Investigations 

Find out what investigations we may require and how to arrange for these tests.

Blood Tests

 Follicle Stimulating Hormone (FSH) and Luteinising Hormone (LH):

• Hormones are released from the pituitary gland in the brain
• Regulate the menstrual cycle and levels fluctuate throughout the cycle to cause egg maturation and release
• The ratio between them can be altered if you have a condition such as PCOS which is why periods can be irregular
• As you reach the age of menopause the eggs within your ovaries will be low in number (known as a low ovarian reserve), as you are born with all your eggs and do not produce any new ones after birth
• Other conditions may cause you to have low ovarian reserve - in these cases the FSH level will be high as it tries to stimulate egg release without success
• If there appears to be an issue with your ovarian reserve based on these tests, we may request testing of another hormone, anti-Mullerian hormone (AMH) which is a more specific test for ovarian reserve as it is released directly from the eggs, so will be low if ovarian reserve is low

 Progesterone:

• Hormone which reaches a peak level after an egg is released from the ovary (ovulation)
• For women with a regular cycle we can calculate the day when ovulation would occur, and so can test for this rise in progesterone level
• In those with an irregular cycle it can be more difficult, so we have to estimate when this will occur based on your cycle history
• A progesterone level more than 30 means there is a very high probability that ovulation has occurred
• If there is a problem with ovulation we may start a medication to increase your chance of ovulation, and we can test the progesterone level after every period to see if it has worked.

 Oestradiol:

• A form of oestrogen which is the main female sex hormone
• It is released by the follicles in the ovary which contain the eggs so is another marker of ovarian reserve
• It can also affect other hormones such as FSH, so may provide additional information as to why getting pregnant is difficult
• Low oestradiol levels can indicate a problem with the ovaries, with the hormone regulation system, or can be a sign of PCOS

 Testosterone:

• The hormone usually associated with males where it is released from the testes and is responsible for male characteristics such as body/facial hair, deepening of the voice, increased bone strength and muscle mass, and libido (sex drive)
• Testosterone is also released from the ovaries in women where it regulates production of blood, the release of other hormones which can affect menstruation, and libido
• High levels of testosterone are found in women with PCOS

 Sex-Hormone Binding Hormone (SHBG):

• Essentially a carrier hormone which picks up extra oestradiol and testosterone in the blood
• It can also carry other hormones including thyroid hormones
• The hormones it carries are then inactive and will be removed from the body via urine or faeces
• This is the body’s way of regulating how much of the active hormone is in the body and will produce its effects
• If SHBG is too high/low, then the levels of other hormones will decrease/increase which can affect fertility and the menstrual cycle

 Prolactin:

• Released from the pituitary gland, this hormone is more commonly known as the 'milk hormone' because it is the main hormone involved in breast milk production after giving birth.
• It also acts on the ovaries, so problems where the level is too high or low can affect ovulation
• High levels of prolactin may cause milk discharge from the nipples not associated with pregnancy and may indicate a problem with the pituitary gland in the brain
• The rise in prolactin after birth to stimulate breast milk production reduces FSH release to prevent ovulation, so acts as a natural contraception to exclusively breastfeeding mothers
• In the absence of pregnancy, a rise in prolactin may prevent ovulation and can be a cause of infertility

 Thyroid Stimulating Hormone (TSH):

• TSH is released from the pituitary gland and acts on the thyroid gland which regulates many body functions including heart rate, blood pressure and body temperature
• Thyroid hormones are also very important for the development of a growing baby during pregnancy, so any underlying disease of the thyroid may be exaggerated during pregnancy
• For this reason your TSH should be within a healthy range prior to conceiving
• It is also important to note that as the pituitary gland releases multiple other hormones, mechanisms that regulate the level of TSH release may also affect release of others such as prolactin and FSH, which can also contribute to infertility

 Rubella Antibody:

