Female Infertility Investigations

Female Infertility Investigations


What is SIS?

  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 Paracetamol.

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.

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).


Anti-Müllerian Hormone (AMH) blood test 

Knowledge of how you will respond to hormone injections during an IVF treatment cycle is a very important part of fertility treatment. Depending on your own individual characteristics, you may fall into the extremes of response – an excessive response or and inadequate response. A recently developed test allows us to modify our approach, resulting in a reduced incidence of both of these extremes.

It has now been established that the hormone AMH, which is made by the ovarian follicle containing the egg, can accurately predict how your ovaries will respond to fertility drugs. This is sometimes called the ovarian reserve. Armed with this information, your consultant can make better decisions from the outset as to how to best proceed with your assisted reproduction cycle.

AMH involves a single blood test which can be performed at any stage in the menstrual cycle. At the Sims Clinic, we can analyse your AMH levels in our own dedicated laboratory. Other relevant hormones may be measured in parallel with AMH, these are thyroid stimulation hormone (TSH) and Prolactin. Together these are known as the AMH profile.