Pre-conception Information
I am a specialist obstetrician and gynaecologist. Most of my practice is obstetrics – the care of women during pregnancy and childbirth. I also see women for gynaecological checks, including routine Pap smears, management of abnormal Pap smears, long-acting reversible contraception, such as Mirena and Implanon, abnormal bleeding, and for fertility and pre-conceptual counselling.
Around 80-90% of couples will conceive within twelve months of trying, if they are having intercourse at the fertile time of the woman’s cycle. Most women have a menstrual cycle length of around 28 days. Day 1 of the cycle is the first day of proper bleeding, and most women will ovulate on around Day 14. The egg (or ovum) will typically last for around 24 hours, while the sperm will often survive for around three to four days, sometimes longer. That means the fertile ‘window’ of the woman’s cycle is from around day 10 to day 15 of a 28-day cycle, but especially days 13 to 14.
There are several ways of checking whether and when you are ovulating. The most reliable form of confirming whether you have already ovulated is to perform a blood test about one week after ovulating, ie on day 21, to measure your Progesterone level. This level should be well above 10, depending on the pathology provider, and ideally above 30. The best way to check whether you are currently ovulating or about to ovulate is urinary ovulation kit testing between day 10 and day 12 of a 28 day cycle. This test measures the levels of an ovarian hormone, known as LH (luteinizing hormone), which rises or “surges” about 36 hours prior to ovulation. This test is helpful, as it tells you that you are in or entering your fertile ‘window’. Other forms of checking include core temperature charts and tracking of ovarian follicles on vaginal ultrasound scanning.
Infertility and Sub-fertility
For women who do not appear to be ovulating it may be that your ovulation is occurring either earlier, or more likely, later in your cycle, and this will need to be assessed. It could also mean that you are not ovulating at all, in which case you may have a hormonal disorder, such as polycystic ovarian syndrome (PCOS), which can stop you from ovulating, or make your ovulation erratic.
PCOS is a common condition, and one that can be treated, to restore your fertility.
PCOS can occur in both overweight, and slim women. PCOS can be associated with a prior eating disorder, or with a form of pre-diabetes, known as insulin resistance, which is one of the things I may need to test for. It can also be associated with an excess of male hormones, that can cause acne and excess facial hair in women. Lack of ovulation caused by PCOS can be treated with a diabetes tablet, known as Metformin, or fertility medications, such as Clomid or Letrozole.
Metformin can help you to lose weight, as well as help you to ovulate, but it can cause significant abdominal cramping, bloating and diarrhoea. Clomid or Letrozole have fewer gastro-intestinal side effects, but can overstimulate the ovaries, and carry a risk of twin pregnancy of around 15%.
For women who are ovulating but still not able to conceive it may be that you have endometriosis. This is an inflammatory condition affecting the internal lining of the pelvis and abdomen.
Endometriosis can cause painful menstrual periods, especially pain in the days prior to the onset of menstruation, as well as deep pain with intercourse, and occasionally pain with opening bowels or with emptying the bladder. Sometimes endometriosis can cause thickening, scarring or nodularity of your internal tissues, which can be felt on deep internal vaginal examination. Often endometriosis causes no symptoms and no obvious scarring, in which case the only way to confirm it, and the best way to treat it is with a laparoscopy – “keyhole” surgery.
Another possible cause of infertility is poor quality sperm. This may be related to an inadequate volume, concentration, shape (morphology) of sperm, poor movement (motility) of sperm, anti- sperm antibodies, or high levels of oxidative stress, resulting in high DNA fragmentation levels. The latter may be treated with high levels of anti-oxidants, such as green tea and Vitamin C, a male fertility supplement, known as Menovit, or other supplements. Ova and sperm are very sensitive to toxins, so I recommend a healthy lifestyle for 4 about months before conceiving.
Investigations
There is a vast array of testing options for fertility, some of which are of little benefit, at least initially. They are commonly performed in a fertility setting, but there is often little or no evidence to prove that testing or treating suspected problems will help with fertility. The difficulty is that treatment may just help and for that reason it is often hard to resist, as it means at least trying to do something. Occasionally there is no time to wait and it is better just to do everything at once.
Commonly Performed Tests for Infertility
Pathology Tests
High Vaginal Swab:
This is mainly looking for vaginal infection, known as Bacterial Vaginosis. It may also show Candida, a yeast infection, known as “thrush”, which is often harmless, but can occasionally cause problems. Other bacteria I sometimes test for include Mycoplasma and Ureaplasma.