• Rubella (German measles) is a virus that is commonly vaccinated against with the MMR (measles, mumps, rubella) vaccine as part of the NHS Vaccination Schedule
• Some women may not have had this vaccine and so will be at risk of developing the associated disease
• Rubella during pregnancy is very dangerous as it can lead to miscarriage, congenital abnormalities of the baby including intellectual disability and damage to the heart, hearing, eyesight, and liver (together known as Congenital Rubella Syndrome), and can cause death of the baby soon after birth
• We check that your body is protected against the virus by testing if you have antibodies (part of the response to fight infection)
• If you do not have these antibodies we recommend getting the vaccine prior to conception, and using contraception to prevent pregnancy up until 4 weeks after the vaccine is given

Ultrasound Scan

• An ultrasound scan is a simple form of imaging used to visualise the uterus (womb) and ovaries; it is the same as the scans used throughout pregnancy to monitor the baby
• In order to get the best views it is recommended that the scan be performed transvaginally – this means using a sterile probe inserted into the vagina to capture the images (you do not require a full bladder for this scan)
• Although it can be uncomfortable this should not be painful, and it provides important information about your fertility.

Ultrasound scans can identify abnormalities of the uterus such as an unusual shape and non-cancerous growths such as polyps and fibroids. We use this information to guide us as to whether surgical intervention would be beneficial for you.  

Fallopian Tube Dye Test

• To visualise whether there is a blockage in either of your tubes we perform a fallopian tube dye test, also known as a hysterosalpingogram or HSG
• This is done between day 5 and day 10 of your cycle (see below about how to arrange this)

The procedure requires you to lie down on your back with both heels brought in towards your bottom and your knees dropped down to the sides, the same as when you have a smear test. The nurse will insert a small catheter into the neck of your womb (the cervix) and through this will insert some blue dye. This can cause some uncomfortable crampy pain but it should soon settle down. An X-ray is then taken which shows where the dye has gone – it should travel from the neck of the womb into the entire uterus, flowing into both fallopian tubes and spilling out at the ends of both tubes (don’t worry, this is a safe dye and will not cause any damage). If there is a blockage in either tube the dye will not flow and we can see this on the X-ray images. Once the images are taken the nurse will remove the catheter, give you some towels to clean yourself up as the dye can spill, and provide you with a sanitary towel to wear as the dye will drain out over the next few hours. The total time for this procedure is 15-30 minutes and the nurse will be there to answer any questions throughout. The results will be discussed with you at your next Fertility Clinic appointment.

• Prior to this procedure we will send you a chlamydia swab which you need to do and bring to the hospital labs (see the information below on how to arrange the HSG)
• You must not have sex from day 1 of your period up until the procedure
• On the day we will perform a urine pregnancy test before starting the procedure
• You can take all medications and eat and drink as normal on the day of your procedure
• Please ensure you are not wearing any jewellery
• After the procedure you can return to normal activities including driving, however you may have 1-2 days of mild cramping pain and some vaginal spotting of blood – if this does not improve after a few days or starts getting worse then please call the clinic
• Complications of this procedure are rare but can include infection, prolonged bleeding, allergic reaction to the dye, or injury to the uterus which may require surgery 

If you have a history of risk factors for tubal blockage such as previous chlamydia infection or tubal surgery we may recommend a fallopian tube dye test visualised by laparoscopy. We would also recommend this if the HSG test above is inconclusive for whether the tubes are blocked or not.

• This means the same procedure but performed when you are asleep under general anaesthetic and with keyhole surgery so we can try to fix any blockages we find, as well as assessing for any other potential causes of subfertility
• There are additional risks of the anaesthetic and injury to the tissues around the uterus and tubes, as well as infection, bleeding, pain and injury to the uterus, however these risks are uncommon and would be managed immediately

  Semen Analysis

• Problems with production and delivery and semen can be identified using a semen analysis
• This means providing a sample of semen in a specific collection pot that will be sent to you
• This sample is then visualised under a microscope to determine the number of sperm (count) in the semen, the shape (morphology) and the movement (motility) of the sperm
• A problem with any of these characteristics can reduce male fertility and should be investigated unless a probable cause is known, such as if you have had previous testicle surgery or cancer treatment
• An abnormal result should be repeated, and may prompt testing for chromosome abnormalities and cystic fibrosis (genetic conditions which can affect sperm)
• If a problem is found with the semen then you may require assisted conception to help get the sperm in the right place to enable you to conceive.