Testing, Testing...

With infertility comes a lot of tests. What's wrong? Which part is wrong? How many parts are wrong? In the beginning, the tests can help you figure out if you are dealing with male factor or female factor, or both. They can help you figure out which course of treatment is best for you. Or, they can invade your body and NOT tell you anything about why you can't get pregnant. I am lucky to have a definitive diagnosis (PCOS and male factor infertility). Even though it sucks to be in a position to have a diagnosis, there is a clear reason for why I can't get pregnant. I can't imagine how frustrating it must be to be labeled with "unexplained infertility."

Testing is on my mind because I am checking two more tests, hopefully my last, off my list this month. Today I had a Saline Sonohistogram, and I've been in the midst of a Clomid Challenge Test for a week now. But, up until this point I have also had oodles of blood tests to gauge hormone levels, Bryce has had oodles of semen analyses, and I have had two HSGs. Some of these tests occur during your initial workup. Some of these tests will come up after you've started treatment and there's an idea that there may be further sleuthing to do. And some of these tests you may want to ask for.

Semen Analysis: Ok, so I didn't go through this one, but it's one of the first tests a clinic (or your OB/GYN) will do to rule out male factor. This is most commonly the only test that the men going through fertility treatment have to do. Basically, they provide their contribution in a cup--this is called "collecting." They can collect at home or at the clinic, in a lovely room with dorm-style furniture (that is hopefully easily sanitized) and a host of supposedly exciting magazines and/or videotapes. There are also explicit instructions on how to make sure that your sample stays sterile (and by sterile I mean uncontaminated. Bad choice of words). Your partner can go in the room with you and there are specific instructions for what you can and can't do to "help." It is a very bizarre setup. If you collect at home, you have to live 45 minutes or less from the clinic and you have to keep the sample warm en route. Which means it gets tucked into your pants or in your bra if you (the lucky lady) are delivering the goods alone. It seems like boys get off easy (haha) here--their test is somewhat familiar territory to them and supposedly "fun." But, speaking for the boys, there is a tremendous amount of pressure to perform in this situation. It is not fun. There are people walking by the collection room at the clinic and people are waiting (in the case of IVF, really clear that they are WAITING for you so that they can get mixing). Or your wife or partner is sitting in the car, not so patiently waiting for you to come out with your cup so that you won't be late for your appointment at the clinic. There is a lot of stress and uncertainty and feelings of having your manliness judged by the meager contents of a sterile cup. It is definitely not a sexy moment. I think the best thing you can do is have an honest conversation about what works for your guy. Some guys welcome help, and others want to just be left to do their thing. You can talk to your clinic and see if collecting there is less stressful than collecting at home--everyone wants you to have the best possible sample. Once the sample is in the andrologist's lab, it is analyzed. You get a report that explains the quality of the sperm. It will tell you the total number of sperm in the sample. Then it will tell you the total motile sperm per sample. "Motile" is the same as "good swimmer." It will also tell you the morphology, or the shape of the sperm. Odd-shaped sperm don't swim as well and can't fertilize, so those count against you. The average man has 40 million sperm. When you have male factor, it's way less. Or it can be not so much less, but those that are there are not good swimmers, funny-looking, or both. If you have 20 million sperm but only 2 million are motile, that's not so great. In order for IUI to be a truly viable option with a good prognosis you need to have 10 million or more, or so we have been told. BUT, male factor infertility can be pretty treatable, at least in the IVF stage. You only need 100,000 motile sperm to qualify for a financing program for IVF at my clinic--that's pretty amazing. And, as people say over, and over, and OVER, "It only takes one." 


