Tuesday, June 16, 2009

Tests prior to IVF

If you need IVF treatment in order to get pregnant, we will need to do certain tests to determine:

1. If we can do IVF for you

2. What kind of IVF treatment would be best for you ( IVF ? ICSI ? ZIFT ? donor eggs ?)

3. What your chances of success will be

Many clinics order a huge battery of tests routinely before starting IVF treatment. They use a mindless checklist approach – which can drain quite a bit of blood – and money ! Many of these tests are pointless, because they provide little useful information. However, this seems to be the norm, especially in large IVF centers ( which are run as mills and employ a huge number of doctors); as well as in the US, where testing is often done for non-medical reasons.

We prefer taking a simplified, patient-friendly approach by focusing on what is medially important. We customize this testing, depending upon the patient. In order to do IVF, remember that we only need to check the following: eggs; sperm; uterus and tubes.

We usually do just the following simple medical tests before starting an IVF cycle. If the tests have been done in the past one year, there is no need to repeat them.

For the husband, all we need is a simple semen analysis ( www.drmalpani.com/semen-analysis.htm) , to check sperm count , motility and morphology.

a. If it’s normal, then we plan to do IVF.

b. If it’s abnormal, then we plan to do ICSI. If there is an element of doubt ( for example, if the counts vary a lot), then ICSI is a safer option, as fertilization is guaranteed

c. If it’s zero, then we need to consider sperm retrieval through TESE or PESA

The wife needs more extensive testing.

1. blood tests for the following reproductive hormones : FSH ( follicle-stimulating hormone),LH ( luteinising hormone),PRL ( prolactin) and TSH ( thyroid stimulating hormone) on Day 3 of the cycle, ( to check the quality of the eggs). This needs to be done from a reliable lab such as Specialty Ranbaxy ( www.srl.in). If these tests are normal, then the standard superovulation regimen can be followed . However, if there is a problem, then this will need to be corrected.

a. A high prolactin ( www.drmalpani.com/prolactin.htm) can be corrected by treatment with bromocriptine or cabergoline

b. Abnormal thyroid levels ( www.drmalpani.com/thyroid.htm) can be treated with medications

c. An abnormal LH:FSH ratio suggests PCOD. This may need to be corrected with metformin prior to starting IVF. Also, the superovulation will need to be gentler

d. A high FSH level or a high FSH:LH level suggests poor ovarian reserve. This means that the response to superovulation may be poor and reduces the success rate. Poor ovarian reserve ( www.drmalpani.com/oopause.htm) . Additional testing may be needed, such as a clomid challenge test; tests for AMH ( anti-mullerian hormone levels) and an antral follicle count. Options may include trying to improve ovarian reserve with empirical treatment and using more aggressive superovulation for IVF. An alternative would be to consider donor eggs or donor embryos

2 . a HSG ( hysterosalpingogram, X-ray of the uterus and tubes) on Day 8 of the cycle ( to confirm the uterine cavity is normal and the fallopian tubes are open. You can read about this at www.drmalpani.com/hsg.htm. An HSG can be painful and this is not always essential prior to doing IVF. However, it is a very good way of documenting that the uterine cavity is anatomically normal ( especially in towns with poor medical facilities). Alternatives to HSG include vaginal ultrasound scanning , but this should be high quality. If the HSG is normal and the fallopian tubes are normal, then an additional treatment option which can be offered is ZIFT ( www.drmalpani.com/zift.htm), where the embryos can be transferred directly into the fallopian tubes, instead of the uterine cavity, to improve the chances of implantation.

3. a vaginal ultrasound scan on Day 10 or 11 , which should check for the following.

a. ovarian volume

b. antral follicle count

c. uterus morphology

d. endometrial thickness and texture

Because ultrasound interpretation is so subjective, it’s important to do this at a good quality center. The better centers have digital ultrasound machines, which allow them to give you the scans as a jpeg file which you can save on a DVD or a flash drive.

In case there is an abnormality, then newer ultrasound techniques, such as 3-D vaginal ultrasound provide more information. If there is a polyp, then this will need to be removed by doing a hysteroscopy. Intramural fibroids ( in the wall of the uterus) do not need to be removed prior to IVF, as they do not affect embryo implantation. You can read more about this at http://www.drmalpani.com/fibroids-and-infertility.htm. Submucous fibroids ( which are in the uterine cavity) need to be removed. These can be best removed with an operative hysteroscopy ( www.drmalpani.com/hysteroscopy.htm).

You should always insist on a copy of all your medical records.

What other tests are needed ? All clinics will also test you for infectious diseases, such as HIV, Hep B and VDRL. Other tests include checking your rubella immunity, in case you have not been vaccinated against rubella. If the test show there is a problem, then this can be treated prior to starting IVF!

Other clinics will perform much more extensive testing. These include tests for esoteric conditions such as: immune testing; testing for TB ( including blood tests for TB antibodies and PCR on an endometrial biopsy) ; routine hysteroscopy to check the uterine cavity; and TORCH tests.

Many patients are very impressed by doctors who order so many tests. They feel these doctors are very careful and thorough ! However, the truth is that most of these tests are pointless and just waste time and money. Before doing all these tests, just ask your doctor one simple question – How will the results of this test change my IVF treatment ? Remember, that if the result of the test will not change your treatment, then there’s no point in doing the test !

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