Many women carry Ureaplasma or Mycoplasma, and they are often considered to be a harmless part of normal bodily bacteria, and for many women they probably are, however there is some evidence of an association between these bacteria and poor pregnancy outcomes, including infertility, miscarriage, and pre-term labour. I therefore screen and treat women who may experience any of these problems. It is important to remember that “association” is different from “proven cause”, and there is no evidence from studies to show that treatment improves any of the above outcomes.
The treatment is a ten-day course of Doxycycline for you and your partner, after which I usually repeat the swab. Treatment is empiric, as there is no sensitivity testing for Ureaplasma or Mycoplasma.
Doxycycline must not be taken in the second or third trimester of pregnancy. I usually avoid using it entirely in pregnancy, although there is no evidence of harm in the first trimester. There is no evidence to recommend repeated use of antibiotics, and maybe if you have not responded to a single course then a repeated course will not be of more help. Nevertheless I may still try it.
Whenever you take a course of antibiotics you can wipe out the healthy and helpful bacteria that normally inhabit your gut, so I recommend probiotics, such as Qiara, VSL, or Inner Health Plus, and the natural yoghurts, such as Yakult, to help replenish the “good” bacteria. Remember also that although Doxycycline is well tolerated by most people it can have significant side-effects on some people.
Routine Pap Smear
A Pap smear is an important five yearly screening test to prevent cancer of the cervix. I routinely perform the Thin Prep test with the Pap smear at your first visit if it has not been performed recently. The Thin Prep improves the detection rate of abnormal cells, and is useful, as it improves the detection rate of abnormal cells, but it is not covered by Medicare, and costs you around $60.
Day 2-3 Blood Tests: Blood tests in the early part of your cycle tell us about basic functioning of the ovary, and ovarian reserve. These include:
- LH, FSH, Oestradiol – looking for low FSH
- Anti-Mullerian Hormone (AMH) – the so-called “egg-timer” test – looking for an AMH > 10
- Prolactin, especially if you are not menstruating – looking for a level under 500
Day 12-13 Blood Tests: Blood tests in the mid part of your cycle tell us about functioning of the ovary, as it prepares to ovulate
- LH, FSH, Oestradiol – looking for rising LH and Oestradiol around 1000
- Progesterone – looking for slowly rising level
Day 21 Blood Tests: Blood tests in the second half or “luteal phase” of your cycle confirm whether you have ovulated:
- Progesterone – looking for a level at least above 10 and ideally above 30
PCOS Screen:
Blood tests at any stage of your cycle tell us whether you have high levels of male hormone, and whether you have insulin resistance, a form of pre-diabetes, that is common with polycystic ovarian syndrome
- LH, FSH, Oestradiol
- Androgens (male hormones) and sex hormone binding globulin (SHBG)
- Fasting, 1 and 2 hour Glucose Tolerance and Insulin Test – this must be booked and needs special preparation, including a 3 day high carb diet – please see A5 diabetes screening sheet
Autoimmune and Thrombophilia Screen:
These are the tests for which there is the least evidence. They can be helpful in identifying women at increased risk of recurrent miscarriage, growth restriction, severe pre-eclampsia, and stillbirth:
- Anti-phospholipid Antibody Screen
- ANA – looking for evidence of an autoimmune, inflammatory condition, known as “Lupus”
- Thrombophilia Screen – increasingly the evidence suggests that this testing is unhelpful in this setting. It is expensive, and not covered by Medicare, and as some testing is for genetic conditions, it is important to understand that a positive result may have implications for your future, such as affecting life insurance and insurance premiums.
Booking Bloods and Other Tests:
It is helpful to perform routine pregnancy booking blood tests for when you do conceive, including:
- Blood Group and Antibody Screen
- Full Blood Count
- Ferritin (iron) level
- Screening for: Rubella, Syphilis, Hepatitis B, Hepatitis C, and HIV.
A mid-stream urine sample, is also advisable, to screen for urinary infection.
I also recommend screening for –
- Chickenpox (Varicella), Parvovirus (“Slap Cheek”), and sometimes CMV and Toxoplasmosis
- Vitamin D levels
- Thyroid function tests
Testing for hereditary conditions, such as cystic fibrosis, is not performed as a matter of routine, but such testing is available and I am happy to refer you for it at your request.
Pelvic Ultrasound: A pelvic ultrasound is a helpful baseline test to tell us that the anatomy of your pelvis is normal. It is important to have your ultrasound in a practice that specialises in gynaecological ultrasound. Going to a general imaging practice is certainly cheaper but the quality of the scan and the resulting report may not be worth the saving.