Blood Tests: The lucky lady gets these. All the time. They start in testing and then just keep on coming. You will have blood tests to check your thyroid (sometimes that's the culprit). To check your prolactin levels (too much of the hormone prolactin can cause irregular ovulation). To check your estrogen, progesterone, and FSH (follicle stimulating hormone) levels. Your FSH levels will tell you what your ovarian reserve is--how many quality eggs you have to play with and the likelihood that you will be able to get and stay pregnant. Levels that are too high early in a cycle indicate a low ovarian reserve and possible premature ovarian failure. You actually want low levels of FSH. High estrogen at the start of your cycle can also indicate poor ovarian reserve. Estrogen levels should steadily increase when you are responding to treatment (or normal and producing a healthy mature follicle). Then there's progesterone. That comes from the empty follicle sac (called the corpus luteum) and tells your body to keep that uterine lining nice and plush so that an embryo can implant itself and stay there. If you have low progesterone levels, or they drop too soon, then you might be able to have a fertilized egg become an embryo but your uterus can't sustain it through implantation. If this is the only issue it's great--they can give you progesterone support in the form of suppositories, gel, or shots. Or in my case you can add this to a host of issues, but at least there's a fix for this one. The Clomid Challenge Test is also a blood test, but you have to take Clomid cycle days 5-9. They look at your FSH levels on day 2 or 3 and then they look again around day 10 to make sure you have a good ovarian reserve. I am actually not sure why you take Clomid for this other than maybe it causes your body to start the process if it wouldn't otherwise, but it seems just mean to have such a nasty little drug be a part of a test. 


HSG: This is the Hysterosalpingogram (go ahead, try to say it!). It looks at your uterine cavity and the tubes to make sure they are clear. It is usually done at the hospital. They do an x-ray of your uterus and fallopian tubes while they are pushing dye through your uterus and out your tubes. Sound uncomfortable? It is. Some people have no problem with the HSG--a little pinching, a little cramping, that's it. That was not my experience. I actually had the HSG twice in a 2-month period because there was an error in the first one. An error where the radiologist did not do the test correctly. There is a balloon on the catheter that is supposed to inflate and then sit like a stopper in your cervix to keep the dye in your uterus and the pressure such that the dye can be easily pushed through the tubes if they're clear. In my case, the balloon was in the middle of my uterus and so there wasn't enough pressure. So the doctor told me that both my tubes were blocked, which would have made all my IUIs up until that point a total and complete waste of time, and would mean IVF was my only chance barring surgical correction, since you don't need tubes to do IVF. Understandably I was very, very upset. Especially since I had already done 5 IUIs and was in the middle of a 6th, and had requested the HSG since it was not a part of my initial workup. Luckily for me, upon reviewing the films and seeing the error, my doctor at the clinic called for a re-do, that he personally would administer, and which turned out normal. My tubes were not blocked at all. Whew! It just stunk that I had to do a painful test twice to figure that out. My thoughts on the HSG: Definitely take ibuprofen before to help take the edge off. I honestly don't know why they don't offer light sedation for this test! Know that your husband or partner can't come into the room with you, since it's an x-ray. He will be able to come in with you to review the results later, after you've really needed a hand to hold and squeeze.  Request that a reproductive endocrinologist (RE) from your clinic perform the test, not a radiologist. I love radiologists and they are very nice and talented people. But radiologists perform a lot of different tests throughout the days and weeks, and they do NOT do a lot of HSGs. REs do these ALL THE TIME and so it will most likely be faster, more comfortable, and more accurate if you have an RE do it. And, lastly, I would ask for this test if it is not part of your early work-up. If your tubes are clear, you are all set and have one less thing to worry about. If not, you will find out before spend time and money and mental energy on IUI cycles that will not work because of tubal blockage. 


Saline Sonohistogram: This test looks solely at your uterus. You can do it in the doctor's office, no need to go to the hospital. It is also not as uncomfortable as the HSG, although I had one today and while it was less uncomfortable during the procedure, I feel much more tender afterwards. I did take Advil before just like the HSG, but it didn't seem to be too effective. The HSG looks at the periphery of the uterus, while the saline sonohistogram looks at your entire uterine cavity. It can unearth fibroids and polyps that may have been missed on an HSG that could compromise your ability to carry. I asked for this test because I wanted to make absolutely sure before we paid a lot of money to put my body through IVF again that NOTHING was physically wrong with my uterus. The actual test is kind of cool--a catheter with a balloon (again with the balloon!) is passed through the cervix and a saline solution is injected into your uterus to highlight what's inside. At the same time, the lovely internal ultrasound is making a nice movie of your innards on the screen. It's a little crowded down there. But, luckily for me, this test was also normal--there is no physical reason why a little nugget couldn't nestle into my womb for nice long while. That peace of mind is definitely worth the discomfort. 


So there you have it--some tests that we have gone through in the course of our infertility journey. There are others, of course, for both men and women, but hopefully I won't have to experience those too!