First Line Investigations / Female

Sonohysterography is a technique developed to better visualize the uterine cavity compared to a regular ultrasound. It uses an infusion of sterile saline solution through a soft catheter placed in the cervix with simultaneous transvaginal ultrasound. The saline infusion distends the uterine cavity and provides an excellent contrast to the lining, giving improved visualization of uterine and endometrial pathology (polyps or fibroids, for example). This technique can also be used to assess the fallopian tubes by demonstrating fluid spill into the pelvis. Additional use of contrast and Doppler can better demonstrate the movement of ultrasound contrast medium within the tube itself, providing unequivocal evidence of tubal patency.

It is important to note that there are inherent false positives and negatives with SHG as a screening test. Tubes that appear blocked on SHG may actually be patent under direct vision with laparoscopy (up to a 40% rate of false alarm). Also, patent or open tubes do not always mean that the tubes are healthy and fully functional (tubes can be chronically inflamed or surrounded by adhesions, yet still be patent).

The sonohysterogram has a notorious reputation as a painful test; however, in experienced hands, it is typically well tolerated and causes minimal discomfort.

The hysterosalpingogram is the primary screening test for abnormalities in female reproductive anatomy. Under x-ray imaging, liquid dye is injected into the uterus to characterize the shape of the uterine cavity. If the fallopian tubes are open, dye will be observed to be spilling out of the fallopian tubes. Once the dye spills from the tubes, the manner in which it spreads through the abdomen can provide some information regarding the presence or absence of adhesions or scarring around the tubes. It is important to note that there are inherent false positives and negatives with HSG as a screening test. Tubes that appear blocked on HSG may actually be patent under direct vision with laparoscopy (up to a 40% rate of false alarm). Also, patent or open tubes with HSG do not always mean the tubes are healthy and fully functional (tubes can be chronically inflamed or surrounded by adhesions, yet still be patent).

Three dimensional (3D) ultrasound has become an essential component of fertility evaluationsas it accurately outlines the shape of the uterus and its cavity. A 3D scan of the uterus is essential in mapping uterine fibroids and diagnosing uterine anomalies. Conventional 2D ultrasound can easily miss thesesignificant abnormalities that may be hindering your fertility and could otherwise be simply corrected.

Post-coital testing and endometrial testing are done only in select cases and are not considered as part of standard fertility testing.

Post Coital Testing
The postcoital test (PCT) is a test in the evaluation of infertility.

A postcoital test checks a woman’s cervical mucus after intercourse to see whether sperms are present and moving normally. This test may be used if a woman is not able to become pregnant (infertility) and other tests have not found a fertility problem.

This test is typically performed 1 to 2 days prior to ovulation when the cervical mucus is thin and stretchy so that sperm can easily filter through to reach higher up searching for the egg in the fallopian tubes. Your doctor will microscopically examine a cervical mucus sample collected within 2-8 hours after intercourse. The test is a good positive test, which means it rules out sperm delivery problems if healthy, sufficient, moving sperms are found. However, the validity of a negative test is questionable.

Endometrial Biopsy

Endometrial lining assessment can be done in select cases and is not considered as a part of standard fertility testing.

An endometrial biopsy is a test that evaluates the endometrial tissue that lines the inside walls of your uterus. The quality of this tissue can be important in predicting success of implantation of an embryo. Around the time that you ovulate (release an egg from your ovary), your endometrium (inside lining of your uterus) grows thicker withthe development of blood vessels, glands, and stored nutrients to allow an early embryo to implant and grow. If fertilization does not occur, the endometrial tissue sheds as menstrual flow to mark the beginning of your next cycle.

Progesterone and estrogen control the growth and stabilization of the endometrial tissue. If your ovary doesn’t produce enough of these hormones, your uterus may not be able to maintain a pregnancy.

An endometrial biopsy is taken by your doctor and then sent to a pathologist who will examine the collected sample of your endometrial tissue under a microscope. Your doctor can tell if your endometrium is getting enough of these hormones by judging the thickness and cellular pattern of the cells obtained from the endometrial biopsy. If your body is not producing enough hormones, as judged by the histologic appearance of the endometrium, hormonal supplementation can then be prescribed to correct the defect, and ultimately improve the lining of your uterus.

Chronic inflammation of the endometrium will also be treated if diagnosed in the biopsy sample so that implantation chances can improve.