Sonohysterogram: This is a special (but painful) ultrasound scan where fluid is injected through the cervix, into the womb, to ensure that cavity of your womb is normal (ie no polyps, septum or adhesions).
Hy-Co-Sy: This is a special (but painful) ultrasound scan where fluid is injected through the cervix, into the womb and tracked on ultrasound to ensure that your fallopian tubes are not blocked.
Semenalysis: This is an important test to ensure that your partner’s sperm is normal. For best results it should be performed in a centre that specialises in sperm testing.
Treatment
If you have not been successful within twelve months of trying to conceive it is time to consider whether there is an underlying cause. For women over the age of 35 you may want to start investigating after just 6 months.
Procedures
Laparoscopy
Endometriosis is an inflammatory condition that can be diagnosed and treated with laparoscopy. Laparoscopy is a keyhole surgical procedure, performed under general anaesthetic. It is best performed by someone who sub-specialises in keyhole surgery, so if you need a laparoscopy I will refer you to a keyhole surgery sub-specialist colleague. If endometriosis is found at laparoscopy it can be removed surgically at the same time. And this will increase your chance of conceiving.
IVF
I am not a fertility specialist, so if there appears to be a fertility issue I shall discuss with you whether you would consider a referral for IVF. IVF is difficult. It is expensive and both physically and emotionally demanding. It can put a serious strain on relationships, and on finances.
IVF is, however, very successful in helping couples to conceive who have been unsuccessful by other methods. If you do decide to pursue IVF then you have a choice between small, “boutique” fertility specialists and large, “corporate” style fertility organisations. The small providers tend to provide more personal, individualised service, but do not necessarily have access to the very latest technology.
The big IVF groups, on the other hand, seem a bit more like a production line, but have the very latest technology in an area where the science is constantly being refined. I have colleagues I refer to within all the different groups, and will discuss this with you if the need arises.
Egg Donation
If IVF is not successful then another option is IVF with egg donation. This is an expensive option, but does allow you to carry a pregnancy yourself, and is the final fertility option for some women.
There is an international register, however it is often cheaper to go overseas for treatment, such as to South Africa or Hawaii. There are also donor egg programs in Spain and Greece.
Miscarriage
Miscarriage is surprisingly common – around 15-20% of all recognised pregnancies. This increases to over 40% by age 40. Healthy lifestyle, avoidance of cigarettes or alcohol, and a pregnancy supplement, such as Elevit or In Natal may help. When you do conceive, I recommend an early pregnancy ultrasound scan in my rooms at around 8 weeks, to check that the pregnancy is progressing normally.
Recurrent Miscarriage
Recurrent miscarriage is technically three consecutive miscarriages. Current guidelines recommend not testing until this has occurred, but in practice no women wants to wait that long, so I often start investigations after two miscarriages. It is important (and reassuring) to know that the chance of a normally progressing pregnancy even after two miscarriages is very high, and for that reason I do not usually recommend testing at all after a single miscarriage.
If I do start investigations I usually check for antiphospholipid antibodies. The disadvantages of this approach are that it can be expensive, and the treatment guidelines are based on women who test positive and have had three miscarriages. Those benefits do not necessarily apply after two miscarriages. If I perform a curettage following miscarriage, also known as D&C or ERPC, I can send tissue for MLPA or chromosome testing, which may help explain the cause of miscarriage.
Costs
Consultations
Your first visit (45-60 minutes) is $425
Each subsequent visit (15-30 minutes) is $250
Pathology Fees
- The cost of the Pap smear with Thin Prep is around $60 if you have a Medicare card
- The cost of the vaginal swab test is around $100
- The cost of Day 1-2 testing is: around $300
- The cost of Day 12-13 testing is: $200
- The cost of Day 21 testing is: $120
- The cost of general pre-pregnancy testing is: $400
- The cost of thrombophilia testing is: $800
- The cost of glucose tolerance and insulin resistance testing is: $350
- The cost of MLPA testing is: $150-$250
Sperm Testing
The cost of the sperm testing is $350-$450
Ovulation Kit Testing
The cost of the home urinary ovulation kits is around $50 for a pack of 10 from most pharmacists.
Ultrasound Fees
The cost for the pelvic ultrasound is $350, for sonohysterogram is $450 and for Hy-Co-Sy is $550.
Privacy Policy
I may need to consult with colleagues regarding aspects of your care, in which case it may be necessary to disclose your personal details. If you have any particular details which you do not wish me to disclose then please let me know.
I hope you to achieve a successful pregnancy. Remember to see me at 8 weeks for a dating scan.
Dr Rahul Sen