Everything men and women should know about fertility testing
This is the latest article in a Global News investigation into fertility in Canada, and the emotional and financial impact infertility has on Canadians struggling to conceive.
It took Katherine Keeling and her husband David seven years and three rounds of in vitro fertilization (IVF) to become parents.
For the Toronto couple, the hardest part at the beginning of the process was accepting the fact that a pregnancy wasn’t going to happen naturally.
“We thought… this will be good, we’ll just go the natural route and that will be that,” Keeling says. “But within six months of nothing happening, I started thinking; maybe it’s not going to be that easy.”
After several fertility testing procedures – some of which were painful – 36-year-old Keeling was told that her fallopian tubes were blocked, which was stopping her from becoming pregnant.
“There was a grieving process knowing that it wasn’t going to be as easy as a normal couple,” she says. “It was something that we both had to deal with and try and come to terms with.”
After years of IVF treatments and several miscarriages, Keeling started to feel defeated.
“We were reaching a point where after each time it didn’t work, it was taking me longer and longer to recover.”
It wasn’t until Keeling’s final round of IVF when she started taking intralipid through an IV – a prenatal mix of soybean, egg yolk and water that stimulated her immune system – that she eventually got pregnant.
She believes the concoction worked because it stopped her body from rejecting the growing embryos.
Today, Keeling has a healthy three-year-old boy named Bruce, and her story has come to represent the struggle of many people: the inability to conceive.
Despite the increasing numbers, many men and women – like Keeling – aren’t aware of possible fertility problems until they’re ready to conceive.
“I had a close female family member who I knew had problems conceiving. In the back of my head, I would always wonder if that meant I may also have issues,” Keeling said. “It wasn’t until we tried to get pregnant that I found out, we couldn’t conceive.”
Considering couples are holding off longer than ever to have kids, however, experts say waiting until babies are on the brain may be too late.
Signs of infertility
Signs of infertility in men and women can vary depending on the patient. Generally speaking, however, issues with menstruation can be a significant indicator of infertility in women.
According to Dr. Marjorie Dixon, founder of Anova Fertility and Reproductive Health in Toronto, common signs for women include irregular menstrual cycles, lack of menstruation, painful periods and vomiting and/or diarrhea while menstruating. Women should also get checked if they’ve contracted a pelvic infection like Chlamydia or gonorrhea.
According to the CDC, Chlamydia and gonorrhea may cause an infection of the fallopian tubes and often symptoms go unnoticed. By not treating the infection in the upper genital tract, the fallopian tubes, uterus and surrounding tissues may be permanently damaged, leading to infertility.
WATCH: Katherine Keeling opens up about the emotional struggle of going through IVF
The Government of Canada also advises women get checked if they:
- Are 35 years old or younger and have not become pregnant after one year of trying
- If they are older than 35 and have not become pregnant after six months of trying
- Have severe pain during sex (as it may be a sign of endometriosis)
- Had surgery in their abdomen or uterus in the past
- Had more than one miscarriage
- Had cancer treatment in the past
- Have a family history of early menopause before age 40
But infertility isn’t just a women’s issue; men can have fertility problems as well.
According to the Government of Canada, three times out of 10 the cause of infertility is in men.
For gents, Dr. Dixon says common signs and predictors of infertility may include experiencing a testicular torsion (e.g. through a sports injury that caused bruising on their testicle) and having surgery as a child for an undescended testicle.
The Government of Canada also says men should get tested if they experience premature ejaculation or lack of ejaculations, have a history of a sexually transmitted infection (STI) and/or had cancer treatment in the past.
Causes of infertility
There are several common causes of infertility in women, most of which revolve around ovulation issues, according to Dr. Ellen Greenblatt, medical director of the Mount Sinai Fertility and IVF unit.
“Probably the most common cause is irregular or absent ovulation,” she says. “Another common cause would be damage, scarring or blockage of the fallopian tubes. It’s where the sperm and egg have to meet… so any damage or blockage of that area would be a major cause [of infertility].”
