Wednesday, May 22, 2024


Infertility Testing and Management

If you are planning on receiving IVF treatment, regardless of the type of treatment you are about to undergo, you and your partner will need to undergo a series of testing so that an accurate assessment can be made with regards to your fertility levels, which in turn helps your IVF specialist design you a suitable treatment protocol aimed to maximizing success with your treatment.

Infertility testing can be very confusing. If you have done your homework and researched about infertility testing, you must have come across a thousand different tests and what each of these tests mean. This is because the internet may not always provide you with customized answers to your queries and the results you obtain may not always be filtered to suit your specific needs. For this end, we have tried to make things a lot simpler by breaking down infertility testing and assessment into a number of alternative scenarios:

Scenario 1: If you are a heterosexual couple intending to use own eggs and own sperm during an IVF cycle, and you have had no previous infertility testing and/or screening, then the tests and screening below are the necessary first step before a treatment protocol can be designed to meet your specific needs:

  • Ovarian reserve testing. A number of tests are used when assessing a patient’s ovarian reserves. These include hormone testing such as FSH, LH, Estradiol, Prolactin, TSH and AMH tests. Not all of these tests are aimed at measuring your ovarian reserve level, but they all measure things that are closely inter-related. Apart from hormone testing, you will be asked to have a trans-vaginal ultrasound scan for ovarian and uterine assessment. The number of antral follicles in each ovary will let your doctor know about your ovarian reserves, when coupled with your hormone levels.
  • Semen analysis. A semen analysis is an important part of any infertility check-up. A semen analysis helps assess the quality of a sperm sample with respect to key parameters including sperm volume, concentration (count) per mL, motility, morphology, pH and round cell count. While semen testing is sometimes viewed as less important compared to female screening, it should be kept in mind that around one-third of all infertility cases are a result of sperm problems, which in most cases can be prevented.
  • Infectious disease screening. You and your partner will both be screened for infectious diseases. These tests must be performed at our own laboratory due to our high level safety protocols. The purpose of these tests is twofold. One is to make sure we don’t expose your offspring to a known infectious disease. The second, which is very important for an IVF laboratory, is to protect our laboratory from cross-contamination with blood-borne pathogens that can expose gametes and embryos to additional risk of contamination.
  • Practice (mock) embryo transfer. A mock transfer test will be performed prior to the actual embryo transfer in order to determine the depth of the uterine cavity and to identify the most optimal technique of placing your embryos into the uterus for maximum success.

Scenario 2: In this scenario, we have heterosexual couples who have had their initial testing where the test results did not indicate a specific problem and possibly have undergone a round or two of fertility treatments. In this case, we will need further investigation beyond the basic infertility testing. Based on the problems or the lack of problems thereof, which may have been observed during initial testing, the following will be investigated:

– A hysterosalpingography (HSG) for a thorough investigation into the tubes and the uterus of the female partner.
– Infectious disease screening for both partners including Toxoplasmosis, CMV and Chlamydia for the female partner. Sometimes a small infection can cause your body to reject embryo implantation and therefore prevent you from getting pregnant. A short cure of antibiotherapy can sometimes be a solution to a long-suffered infertility problem.
– A karyotype analysis for chromosome testing. If one of the partners suffers from an abnormal karyotype, a genetic problem may be transferred to the offspring. The nature and the severity of the problem will be indicative of what types of measures should be taken.

These tests are additional on top of the standard infertility testing in scenario 1. Some of these tests will not be necessary if you are not planning on using your own eggs or sperm cells during the IVF treatment, however, even if own eggs and sperm will not be used, you will still need to undergo testing to make sure that there aren’t other problems that can interfere with a successful pregnancy.

Scenario 3: For heterosexual couples with repeated IVF failures and/or repeated miscarriages, in addition to the tests mentioned above in secnario 1, additional tests will be in order. Female thrombophilia testing is one common test administered in this group of patients. Thrombophilia defects can potentially cause blood clotting problems, where blood clots can get into the placental circulation and stop your baby’s heart, therefore, resulting in a miscarriage. Thrombophilia defects have also been identified with implantation failures. Therefore, if you have been suffering from recurrent miscarriages or unexplained IVF failures, thrombophilia testing is always a must. In addition to thrombophila testing, some other tests can be ordered including tests to detect presence of natural killer cells or any other immunological problems. With this group of patients, our clinic uses granulocyte colony stimulating factor (GCSR) prior to an embryo transfer in order to improve the chances of embryo implantation. This application has proven successful with patients suffering from repeated IVF failures.

