Tests to be done when pregnancy does not arrive: tests for the woman, the man and the couple
When you start the search for pregnancy very often you are led to think that it can already reach the first month of attempts. In most cases this is not the case.
Although many manage to conceive a child within 12 months of targeted attempts, one in 5 couples does not make it and at that point further studies are necessary (which must be brought forward to 6 months of failed attempts if the woman is over 36 years of age).
Targeted attempts mean that in the 12 months (or 6 months) of attempts, intercourse must have occurred on fertile days.
The woman has a fertility window of about 6 days which are the 5 days before ovulation, the day of ovulation and the day after.
Ovulation can be detected in various ways:
- with sticks,
- monitoring changes in cervical mucus,
- monitoring the position of the cervix
- monitoring basal temperature.
It is important to emphasize that when you decide to have a baby it is essential to do both preconception examinations, free for the couple, a gynecological examination, and, for the woman, take folic acid.
The adoption of a healthy lifestyle (no smoking, alcohol, drugs, yes to moderate physical activity and balanced nutrition), helps fertility of both men and women.
The diagnostic process of infertility should therefore not be started before 12 months of intercourse without conception. The examinations are anticipated, as we said, if the woman is over 36 years old, or if there are already known conditions of subfertility in men and / or women.
What are the tests to do when pregnancy does not arrive?
Diagnostic investigations for humans
First of all, a medical and reproductive history is important, followed by the analysis of the seminal fluid and any second level investigations.
As far as anamnesis is concerned, it is important to know if there are factors or behaviors predisposing to infertility. It is important to know if in the family there are other cases of infertility, recurrent miscarriages, fetal malformations, sexual dysfunctions, cryptorchidism, previous trauma or infections, various pathologies , exposure to toxic substances, alcohol abuse, drugs, steroids, …
To the anamnesis and analysis of seminal fluid must also be added an evaluation of the genitals, the measurement of the volume of the testicles, the scrotal palpation for the search for varicocele, or other lesions, and the evaluation of the prostate and seminal vesicles.
The second level examinations concern: biochemical, hormonal (in particular FSH, LH and testosterone), infectious, genetic and immunological tests.
Diagnostic imaging investigations (ultrasound or more detailed examinations), as well as genetic ones (e.g. Y chromosome microdeletions, AR receptor mutations, sperm DNA fragmentation, cystic fibrosis mutations), are requested based on the results of previous examinations (cystic fibrosis test is always required in case of PMA).
Testicular biopsy is used in obstructive forms to retrieve sperm (in case of azoozpermia), to then use them in an assisted reproduction treatment.
Diagnostic investigations for women
An accurate family history is also essential for women. It is important to know the maternal age of menopause and first pregnancy, the age of the woman’s first menstruation, the presence of family history for diabetes, cancer, thyroid problems, and cardiovascular problems.
During the anamnesis, the woman is asked for weight and height for the calculation of thebody mass index (BMI), the frequency of intercourse, smoking habits, menstrual frequency, duration of infertility, any pregnancy, or abortions had in the past, the possible use of drugs, …
Gynecological examination
The gynecological examination includes the evaluation of the cervix and the pap smear (if it has not been done in the last year).
The ultrasound examination during the visit involves the evaluation of the morphology of the ovaries to verify the presence, for example, of polycystic ovary syndrome. Or ovarian cysts, which can be a consequence of ovulatory dysfunctions, or endomeriosic.
Always with ultrasound the morphology of the uterus and the presence of myomas or polyps, or the presence of uterine septa are evaluated and the results of infections such as sactosalpinx or hydrosalpinx are excluded.
By performing the ultrasound in the very first days of menstruation it is possible to count the antral follicles (between 2 and 9 mm in size). The antral follicle count and the dosage of anti-Müllerian hormone (AMH) and FSH allow to give an estimate of the woman’s ovarian reserve.
Obviously, the ultrasound performed in a programmed way allows to monitor ovulation. If the dosage of progesterone in the luteal phase is also associated, this allows to exclude anovulatory causes of infertility.
Laboratory tests
Blood tests (hormonal ones are to be done on the second or third day of menstruation) provide for the dosage of
- FSH
- LH
- estradiol
- Progesterone and androgenic quota
- thyroid function markers
- AMH (can be done at any time of the menstrual cycle but with an automated method because it gives more reliable results)
- Prolactin
- SHBG (binding globulin, testosterone and estrogen)
- blood glucose, insulinemia and any oral glucose tolerance test (OGTT)
To these are added:
- infectious tests
- tests to evaluate the autoimmune and coagulative status (eg homocysteine that if greater than 10ng / ml and in the presence of familiarity with thromboembolic events in young age, should be integrated with the search for mutations for MTHFR, prothrombin, factor V Leiden
Instrumental examinations
- Hysteroscopy to assess the presence of myomas, polyps or uterine septa
- sonohysterosalpingography or hysterosalpingography to assess tubal patency
For the couple
- Genetic counseling
- Karyotype
On the basis of the results, the treatments or interventions to be carried out will be decided and the need for an assisted reproduction path will be evaluated.
Kathryn Barlow is an OB/GYN doctor, which is the medical specialty that deals with the care of women's reproductive health, including pregnancy and childbirth.
Obstetricians provide care to women during pregnancy, labor, and delivery, while gynecologists focus on the health of the female reproductive system, including the ovaries, uterus, vagina, and breasts. OB/GYN doctors are trained to provide medical and surgical care for a wide range of conditions related to women's reproductive health.