HYSTEROSALPINGOGRAM (x-ray dye test or HSG)
Most infertility patients in the U.S. have had this test done as part of their initial evaluation. Many overseas patients have not, and some American women have not. This test is important because it looks both at the uterus and the tubes. A combined laparoscopy/hysteroscopy, though more invasive is a suitable substitute for this test. Abnormalities of the uterus, such as polyps, fibroids, scar tissue, and septums can interfere with implantation or cause miscarriages. All of these conditions should be corrected before undergoing IVF. In addition, if the tubes are blocked at their far ends (Hydrosalpinx), many studies have shown this condition to decrease IVF success rates by 50%. When these blocked tubes are found, they need to be surgically removed.
If an HSG was done in the past, hysteroscopy is useful to find new problems like polyps or small septums that have been ignored. Hysteroscopy can be done as an office procedure or with light anesthesia.
SPERM DNA FRAGMENTATION
A number of tests have been developed that evaluate the integrity sperm DNA. The most popular version is called the DNA fragmentation assay. It evaluates the integrity of DNA in the sperm. If this is abnormally high, the evidence shows that this will result in lower fertilization rates, lower implantation rates, and higher miscarriage rates. Men with normal semen analysis results can have abnormal DNA results. If an abnormal result is obtained, a urological consultation may be appropriate. If no physical abnormalities are found, various approaches have been tried to improve the DNA quality.
ENDOMETRIAL BIOPSY TESTS FOR IMPLANTATION MARKERS
Over the past 25 years, a variety of tests have been developed that help determine if the endometrium (uterine lining) is receptive to implantation. The older tests, while backed by scientific articles, do not generally guide the physician as to how the problem can be improved. A “third- generation” version called the Endometrial Receptive Assay (ERA) uses more current gene expression technology to see if the endometrial “implantation window” is open on the correct day of the cycle. If it is not, this can be manipulated by freezing embryos and transferring them in a protocol that adjusts the number of days of progesterone given prior to the transfer.
Our experience with this assay confirms their finding that about 1 in 5 infertile women have an endometrial implantation problem, and changing the number of days of progesterone has helped many women with prior failed cycles finally conceive.