Other factors that may cause infertility in women include endometriosis, and – less commonly – problems related to the uterine cavity and distortion from fibroids. While fibroids are common, Dr. Greenblatt says they’re uncommonly the cause of infertility.
Age is another factor to consider.
At puberty, women will have about 300,000 to 400,000 eggs in her ovarian reserve. However, a 2010 St. Andrews University study says that about 1,000 of those eggs will die during every menstrual cycle, leaving women with only 12 per cent of their eggs when they reach 30 years of age and eventually only three per cent when they reach 40.
The U.S. Department of Health and Human Services, also lists additional risks that are associated with infertility in women. They include:
- Excess alcohol use
- Poor diet
- Athletic training
- Being overweight or underweight
- Health problems that cause hormonal changes (e.g. polycystic ovarian syndrome)
For men, low sperm count, low sperm motility (percentage of sperm swimming forward) and irregular sperm shape (also known as morphology) can all be signs of infertility.
The testing process
Testing for infertility in men is quite simple. They are required to ejaculate into a cup and provide a semen sample. That sample is then analyzed for sperm count, sperm shape and the sperm’s ability to swim forward.
For women, testing is often invasive.
One test, called an ovarian reserve assessment measures how well a woman’s eggs are functioning, Dr. Dixon says.
This is done with blood tests that measure FSH levels (the gas released by the pituitary gland to get a follicle going at the beginning of menstrual cycles) on day three of a woman’s cycle and/or anti-mullerian hormone (AMH) levels (it tells the size of the remaining egg supply). A transvaginal ultrasound is also used to look at a woman’s antral follicle count (which can also look at the remaining egg supply) and ovarian volume.
There are a few ways to determine if a woman’s fallopian tubes are open and if the uterine cavity is normal as well, Dr. Greenblatt says. One test is called a saline infusion sonogram – or a sonohysterogram. It can either be done as an ultrasound where water is injected into the uterus or as an X-ray with an injectable contrast.
“It’s a little uncomfortable,” Dr. Greenblatt says. “It can be associated with a bit of cramping but it’s not terribly painful.”
A vaginal ultrasound is also helpful in determining if there are cysts on the ovaries related to endometriosis and is not a painful procedure, Dr. Greenblatt says.
Should a physician suspect there are pelvic abnormalities, a laparoscopy may be ordered.
“It’s a surgical procedure but it’s done less and less frequently,” Dr. Greenblatt says. “I’d say it’s done in the context of suspicion where you would want to maybe do corrective surgery but we have pretty effective imaging methods so that would be done in a real minority of patients.”
Most of the tests involved are covered by provincial governments, says Dr. Dixon.
The AMH test, however, is not covered and may cost between $125 and $200 depending on the clinic.
Other tests may be available and/or suggested to women by their physician and the decision of which tests to go through are made on a case-by-case basis.
When to get tested
Getting tested sooner rather than later is the way to go even if you’re not trying to get pregnant at the moment, both Dr. Dixon and Dr. Greenblatt say.
“I say you should have a fertility evaluation in your late 20s,” says Dr. Dixon. “Just get an assessment. Check your sperm if you’re a guy and if you’re a woman have an ovarian reserve assessment and an assessment of your uterus and tubes so that you will be able to do conception planning. It’s all about planning.”
“Fertility doesn’t go on forever so plan your life accordingly,” Dr. Greenblatt adds. “Think about if you want to have kids in the future. Family planning is a big part of preventing infertility.”
WATCH: Katherine Keeling gives fertility treatment advice to other couples
As for Keeling, she says she is very grateful that there were fertility tests available to her but wishes she knew about all of them from the get-go so she could have navigated the process better.
“Had I known about some of the blood tests that weren’t covered by OHIP from the beginning I would have most likely asked for them as well so we had a full scope of what was going on with our fertility,” she says.
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