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Doctors’ investigations before proceeding with IVF treatment

13 October 2009

Preliminary testing. When attending an IVF clinic for the first time, the doctor will conduct a consultation. He or she will review in depth the past medical history, conduct physical and internal examination and your doctor may perform a ‘dummy’ embryo transfer to make sure there is no technical problems with the procedure. The doctor may order some investigations before proceeding with treatment.
These usually include:
• Semen analysis to check for sperm number, swimming ability, shape, and survival. . For men who have difficulty in producing semen samples on demand, the doctor may recommend that semen is produced at a convenient time and then frozen and stored prior to IVF treatment as a ‘back up’ just in case the male partner is unable to perform on the day of egg collection.
• Blood hormone tests to assess the female partners response to fertility drugs (ovarian reserve). The commonly used tests include baseline levels of FSH, LH, estradiol, inhibin B and anti-Mullerian hormone (AMH). The ovarian reserve tests to date have only modest-to-poor predictive value (Broekmans et al 2006 Human Reproduction).
• Blood test to check for immunity to German measles.
• In some women, hysteroscopy or HSG may be ordered to inspect the uterine cavity.
• Screening for chlamydia infection is usually considered if the patient is at risk.
• Some clinics will require screening both partners for HIV, hepatitis B and Hepatitis C and only accept the couple for treatment if the tests results are negative.
• Transvaginal ultrasound scan for antral follicle count (AFC) and ovarian volume, this have only moderate to poor predictive value for assessing ovarian reserve. In addition Assesssing endometrial thickness, texture and any significant distortion of the uterine cavity by polyp or fibroid which may hinder embryo implantation.

Consent forms. Before a couple starts IVF treatment, they should be issued with consent forms and information sheets about their treatment. In addition, in the United Kingdom, couples are given HFEA consent forms to fill in.
The consents are complex documents. We recommend that you read them carefully, do no hesitate to ask for help from your doctor or the clinic’s co-ordinator if there is anything you can not fully understand.
You should only give your consent after you are satisfied that you understand what you are agreeing to.
Baseline assessment. The baseline assessment is very important to ensure that you are ready to start IVF treatment. It involves having an ultrasound scan and a blood sample to check the women’s womb, ovaries and hormone levels.
An ultrasound scan is performed, preferably vaginal scan as it gives a better image compared to an abdominal scan. The scan is used to check the lining of the womb and ovaries. It will diagnose abnormalities such as ovarian cysts, endometrium polyps, etc.
A blood sample is usually taken to measure hormone levels such as estrogen, LH, FSH and AMH to assess ovarian reserve. The levels of these hormones may give an idea about the expected response to ovulation stimulation drugs. For instance, high levels of FSH may indicate poor response to ovarian stimulation, poor pregnancy rates and high rates of pregancy loss regardless of age when compared with women who have normal results.
Superovulation. Superovulation involves the use of fertility drugs to stimulate the ovaries. The aim is to grow several mature eggs rather than a single egg that normally develops each month. With the introduction of cryopreservation, excess embryos can now be stored so that the woman does not have to go through ovarian stimulation and egg collection each cycle.
Some IVF clinics carry out natural cycle IVF treatments; this does not employ fertility drugs. However, with only one egg is usually obtained; the pregnancy rate per treatment cycle initiated is much lower than when superovulation is used. Obviously there will be no additional cost for medication. Natural cycle IVF is not recommended, except in special circumstances such as when gonadotropins are contraindicated. Women who have had breast cancer which is estrogen receptor positive may be offered natural cycle IVF. Natural IVF cycles may also be offered to older patients who have failed to become pregnant after stimulated IVF cycles and women who have regular ovulatory cycles.