem, such as an endometrial polyp is suspected via the pelvic ultrasound scan. Hysteroscopy gives a clearer picture of the structural normality of the womb lining compared to an indirect assessment by pelvic ultrasound scan.

In fertility practice, hysteroscopy is also done to assess the womb lining after an unsuccessful embryo implantation in an IVF cycle.

Laparoscopy

Laparoscopy is a more invasive surgical procedure, at times utilised in infertility work-up. It is not a routine procedure for all patients. It is done for patients who might need a surgery to correct uterine fibroids, ovarian cyst or endometriosis. It is also done to remove a swollen Fallopian tube before an embryo transfer procedure in IVF.

Laparoscopy surgery will not be able to assess every ‘infertility factor’ related to your reproductive organs. Even though it is the most direct way to look at your reproductive organs, its usefulness is only limited to structural abnormalities.  Thus, it is not routinely done for all women seeking infertility treatment.

Conclusion

For couples facing infertility, it is understandable that they would want to do all possible tests to find the root cause and hopefully institute the right treatment plan to get pregnant. The reality is that no fertility tests could identify all possible reasons for infertility. It is wise to discuss this with your fertility specialist before undergoing fertility tests.

I wish you all the best in your journey towards parenthood.