Essential Pre-IVF Tests Every Patient Needs

After adhesiolysis we give a combination of estrogen throughout the cycle and progesterone added in the last 14 days, and it takes about 3 months for regeneration, confirmed with transvaginal sonography for endometrial thickness before and after. Many patients start to show improvement even after about a month and a half, where the scarring and adhesions are not so severe that they have permanently damaged the endometrium.

A lot of times when an HSG is done without sedation, the patient tenses up so much that there is a tubal spasm, which can appear as a bilateral proximal tubal blockage. One good approach is to give the patient an anti-spasmodic before the procedure, or do it with a little sedation, which removes many of these false positives. But if it still appears to be a genuine proximal blockage in both tubes, it's better to go directly for a diagnostic hysterolaparoscopy with chromopertubation, since that lets you directly visualise the tubes — and most patients also find repeating an HSG very painful.

Success rates of IVF in good centres are now around 60%. Cost depends on the kind of IVF procedure required — sometimes an ICSI procedure, sometimes donor eggs are needed — but it would typically start around 3 to 4 lakh rupees, roughly $3,200 to $4,500 per cycle.

There isn't a specific size used as a strict benchmark — even small fibroids can require removal if they are causing a cornual blockage, and submucous fibroids or polyps will usually require removal regardless of size. But anything bigger than roughly the equivalent of a 12–14 week pregnant uterus is a very large fibroid that definitely requires removal. On medical management: GnRH antagonists such as elagolix are used to help shrink fibroids, as are GnRH analogues/injections like leuprolide, which reduce the size of the uterus. However, submucous fibroids — the main culprits behind infertility — often will not respond well to medical management.

We need a good, plush endometrial lining, and if it isn't good we have medicines that can improve it. For example, in a recent case of severe intrauterine adhesions from a missed abortion managed elsewhere, the endometrial thickness was under 1mm in places and completely scarred. We did adhesiolysis and then gave a combination of estrogen and progesterone — estrogen helps regenerate the endometrium. It takes about 3 months for regeneration, though outcomes depend on how bad the scarring is; in some patients with very severe scarring we may not be able to regenerate a good lining at all.

A transvaginal sonography reveals uterine size and shape, endometrial thickness, submucous fibroids, polyps, adhesions, ovarian volume and antral follicle count, giving a comprehensive picture of reproductive anatomy before IVF.

A three-dimensional transvaginal sonography is preferred where available, or a good-resolution two-dimensional scan if not, performed on day two or three of the patient's cycle.

There are three categories of bare essential testing: one relating to the fallopian tubes, one relating to ovulation, and one relating to uterine problems via sonography, each addressing a different potential cause of infertility.

Because patients often see their GP before a fertility specialist, a GP ordering a transvaginal sonography in advance makes the fertility specialist's job considerably easier and helps kickstart infertility care sooner.