Required Tests and Screening Before an IVF Cycle

I. Patients without prior history of testing and/or fertility treatments

This category is usually the most common presentation at a fertility specialist’s office. Couples may have been trying to conceive for some time without success and they would like to begin investigating the cause of this problem.

Testing Strategy for patients trying to conceive without prior fertility treatments and/or testing should always include basic male and female infertility assessment without going into more invasive and expensive tests. The basic testing often provides a general overview of the female and male reproductive function and is often sufficient for identifying the most suitable course of action.

Basic female testing:

A basic female infertility assessment includes the following tests:

• A trans-vaginal ultrasound scan to be performed on day 2 or 3 of the menstrual period. This is called a “baseline scan”. It is a “baseline” scan because it is immediately after heavy bleeding starts, therefore, allows the endometrium to shed and return to its baseline (thin) structure. At this point during the menstrual cycle, the ovarian follicles are also at their smallest size. Therefore, with this scan, we ask for the following:
  • An assessment of the endometrium (thickness, appearance)
  • An assessment of the uterus in general for any pathologies (polyps/fibroids/free fluid)
  • An assessment of the ovarian follicles for antral follicle count (AFC)
• Hormone testing, again, on the same day as the ultrasound scan. The hormone tests should include the following:
• Follicle stimulating hormone (FSH) is a glycoprotein that is produced and secreted by the anterior pituitary gland as a response to secretion of gonadotropin releasing hormone (GnRH) by the hypothalamus. FSH is an important part of female reproduction as it initiates follicular growth. During the follicular phase of the ovarian cycle, follicles are FSH-dependent more than anything else. With secretion of FSH, follicles begin to grow and secrete estrogen, which lays the groundwork for endometrial growth.
• Luteinizing hormone (LH) is also a glycoprotein that is produced and secreted by the pituitary gland in response GnRH secretion from the hypothalamus. An acute rise of LH (also known as the LH surge) triggers a chain of events which leads to ovulation.
• Estradiol is mainly produced by the ovarian follicles. As follicles grow and develop, they start secreting estradiol, which, in turn, helps maintain several reproductive functions, including endometrial development. Endometrium is the structure where a developing embryo attaches for pregnancy to occur. Therefore, estradiol is highly important in achieving and maintaining a successful pregnancy.
• Thyroid stimulating hormone (TSH) is a hormone produced and secreted by the anterior pituitary. Its main role is to stimulate the thyroid gland to produce thyroxine (T4), and then triiodothyronine (T3). These thyroid hormones are involved in all the cellular metabolic activities in the human body. As such, TSH modulates the metabolism and development of ovarian, uterine, and placental tissues. While TSH is not directly involved in reproductive physiology, its over or under activity can result in subfertility as well as infertility.
• Anti-Mullerian Hormone (AMH) is involved in growth differentiation and folliculogenesis. During differentiation between a male and a female fetus, its expression is through a different process. However, in an adult female, it is secreted by the granulosa cells that surround the preantral and small antral follicles in the ovaries. As such, it is accepted as the most reliable biomarker of the size of the ovarian reserve and ovarian reproductive function.

Basic Male Testing:

Male patients who have not had any prior testing and/or known reproductive problems will undergo a semen analysis. A semen analysis aims to measure several parameters associated with male reproductive function. A standard semen analysis includes the following parameters:

• Count: refers to the concentration of sperm cells in 1 ml of semen sample. A count of at least 15 million/mL is a standard established by the World Health Organization (WHO) as the minimally accepted value for natural conception.
• Motility: refers to the sperm cells’ ability to move through the female reproductive tract and reach the fallopian tubes where the female oocyte resides after ovulation. WHO has established a value of 40% as the minimally accepted standard for motile sperm count for natural conception.
• pH: is expected to be higher than 7.2. Given the acidity of the female reproductive tract, semen needs to be alkaline in order to withstand the hostile acidic environment.
• Morphology: refers to the total percentage of sperm cells that have a normal appearance without any visible head or tail defects. The minimally acceptable percentage for morphology is 4%. Below this percentage, the sperm cells’ ability to achieve natural fertilization declines markedly. Furthermore, severe morphological abnormalities can also be associated with sperm DNA fragmentation. In such cases, we often recommend the use of microfluidic chip for sperm selection.
• Round cell count, liquefaction and appearance are also important parameters that are screened via semen analysis.

