1) Complete medical history with all relevant reproductive questions for both you and your partner.
- The medical history with focuses on reproductive function and medical conditions that could possibly affect reproductive function. For example, if the medical history indicates that the patient has experienced blood clotting disorders this could be contributing to infertility or recurrent miscarriages. Likewise, the presence in the history of autoimmune conditions such as IBS, multiple sclerosis, eczema, psoriasis, Hashimoto’s, and the like, increase the probability of a deregulated immune system that causes infertility and/or recurrent miscarriages.
- Such findings in the history should prompt a more detailed immune assessment involving NK cells, inflammatory cytokines, maternal KIR, and HLA-C sequencing. These tests can only be done and properly interpreted by a reproductive immunologist who will then create a special medical treatment protocol.
- If the history indicates past problems with pelvic infection (salpingitis or appendicitis) or a high risk of endometriosis, then a hysterosalpingogram (HSG) is indicated to rule out tubal obstruction.
2) Expert pelvic ultrasound to evaluate uterine anatomy and to rule out fibroids, polyps, adenomyosis, and severe endometriosis.
- Fibroids have been associated with infertility and recurrent pregnancy loss. Not all fibroids are equal. The location and the size of the fibroid are important. Fibroids may affect conception and pregnancy by means of physical damage to the uterine lining and inflammatory changes in the surrounding tissues.
- Polyps cause implantation problems because they alter the quality of the endometrium and make it hostile to the implanting embryo.
- Adenomyosis is a condition in which the uterine lining grows outside the uterus and inside the uterine muscle (myometrium). Adenomyosis causes significant inflammation in the surrounding tissues and this inflammation is likely to cause implantation failure or early pregnancy loss.
3) Ovarian Reserve testing
- Day 3 hormonal assessment with AMH and Inhibin B
- Serum Ferritin (high levels are associated with reduced ovarian function and low AMH)
- Ovarian ultrasound to count the number of follicles
- Every woman who contemplates pregnancy should have an ovarian reserve assessment first to make sure that her ovaries are in good health. This test is done on day 3 of the menstrual cycle and it includes an ovarian ultrasound to count the number of available follicles, and hormonal assessment (FSH, LH, AMH, Inhibin B, and other hormones relating to ovarian function). If the ovarian reserve is diminished, then an expert can figure out the cause and select the best treatment to help the ovaries recover and improve the number of eggs as well as the quality.
4) Thyroid assessment: TSH and Free T4 (free thyroxine)
- Hypothyroidism or hyperthyroidism can affect a woman’s ability to conceive. Ruling out thyroid disease if thus valuable and should always be done.
5) Basic autoimmune assessment: Lupus anticoagulant, ANA, Anti-thyroid antibodies (ATA, TPO).
- Autoimmune disease screening is an important step to avoid wasting your time and money. Autoimmune conditions can be treated and if left alone, you will end up with either failed attempts to conceive with or without IVF or recurrent miscarriages. A specialist with experience in reproductive immunology is best to diagnose and treat autoimmune conditions in patients with infertility and recurrent miscarriages.
6) Confirmation of ovulation by means of progesterone level on day 16 of the cycle.
- Many women suffer from oligo-ovulation or anovulation. This is when they either ovulated a few times in a year or they do not ovulate at all. Most patients with anovulation also have amenorrhea (no periods) but it is not always the case. Many women menstruate almost regularly but do not ovulate every month. This can easily be confirmed with a blood progesterone level done on day 16 of the menstrual cycle. Anovulatory dysfunction can be treated with ovulation induction by using Femara or Clomid. If PCOS is diagnosed as the cause of anovulation, then special treatments can be offered by a reproductive specialist.
7) Metabolic evaluation:
- Fasting blood sugar with fasting serum insulin
- HbA1c
- Obesity, overweight, insulin resistance, or diabetes can affect ovarian function and the implantation process. If metabolic dysfunction is identified, should be treated with diet, exercise, Metformin, and insulin-sensitizing supplements, like Berberine InSea2 and CinndromX.
8) Complete blood count with Platelets
- Anemia or excessive blood can both have a negative effect on fertility. An increased number of platelets, in the presence of clotting disorders, could complicate things further. Such platelet issues can be easily treated with low-dose aspirin 81 mg per day.
9) Male partner history
- Weight (obesity is associated with poor semen).
- Illicit drug use (affect the quality of semen)
- Excessive alcohol consumption (affects the quality of semen)
10) Male Partner testing
- Routine semen analysis (semen count, motility, viability, and morphology)
- Semen DNA fragmentation and oxidative stress assessment. (Specialty testing)
- Serum Testosterone, Total and Free (low testosterone causes weak or ineffective semen quality). This can be treated either with Clomid orally or hCG injections according to the reason of low testosterone.
The guidelines promoted by the medical associations tell women to try for 12 months first without any testing and if they fail to conceive, then and only then they should seek specialty care. This guideline belongs to the 1950s and 1960s when most women completed their families by the age of 25 y/o. Now, the average age women decide to have their first baby is 32-33 and rising. This is the age that many women start having reproductive difficulties and before anyone realizes it, they get to be 40 y/o and still trying. Do not allow anyone to push you into this corner of despair and recurrent failure. Please, do yourself a favor and follow my advice. You will thank me for that like the many thousands of patients I have helped in my professional life.
