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Diagnosis and Treatment

At JCRM we offer a complete couple oriented fertility diagnostic evalutation.  Ideally, we like to see both the male and female partners for a new patient visit where we conduct thorough medical interviews and plan for diagnostic testing.  Having both of you there, allows a more global assessment and more direct communication.  At this visit, it is most helpful to have all prior medical records .   These records are best obtained by patients themselves.  Pictures of prior surgeries or at least operative reports are helpful and in addition, ultrasounds, HSG reports, and any laboratory testing results are the primary studies we need to understand your prior work up.

► FEMALE EVALUATION (for those without prior testing)

Three primary areas of focus are utilized in the overall evaluation:  Tubal/Peritoneal, Ovulation and Male factor. 

Some historical factors might be best considered before the visit so that records can be reviewed and the availability of time to remember specific facts.  A careful menstrual history will be taken.  The most important factor in your history is knowing the interval from start of one cycle to the start of the next cycle at times in your life when you were not on birth control pills or other hormones.  Your mother’s age at menopause will often be asked as well as family history of diabetes and endometriosis.  These are the questions patients find it toughest to answer on the spot in the office.

For ovulation, we generally will perform an ultrasound on cycle day 12 to look for an appropriately sized follicle and check a blood progesterone level on cycle day 21.  If cycles are dramatically abnormal, it may not be necessary to test for ovulation since we know by history that there is an ovulation disorder.  To evaluate tubal and peritoneal problems, (endometriosis and adhesions) an HSG (hysterosalpingogram) is done.  Tubal occlusion or suspected adhesions would be the most common findings in this test.  Laparoscopy is another way to evaluate the pelvis for endometriosis and adhesions.  Patients with other symptoms consistent with endometriosis or an abnormal HSG might be candidates for further evaluation via laparoscopy.  Laparoscopy is an outpatient minimally invasive surgery that offers both diagnostic information and the potential for therapeutic intervention.  Endometriosis can be resected and tubal scarring can in some cases be successfully repaired.

Other tests that may be performed include the Clomid Challenge Test (CCCT) andmetabolic testing to further evaluate ovulation disorders.  The CCCT is a test to evaluate for diminished ovarian reserve or premature ovarian aging.  In this test, clomid, an oral ovulation drug, is given to stimulate the ovaries to function at their best and hormone studies are done at three separate time points in the cycle and a mid cycle ultrasound is done to evaluate the number of follicles in response to the clomid.  From these results, we can learn more about ovarian reserve.  These results help us plan other diagnostic studies and treatment strategies.

Metabolic testing relates to ovulatory disorders and specifically PCOD.  If a patient’s history suggests the possibility of an ovulatory disorder of this type, metabolic testing will be recommended.  The most significant of these tests is the 3 hour glucose tolerance test with insulin levels.  Insulin resistance is the underlying metabolic disorder responsible for PCOD and hyperandrogenic anovulation.  If you have irregular cycles (>30 day intervals), acne, facial hair, oily skin or scalp hair loss, you may have this disorder.

► MALE EVALUATION:  

The male evaluation is much less rigorous than the female testing sequence.  Two areas are studied for all males.  The semen (sperm) analysis and a basic hormonal profile.  The semen parameters in most men vary significantly from day to day.  In order to have an accurate assessment of the average state of the semen, two studies are performed.  The accuracy of semen analyses is very much related to the operator’s skill in performing the test.  Most commercial labs do a poor job with this test, so when possible, we prefer the testing in our laboratory.  This gives us the most accurate look at this parameter.

The basic hormonal evaluation includes testing testosterone and the two hormones that stimulate sperm and testosterone production in the testicle.  Some sperm problems are a result of blockage in the spermatic tubules and can be suspected with histories of infection or prior injury.  Some males are born with blockage of both vas deferens.  With obstruction, sperm can almost always be recovered with surgery and correction of certain obstructions is possible.  When applicable, genetic studies might be necessary to make a final diagnosis.

If the semen analysis and basic testing is normal, no specific recommendations would be made regarding sperm.

► PLAN OF TREATMENT APPOINTMENT:

For most couples, we evaluate simultaneously the male and female.  This process can be completed in one cycle or approximately one month.  At the end of this process, we meet with both members of the couple for a plan of treatment appointment where we review all lab testing and studies performed.  At this visit, we will be able to make specific recommendations for treatment.  Our goal is to help you have a safe and successful pregnancy.  We do our best to minimize diagnostic studies in order to avoid costly unecessary diagnostic studies.  Moving to treatment early is our goal to focus our efforts and resources on achieving pregnancy.