Kim Briley
Kim Briley
BSN, CNIII, RNC-EFM, Fertility Nurse and Donor/Third Party Coordinator at Duke Fertility Center in Durham, North Carolina.

Basic infertility work up for women – What happens at the clinic?

Getting ready for your first visit to the fertility center can be a little overwhelming. There are a few tests your provider may discuss and recommend for you, based on your history. Some items can be coordinated through your family doctor or gynecologist’s office, if you have been discussing your fertility with them. This information can be shared with the fertility team and be available during the fertility consultation.

Detailed history and physical

The biggest and most helpful item providers will do at your new patient consultation is discuss your history. Some patients find it helpful to review their history and take notes prior to the visit. This discussion will include a large variety of questions. Some of these include:

  • Medical/surgical information: This will include any underlying medical conditions, medications taken on a daily basis for a medical condition, any surgeries or surgical complications; there may be a discussion of BMI (body mass index) and how it can impact fertility
  • Menstrual information: This will include your age when your periods started, if they are regular, how may days in each menstrual cycle, if you use ovulation predictor kits, and how heavy or painful your period is
  • Sexual information: You will be asked if you have any history of sexually transmitted infections such as chlamydia, gonorrhea, or herpes
  • Infertility information: This will include the length of time you have been trying to get pregnant, if you have been trying with ovulation predictor kits, if you have taken any fertility medication before and what your reproductive goals are.
  • Previous pregnancies: You will be asked if you have been pregnant before and if the pregnancies were with your current partner or with a previous partner as well as planned/unplanned. If you have given birth, the provider will also want to know what type of birth you had and if there were any associated problems

  • Lifestyle: During this part of the discussion, the provider will review alcohol use, tobacco usage, vaping, and recreational drug usage. Sources of stress and coping may be discussed as well

  • Genetic information: This includes if you have done any previous genetic testing or counseling and if you have any heritable conditions in your family. We may review genetic testing that is available to you as part of preconception blood tests

Based on the information gathered during your history and physical examination, your provider may discuss some tests that could narrow down a diagnosis of why you haven’t conceived just yet. Testing can range from lab tests to more invasive testing.

Ovarian assessment

There are several ways to assess ovaries and it varies based on provider preference. Your provider may want you to schedule “day 3 testing” when your next period comes; this may include ultrasound scans and lab tests. Alternatively, they may prefer a blood test or ultrasound scan at any point in the cycle.

The ultrasound scan are typically transvaginal, or where an ultrasound wand is inserted into the vagina. The ultrasonographer or doctor will measure the uterus, the ovaries, and obtain an antral follicle count (AFC). An antral follicle count is when they count the very small follicles to see if there are a lot or just a few. Everyone is a little different!

Blood tests associated with ovarian reserve testing typically includes an estradiol, follicle stimulation hormone (FSH), and anti-mullerian hormone (AMH). Again, your provider may prefer one method of testing over the other and may have guidelines on when these tests need to be performed in your menstrual cycle. These tests give insight in to your ovarian reserve, or ‘how many eggs you have left’. Your provider can use this information to determine dosing of medications and treatment options available to you, if necessary.

Preconception Lab Tests

These lab tests may include a complete blood count (CBC), a thyroid test (TSH), blood type, Rubella titer, Vitamin D level, an infectious disease panel, genetic carrier testing. Some of these may have been coordinated through your OBGYN’s office. The purpose of these is to assess your overall health prior to helping you get pregnant. If anything needs to be addressed (thyroid level is off, not immune to Rubella, carrier of a certain genetic disorder), they will help navigate that with you.

Hysterosalpingogram (HSG)

The hysterosalpingogram is an X-ray test that looks at the patency (or openness) of your fallopian tubes. Most provider’s offices will recommend calling with the first day of your period and scheduling this test between cycle days 5-12. This allows for your uterine lining to be thin and helps get a good evaluation; it’s also at a time where you’re not likely to have ovulated and the risk of disrupting a potential pregnancy is very, very minimal.

Fertility treatment requires a lot of testing, including ultrasound scans

During this visit, an x-ray will be positioned close over your pelvis. The provider will insert a speculum into your vagina and clean off the cervix with betadine or another solution. They will insert a thin catheter, or tube, into the cervix and blow up a small balloon to help keep it in place. This process can cause some cramping and can be a little uncomfortable. They will then remove the speculum, keeping the catheter in place, and start to push in some dye. The dye is clear, but is visible in the x-ray. They will continue to push the dye through your uterus and into your fallopian tubes, while taking pictures with the x-ray. This process can be a bit uncomfortable as well. After the study is over, they will deflate the balloon and remove the catheter. When you’re ready, you can sit up and they will provide you with a review of the study. If the dye did not spill out of one or both of your tubes, or if there was an issue with the shape of your uterus, they will let you know, but also recommend you schedule a follow up visit with your primary provider.

Sonohystogram (saline infused sonogram, SIS, ‘water ultrasound’ scan)

The process of the sonohystogram is quite similar to the HSG. This is a test where they push open the walls of the uterus with a little bit of sterile saline and evaluate the inside of the uterus with the ultrasound scan. This allows the providers to look for any polyps (little finger-like projections) or fibroids within the inner cavity of the uterus, which may potentially impact implantation of an embryo. This test is typically performed at the same window in your cycle as the HSG.

During this visit, the provider will insert a speculum into your vagina and clean off the cervix with betadine or another solution. They will insert a thin catheter, or tube, into the cervix and blow up a small balloon to help keep it in place. This process can cause some cramping and can be a little uncomfortable. They will then remove the speculum, keeping the catheter in place, and insert the ultrasound wand. From here, they will push in a little bit of sterile saline and view it on the ultrasound scan. They will look at the inside of the uterus from a variety of angles, taking pictures with the ultrasound scan along the way. When the study is done, they will remove the ultrasound scan, deflate the balloon and remove the catheter. The saline can be messy afterwards so the office will provide you with a maxi-pad. When you’re ready, you can sit up and they will provide you with a review of the study. If the ultrasound scan images showed a defect, they will briefly discuss with you, but also recommend you schedule a follow up visit with your primary provider

Woman getting results of basic infertility work up

Should one of your initial tests require a follow up test, your provider will review that with you and the team can help get everything explained and coordinated. After your initial consultation and testing is performed, your provider may want you and your partner (if applicable) to return for consultation to discuss. During this second visit, your provider will review your results with you and help develop a treatment plan based on the findings.

There is often a team of individuals at the practice to help you understand every step of the way and are happy to navigate any questions that may come up. Be sure to ask your provider/staff about the best way to communicate with the office so you feel confident on how to reach out to schedule and ask questions as needed. No question is too silly or too small; infertility can be quite complicated sometimes so questions are encouraged and welcome!