II. Patients under the age of 40 who have been through prior fertility treatments without success.

In this group of patients, tests mentioned above are more than likely to have been performed. At this point, further investigation is often necessary. When test results do not point to a significant problem, yet, fertility treatments fail, then there are a number of parameters which need to be explored:

III. Patients over the age of 40 who have been through prior fertility treatments without success.

When the female patient is over the age of 40, oocyte issues become the first suspect in fertility problems. If the previous fertility treatments took place when the female patient was in her 40s, alternative treatment options will need to be considered. However, if there seem to be no problems with the number and quality of oocytes during the IVF cycles, tests recommended in the category above are likely to be requested. However, apart from these tests, patients in this age bracket are often consulted about options such as embryo banking or using donor eggs.

Embryo banking is when multiple egg collections are planned in an attempt to maximize the number of good quality oocytes at hand and ensure availability of viable embryos for transfer.

Egg donation is the fertility treatment option when donor eggs are used instead of the patient’s own eggs in an IVF cycle.

IV. Patients with recurrent miscarriages

Recurrent miscarriages are not only frustrating for a couple trying to conceive, they can also have psychological and social implications who experience them. Having more than 2 consecutive miscarriages is accepted as a reason for further investigation. Apart from the additional tests listed in category 2, the following are often tested for recurrent miscarriages:

• Thrombophilic disorders increase the likelihood of blood clotting. Thrombophilic disorders are associated with both implantation failures and recurrent miscarriages. Patients with recurrent pregnancy loss and/or recurrent IVF failure are often tested for thrombophilic disorders by looking for gene mutations in MTHFR, prothrombin and PAI-1 as well as the factor V mutation. The activity of natural anticoagulants protein S and protein C is also usually tested as part of thrombophilia testing. These tests can be performed with a peripheral blood sample, making thrombophilia testing relatively noninvasive and inexpensive.
• An immunological evaluation usually checks for antiphospholipid antibody, antinuclear antibody, and antithyroid antibody as well as natural killer cell activity in peripheral blood.
• Sperm Cell DNA Analysis can be performed when other tests come back inconclusive. Advanced semen analysis can test for sperm cell DNA fragmentation and sperm chromosomal aneuploidy. While sperm cell DNA testing is not yet incorporated into standard clinical setting, there many studies have established a clear association between sperm cell DNA fragmentation and aneuploidy with infertility. In addition, sperm cell aneuploidy and DNA fragmentation are associated with the inability to naturally conceive, recurrent miscarriages, and IVF failures.

V. Patients who are undergoing an IVF cycle using donor eggs

When using donor eggs, the female patient’s own ovulation markers are usually not a priority in pre-treatment assessment. However, hormonal assessment is still a required part of testing in order to identify the right approach to treatment especially when deciding between down-regulation versus no down-regulation.

As a general approach, tests which have been outlined in category 1 are also suitable in this category. These would be:

For the female patient:

• A trans-vaginal ultrasound scan to be performed on day 2 or 3 of the menstrual period if the female patient still has menstrual cycles. If the patient no longer has menstrual cycles, then the scan can be performed at any time. The purpose of the scan would be to serves as:
  • An assessment of the endometrium (thickness, appearance)
  • An assessment of the uterus in general for any pathologies (polyps/fibroids/free fluid)
• Hormone testing including FSH, LH, Estradiol, Prolactin and TSH. When using donor eggs, FSH and LH tests do not carry too much of a significance. However, they are still used when determining whether down regulation should be done. If FSH and LH tests have been performed, AMH is usually not asked.
• 45+ tests for patients over the age of 45. This is a testing requirement implemented by the North Cyprus Health Ministry. Any patient receiving treatment in Northern Cyprus should complete 45+ testing which will serve as a report for fitness to carry a pregnancy. These tests include:
  • An ECG test
  • Kidney and Liver enzymes
  • An Echocardiogram
  • An internist examination. These tests can be performed at our hospital during a single visit.

For the male patient:

A standard semen analysis is requested from the male patient. Details of the parameters of a semen analysis is outlined in section 1 testing above.

*** Please keep in mind that information contained on this page is for general guidance purposes. Each patient should be assessed on an individual basis and information contained on this page should not replace a professional consultation.