Scenario 4: For patients opting for IVF treatment using donor eggs or donor embryos (donor eggs + donor sperm), some of the tests will not be required. If you are using donor eggs during your IVF cycle, then, a comprehensive assessment of your own ovarian function is not necessary (though there is a very good chance that by the time you have decided to use donor eggs, you have undergone a number of IVF cycles using own eggs and therefore have already completed most of the tests outlined above). In cases where treatment will be carried out using the male partner’s sperm sample along with eggs from an egg donor, the following tests will be in order:

– A sonogram will need to be performed on day 2 or day 3 of the female partner’s menstrual period. This sonogram will be indicative of the number of antral follicle count (potential eggs for ovulation) and it will give your gynecologist a chance to observe if there are any problems such as cysts in the ovaries, or polyps/fibroids in the uterus/cervix that can possibly interfere with a successful pregnancy process. With this assessment, we will see if additional testing will be in order as well as deciding whether and/or how down regulation of the female patient’s own ovaries should be planned before the IVF cycle.
– A semen analysis will need to be performed for the male partner according to WHO 2010 Criteria, as explained in the “Male Infertility” section.
– Infectious disease screening outlined in scenario 1 will also be carried out.

Scenario 5: In this scenario, we have gay couples wanting to have a child through the use of a surrogate mother. In this case, there are two women involved. One woman to donate her eggs for creation of the embryos and one woman to carry pregnancy for the same-sex couple. The testing for the male partner using his sperm sample for the IVF procedure with the egg donor will be identical to the testing process outlined in scenario 1. We will need a thorough investigation of the egg donor’s hormone levels and ovarian function in order to assess her fitness to donate as well as her infectious disease screening. The male partner’s semen analysis will also be an important piece of information when designing treatment. The surrogate mother, on the other hand, would undergo a sonogram for an assessment of her uterine conditions (as outlined in scenario 4), an infectious disease screening and some additional hormone testing to decide how she needs to be down regulated before the cycle. If you do not have your own egg donor and surrogate, our “Surrogacy Program for Gay Couples” can guide you through your journey to parenthood.

***With any fertility treatment, we ask that both the male and the female partner undergo infectious disease screening (communicable disease testing) prior to handling of any gametes. The infectious disease testing will be carried out at our own laboratory due to our high level of security against the risk of pathogenic contaminants in our laboratories. This means that infectious disease testing from our laboratories will not be accepted even though they may be current. This is a strict laboratory policy which aims to protect all of our patients’ samples from possible pathogens that might be introduced via contaminated samples.

***This page does not aim to prescribe a comprehensive list of infertility testing. The intention of this page is to offer a general understanding on infertility testing under different clinical scenaria. We may ask for different tests depending on your unique history of infertility. It should be known that each patient is unique and should be treated as such. One thing that we have repeated at several places on this website is that “one prescription will not fit all”. It is important to understand the role of infertility testing when identifying the right course of treatment for each patient. A treatment regimen that generates success for one patient may not necessarily do so for another patient. This is the main reason why our fertility specialists at North Cyprus IVF Centre will ask for a review of your history of infertility as well as tests and screening before your treatment can be formulated.

Interpreting Infertility Test Results

Infertility test results- what does FSH, LH and AMH mean
We have repeated one key aspect throughout our website, and that is the fact that a single prescription will not fit all! Each patient is unique and each patient is likely to require a custom treatment protocol based on her own history of infertility, history of fertility testing and/or treatments. The more information we have about your infertility history, the more we can comment on your specific needs and requirements. At North Cyprus IVF Centre, our top priority is to make sure that every patient receives customized care and that each treatment protocol is carefully prepared according to each patient’s needs.

Before an effective treatment strategy can be formulated, it is very important that we see some test results that will give us specific information about the factors behind infertility. We can broadly analyze fertility testing in two categories as female and male testing:

Female Infertility Testing
Female infertility testing begins with a series of hormone testing along with a sonogram. This is most often the first step in female fertility assessment unless there is a reason to begin investigation elsewhere.

