Female Infertility Investigations

SIS

What is an SIS? An SIS is an ultrasound procedure performed to (a) assess the direction of the neck of the womb (endocervical canal), (b) confirm that the uterine cavity is normal (ensure there are no polyps or fibroids), and, if applicable, (c) confirm the passage of fluid through the fallopian tubes into the pelvis (pouch of Douglas). It is an outpatient procedure which takes less than half an hour to perform. It is usually done after menstruation has ended but before ovulation (to prevent interference with early pregnancy). It can be performed at any time of the cycle if the patient is on the oral contraceptive pill.

How is it done? The patient lies on a table and the Gynaecologist places a speculum in the vagina and cleans the neck of the womb. Then a small catheter is placed into the opening of the neck of the womb. This gives information necessary for correct placement of embryos at transfer time. The doctor then fills the womb with sterile water or contrast media through the cannula in the womb. This profiles the cavity to confirm normality. The absence of any fluid before the test followed by the presence of fluid in the pouch of Douglas (a space behind the womb) afterwards confirms the patency of the fallopian tubes. The ovaries are also imaged. This test is not designed to diagnosis endometriosis unless there is an endometriotic cyst present (endometrioma). After SIS, the patient can immediately resume normal activities although some doctors ask that the patient refrain from intercourse for a few days. Instructions are given to the patient before discharge.

Is it uncomfortable? It may cause mild or moderate cramping for about five minutes and some patients may experience cramps for several hours. Pain medication can be taken for these including Neurone, Ibuprofen or Paracetomol.

What are the risks and complications of SIS? It is considered a very safe procedure; however there are some rare but serious complications which occur less than 1% of the time.

• Infection – This is the most common serious although rare problem with SIS. It may occur in the presence of previous tubal disease. In rare cases it can damage or necessitate the removal of the fallopian tubes. A patient should call the doctor if she experiences pain or a fever within one to two days of SIS. Antibiotics are given to minimise this chance.

• Fainting – Rarely the patient gets light-headed during or shortly after the procedure.

• Spotting - Spotting commonly occurs for one to two days after the SIS. The patient should notify the doctor if she does experience heavy bleeding after this investigation.

Are there any special precautions I should take before SIS? Yes. Eat before the procedure.

Fibroids

What are fibroids?

Fibroids are benign swellings (also known as tumours) arising from the
muscle of the womb. They are exceptionally common in women - indeed
post-mortem studies show that most women will develop one or more during
their lifetime. They are more common in black women or women who have had a child. There are often more than one and, thankfully, they rarely become
malignant. They usually get bigger during a woman's reproductive life
(especially during pregnancy) and smaller after the change of life, i.e. the menopause.

Where do they arise?

They arise in the outer, middle, or inner layers of the wall of the womb.
Those that arise in the outside layer are known as subserous because they
distend the serous membrane that covers the womb (which is called the
peritoneum). These are the ones your gynaecologist will see at laparoscopy.
Those that arise in the middle of the womb are called intramural and may cause pain or heavy bleeding .Those that arise from the inner layers are called submucous because they stretch the inner mucous layer of the womb (called the endometrium). The specific problem with submucous fibroids is that they distort the normal contour of the cavity of the womb into which the embryo is trying to implant itself. This is clearly not advantageous to getting (or staying) pregnant so is associated with infertility or recurrent miscarriage
. This is why we may suggest making the cavity more normal before proceeding with fertility treatment including IVF. However, if the distortion is minor, the risks associated with surgery (e.g. haemorrhage, infection, scarring in the womb, or rupture of the womb before or during labour) may not be worth incurring.

How are they identified?

While ultrasound is usually used to identify intramural
fibroids (i.e. those in the wall of the womb), alternative methods are often
used to establish whether the cavity of the womb is normal. These include
hysteroscopy, hysterosalpingogram, saline
sonography, or hycosy.

How are they treated?

No treatment is needed if they are not malignant or contributing to pain,
bleeding, infertility, or recurrent miscarriage. Those on the outside
(subserous) or in substance of the muscle of the womb (intramural) are
usually treated by laparotomy or laparoscopy. Those protruding into the cavity may be treated by laparotomy but ideally are treated by operative hysteroscopic resection as the latter has less risks associated with it.

If I have surgery and get pregnant, will I need a Caesarean Section (C/S)?

In most cases you will need a C/S although you would need to discuss this
with your Obstetrician depending on what type of surgery you have had
carried out.

Hormone Assays

Why are hormone tests needed?

Hormone tests are carried out as a part of the investigation of the
infertile couple. The main ones carried out on the female are taken at a
specific time in the menstrual cycle.

What tests are carried out early in the menstrual cycle?

Early or 'basal' tests are carried out on the second or third day of the
menstrual period and assess function of the hypothalamic pituitary axis.
These include gonadotropin (FSH & LH) and hormone levels (oestradiol [E2]
+/- androstenedione, DHEAS, 17-OH progesterone).

If both gonadotropins and oestradiol (E2) are low, then this is because the
brain is not stimulating the ovaries. This is not a frequent cause of female
infertility and is usually treated with gonadotropin drugs given by
injection.

If the gonadotropin levels are high and the oestradiol levels are low, this
means the ovary is not working well (because the brain is sending high
levels of FSH down to stimulate the ovary but it is failing to respond and
produce oestradiol (or follicles or eggs)). This is an ominous sign of
ovarian function called diminished ovarian reserve. It is a cause of female factor infertility and is associated with irregular menses, infertility, poor outcomes with infertility treatment (including IVF), poor response to ovarian stimulation, and an early menopause. Unfortunately the significance of an elevated FSH level is not removed even if another test taken some months later.

If the ratio of gonadotropins is reversed - that is, if the normal FSH/LH
ratio is reversed - then this may be associated with a condition called
polycystic ovary syndrome. This is classically also associated
with elevated levels of male-type hormones called androgens
(e.g.andostenedione and dihydroepiandrosterone).

Non-cycle specific tests can also be taken at this time which include
prolactin and TSH. The former, if elevated, is called hyperprolactinaemia. TSH is a test of how well the thyroid gland is functioning. If it is elevated, then the thyroid may be underactive. Hypothyroidism is associated with heavy periods, infertility, and immune dysfunction.

What tests are carried out late in the menstrual cycle?

The most important test is the level of progesterone in the second half
(luteal or secretory phase) of the menstrual cycle. This should be elevated
if ovulation (egg production) has occurred in the middle of the cycle
(mid-cycle is classically described two days after the LH surge on day 12 -
that is, day 14 - although this is often not the case in real life).