Before starting ART therapy, each patient is evaluated to help maximize her chances for success. Patients should have a complete physical exam, including a breast exam and Pap smear, within one year. They should also start taking prenatal vitamins, which may reduce the risk of spine abnormalities (neural tube defects) in the baby. The American College of Obstetricians and Gynecologists recommends that women 40 years of age and older have an annual mammogram.
Prior to starting IVF, the woman's blood type should be verified, and she should be screened for antibodies that could affect the health of a fetus. Documentation of immunity to rubella (German measles) and varicella (chickenpox) may also require a blood test. Rubella during pregnancy can cause serious harm to the fetus. The patient and her partner should also be tested for hepatitis, HIV (AIDS), syphilis (RPR) and Cystic Fibrosis (a serious inherited disease affecting the respiratory system). Other genetic tests may be requested depending on the patient’s genetic background and history.
Good preconception health is essential to achieving pregnancy with IVF. Chronic medical conditions such as diabetes, hypertension and asthma should be well controlled before attempting to conceive. In addition, women planning an IVF cycle should optimize their weight. Obesity has been associated with infertility, a reduced chance of success with IVF, and an increase in the risk of miscarriage and preterm birth. Your primary care provider can help you determine your ideal weight and refer you to appropriate resources for weight management, if needed.
Ovarian Reserve Testing
A woman’s reproductive potential declines with age. This is reflected in the decreased ability to conceive (become pregnant) and an increase in the rate of spontaneous abortions (miscarriages). Although fecundity (the ability to achieve a pregnancy which results in a live birth) decreases in all women as they age, the precise age when a woman can no longer conceive varies between individuals. Approximately one-third of couples in which the female partner is age 35 or older will have problems with fertility. It is estimated that two-thirds of women will not be able to get pregnant spontaneously by the age of 40. Several tests may be useful in assessing fertility potential in older patients and to assist in determining the proper method used to stimulate the patient to produce an optimal number of eggs. For those patients with poor fertility potential, the use of donor eggs or embryos can be considered.
- Day 3 Levels of FSH, LH, and Estradiol. The determination of blood concentrations of follicle stimulating hormone (FSH) and estradiol levels on menstrual cycle day 3 has been used to estimate fertility potential. Women with elevated levels of FSH and/or estradiol measurements on cycle day 3 have reduced pregnancy rates with both ovulation induction and assisted reproductive technologies (ART) such as in vitro fertilization (IVF). Studies have shown that women with elevated blood levels of luteinizing hormone (LH) on cycle day 3 also have poor pregnancy outcomes with fertility therapy.
- Clomiphene Citrate Challenge Test. This test entails the oral (by mouth) administration of 100 milligrams of clomiphene citrate on menstrual cycle days 5-9. Blood levels of FSH are measured on cycle day 3 and again on cycle day 10. Elevated blood levels of FSH on cycle day 3 or cycle day 10 are associated with reduced pregnancy rates with both ovulation induction therapy and ART.
- Anti-Mullerian Hormone Test (AMH). Anti-Mullerian hormone levels are thought to reflect the size of the remaining pool of oocytes a woman might have. This test can be performed at any time of the cycle. Women with higher AMH values tend to produce more eggs.
A complex semen analysis should be performed within one year of ART. Changes in sperm quality may occur over time that could affect ART therapy. The complex semen analysis checks for sperm number, shape, swimming ability, survival, significant infection, and antisperm antibodies. In some cases, additional semen testing may be recommended.
LINKS: ASRM FACT SHEETS
The anatomy of the uterus is usually evaluated prior to ART. Three methods can be used: an x-ray procedure (hysterosalpingogram - "HSG"), an ultrasound procedure (sonohysterogram or SIS), or a hysteroscopy. An HSG is performed by injecting a special liquid through the cervix into the uterus. The liquid is visible on x-ray films and outlines the anatomy of the uterus and tubes. Usually no anesthesia is necessary. An SIS is performed by injecting fluid into the uterus during transvaginal sonography. This procedure is performed in the office without anesthesia. Hysteroscopy involves insertion of a small telescope and light source through the cervix into the uterus to look for abnormalities. This procedure is done in the office using local anesthesia or in the operating room.
Prior to IVF/ET, a uterine measurement called a trial transfer may be done. The purpose of this procedure is to determine the length and direction of the uterine cavity. This enables the physician to guide the embryo transfer catheter into the proper position with minimal trauma for the actual embryo transfer. This trial or “mock” transfer is similar to a pelvic exam or intrauterine insemination. The physician will place a speculum in the vagina and insert a thin, flexible plastic catheter through the cervix into the uterus. The procedure is usually painless, although some patients may experience a small amount of cramping when the catheter goes through the cervix and again when the tip of the catheter touches the top of the uterine cavity. This cramping, which is similar to a mild menstrual cramp, should resolve within 30-60 seconds.
LINKS: ASRM FACT SHEETS