1- Hormone testing: One of the most important pieces of information when it comes to female fertility is ovarian assessment. Ovarian assessment refers to gathering information about the patient’s ovarian reserves and her likely oocyte quality. The hormones that are related to the female patient’s reproductive function are as follows:

Follicle Stimulating Hormone (FSH): This specific hormone is produced by the pituitary gland. The FSH hormone stimulates the granulosa cells found in the ovaries and triggers production of estrogen. Elevated FSH levels are an indication that a woman’s egg supply (ovarian reserve) is diminishing, or diminished, therefore, the pituitary releases more to compensate for this loss. Typically, FSH levels begin to rise naturally years before a woman enters menopause, and postmenopausal women may have levels of FSH that fall between 25.8 and 134.8 mIU/ml.

Luteinizing Hormone (LH): LH hormone is also produced by the pituitary. In females, ovulation of mature follicles on the ovary is induced by a large burst of LH secretion, therefore, the LH hormone is responsible for maturation and the final rupture of the oocyte.

Estradiol (E2): Estradiol is a form of the hormone estrogen. In women, estradiol is produced in the ovaries, and adrenal glands. It is also produced in the placenta during pregnancy. Estradiol helps with the growth of the female sex organs, and is also indicative of a woman’s ovarian function.

Thyroid Stimulating Hormone (TSH): TSH production involves a chain of events. The hypothalamus produces a hormone called TRH, which then triggers the pituitary to release TSH. This hormone helps us assess thyroid gland problems. Thhyroid problems can cause a number of symptoms as well as affecting your fertility.

Anti-Mullerian Hormone (AMH): AMH levels indicate the growth of small follicles in the ovaries. AMH is produced directly by the granulosa cells in ovarian follicles. AMH, therefore, is accepted as a more accurate measure of the ovarian reserves compared to the FSH. This is especially true for women in more advanced age brackets. For patients older than 35 years of age, hormone test results without an AMH measurements will not provide a complete assessmebt of the fertility level.

Ideally, the hormone tests are done on day 2 or day 3 of your menstrual period for an accurate assessment. The normal range of these hormones are as follows:

Normal Range for Hormone Tests:

Test            Normal Range         Measurement unit
FSH                   2.9 – 12.0                         mUI/ml
LH                     1.5 – 8.0                           mUI/ml
Estradiol         18.0 – 147.0                           pg/ml
Prolactin           5.0 – 35.0                            ng/ml
TSH                  0.25 – 5.0                           mUI/ml

< 0.3 ng/ml Very low level of fertility 0.3 – 1.0 ng/ml Low level of fertility 1.0 – 3.0 ng/ml Optimal level of fertility > 3.0 ng/ml Risk of PCOS

Note that there are more than one scale of measurement. Your laboratory may measure your hormone levels in ng/ml, pmol/l or mIU/ml or any other scale. This means that the numbers alone will not make any sense unless the number are provided with a measurement scale. For instance, an AMH level of 5 will not mean anything as an AMH level of 5 ng/ml indicates optimal level of fertility, with the possibility of PCOS while an AMH level of 5 pmol/l indicates a level of fertility which is almost undetectable. Furthermore, you should also keep in mind that even though the measurement scales and units of measurement may be the same, the reference values given by the kit used at your laboratory may be different from the values provided above. You should only use the above numbers for reference purposes and let our IVF specialists interpret what these numbers suggest in order to avoid any confusion.

One common misconception that some patients have is regarding the FSH testing. If you have an elevated FSH level, this is an indication of depleted ovarian reserves. Why FSH alone is not a sufficient parameter for assessment, if your FSH level is elevated beyond the cut-off of 20 ng/mL, then you are likely to have lowered ovarian reserves. We see some patients try alternative medicine and herbal remedies to reduce their elevated serum FSH levels. This is not a good strategy. Regardless of what you eat or what herbal remedies you take, you cannot get your ovaries to produce more reserves. Each woman is born with a certain set of ovarian reserves and starting from puberty, these reserves decline in number via each menstrual cycle. If your reserves have depleted and your level of fertility has declined, then it is of vital importance that you start planning your treatment and seek assistance from your IVF specialist to formulate a treatment program suited for your needs. Using alternative medicine and chinese herbs waiting to restore your ovarian reserves will not hep you reach your goal. However, a well-planned treatment strategy will. Nevertheless, certain supplementation and certain herbal remedies can be incorporated into your IVF protocol in order to help IVF medication work more effectively in recruiting the “best eggs” from the already depleted ovaries.

2- Baseline Ultrasound Scan: A base-line ultrasound scan is a scan performed on day 2 or day 3 of your menstrual period, which is exactly when the hormone tests need to be administered. Therefore, a single trip to your gynecologist’s office will suffice to have all your preliminary infertility assessment done. The scan results will indicate the size of your ovaries, uterus, the number of antral follicles as well as the appearance of endometrium. Your antral follicle count indicates how many follicles are “ready” to be recruited for ovulation during IVF treatment. Usually, a total antral follicle count of 5/6 and above is an indication of an acceptable level of ovarian reserves. If the number of antral follicles exceeds 12 in each ovary, then the patient should be considered a potential candidate for PCOS and examined further for a proper diagnosis. PCO or PCOS can also be indicated by an LH/FH ratio that is markedly higher than an average value of 1. Apart from the antral follicle count, the ultrasound scan also gives us a chance for ovarian and uterine assessment. Should there be a major problem in the uterus or the ovaries that can interfere with a successful pregnancy, it should be visible during this scan.

Male Infertility Testing
Male infertility testing begins with a semen analysis. The semen analysis will evaluate the sperm sample with respect to several parameters such as sperm count, concentration, motility, morphology, round cell count, pH and etc. These parameters will be indicative of the sperm’s capacity to fertilize the egg. A semen analysis will produce more accurate results if it is done following 3 or 4 days of abstinence (no sexual activity). Ideally, you should not consume excessive alcohol or tobacco products a few months prior to your planned pregnancy. The WHO criteria for normal sperm values are as follows:

WHO Criteria for Sperm Assessment
Volume: > 1.5 ml
Concentration: >20 million/ml (This is also referred to as the “sperm count”)
Motility: > 50% (Further broken down to A, B and C categories of motility)
Morphology: >4% with normal morphology
White Blood Cells (Round Cells): < 1 million/ml
pH: 7.2-7.8
These are key parameters considered in a semen analysis.  Semen analysis results interpretation
Further testing may or may not be necessary depending on your history of infertility, testing and or treatments. While the above parameters are the minimum requirements in a sperm sample established by the World Health Organization (WHO), they refer to the normal values that should be present in a sperm sample for obtaining a natural pregnancy through intercourse. During IVF treatments, we often work with sperm samples that have much lower sperm count, motility and morphology. Sperm samples which fall below the standard requirements established by WHO can be categorized as follows:

Oligozoospermia refers to the number of sperm cells in the ejaculate that have been tested to be lower than the normal parameters established by WHO. The normal range of the sperm count is above 20 million/ml, therefore, men whose sperm analyses indicate a sperm count less than 20 million/mL are considered to belong in the oligospermia (oligozoospermia) category.

Astenozoospermia refers to the sample of sperm whose motility has been found to be lower than 50%. Sperm’s ability to move is directly related with its ability to swim through the cervical pathways, reach the fallopian tubes and fertilize the oocytes. The lower the motility, the lower the capability of sperm cells to reach and fertilize the eggs on its own. However, with IVF/ICSI technologies, this is one of the infertility factors that can easily be corrected.

Teratozoospermia refers to a diminished level of sperm cells that are of normal form. In other words, teratospermia (teratozoospermia) refers to a high level of sperm cells in the ejaculate that are considered to be “abnormal”. These abnormalities can correspond to head, tail or mid-piece defects. Depending on the sperm abnormality present, and depending on the other parameters of the sperm, certain treatment methods such as ICSI or the MicroFluidic Chip can provide a solution.

Azoospermia is a condition characterized by the total absence of sperm cells in the sperm. Azoospermia can be classifies as obstructive azoospermia or non-obstructive azoospermia. Depending on your diagnosis, surgical sperm extraction methods may be employed and a successful IVF treatment can be carried out.

You should keep in mind that these are the basic testing performed in order to assess your level of (in)fertility. If you have been trying to conceive for over a year and have not been able to achieve pregnancy, the tests mentioned on this page will be the first round of testing so that an initial assessment can be made. However, there are many other tests that can be performed to reveal possible other problems with infertility. While this page does not provide a complete list of all the infertility testing that exist, it is a very good guide for an initial assessment. With the expenses faced with some of the infertility tests and diagnostic imaging, it may sometimes be a better idea to proceed with IVF treatment as long as the fertility levels indicate acceptable parameters. On the bottom, you will find links to the pages that will direct you to factors causing female infertility, factors causing male infertility, how infertility assessment can be made as well as how to identify the right treatment method for your unique condition. For any queries you may have about any of these subjects, please use the contact form below to contact us with your questions and we will be happy to answer.