Yesh Tikva
A Jewish Fertility Community
Fertility Roadmap
Module 2
Diagnostics
You overcame your fear and are finished with the first consultation. You are now ready to get to the root of the problem. Before you can get any answers, you and your partner will undergo diagnostic tests. If you did not have blood work completed prior to your initial consultation, both partners will likely have it drawn the day of your first visit. Additional blood work for the female may be needed on day 2 or 3 of the next menstrual cycle.
For some these diagnostic tests will be painless and relatively easy, while for others they may be more difficult and cause some physical pain. These tests will begin to give you the answers that you have been looking for. You may do some or all of these depending on the answers that are found and additional ones that may still be needed.
It is normal to be both nervous and relieved.
Self Check-In
Why is it important to check in with yourself?
Sometimes the whirlwind of life while balancing, family, friends, work, combined with fertility treatments prevents us from checking in and asking, “How am I doing in this moment?” We forget the most important person responsible for our well-being…ourselves. On an airplane, the cabin-crew instructs, in the case of an emergency place the masks on yourself before assisting others. It is imperative to focus on our own welfare, both physical and emotional, before we can extend care to others. Checking in with yourself allows time to process feelings during this difficult fertility journey. Put a sticky note on your desk, or set an alert reminding yourself to check in every day.
Try This: Put a sticky note on your desk, or set a daily alert on your phone reminding yourself to check in.
The coming sections will discuss the next phase of diagnostic tests. Keep in mind that your doctor may not prescribe all of these tests and if your doctor does they may not occur in this order.
What are the 4 tests?
Hysterosalpingogram (HSG)
The first consult is now behind you and the blood work done; the next step is a Hysterosalpingogram. Having a hard time saying the name? Most people call it an HSG. The primary goal of this test is to assess the health of the fallopian tubes.
An HSG is an x-ray procedure used to assess whether the fallopian tubes are patent (open) and if the inside of the uterus is normal. A radiologist, gynecologist or a reproductive endocrinologist (RE) will place a speculum in the vagina, clean the cervix and insert a catheter through the opening of the cervix, releasing an iodine based liquid dye into the uterus to allow for x-ray examination of the reproductive tract.
Contrast imaging is taken following the dye through the reproductive tract from the uterus into the fallopian tubes looking for blockages and abnormalities detected if the fluid movement is disrupted.
This is an outpatient procedure, usually takes less than 5 minutes to perform, and one can return to regular activities once it is done.
When to schedule your appointment:
This test must be done after you stop bleeding but before you ovulate (usually cycle days 5-9). To reduce pain and for clearest results it is ideal to schedule this test as close to the last day of your period as possible.
Bring along with you:
1. Come prepared with a pad or panty liner, there will be discharge and this procedure could cause some spotting.
2. An HSG usually causes mild to moderate cramping during the procedure and for a short time (5-10 minutes) following. Some may not feel any pain and others may have cramping for several hours after. Confirm with your Doctor prior to the visit what type of pain relief medication you are allowed to take. With your doctor’s permission, in order to reduce the chance of pain, take the pain relievers 45 minutes prior to the procedure.
A few more things to keep in mind:
1. An HSG is considered a very safe procedure, but as you know, all procedures have associated risks. These occur less than 1% of the time.
2. Though not common, if you have an iodine allergy make sure to inform your doctor before you schedule this procedure.
3. To reduce the chance of infection, typically when an abnormality is found with the fallopian tubes, most doctors will prescribe antibiotics. Some may advise to start taking a day or two before your scheduled HSG appointment. If you have a sensitive stomach, eat carbs before taking your medication to help reduce discomfort.
Note to self: This may not have been your ideal plan for expanding your family but, A BLOCKAGE IS NOT GROUNDS FOR PANIC! Some blockages can be cleared by the HSG, others can be cleared through a surgical procedure or with the help of In Vitro Fertilization (IVF), the blockage can be bypassed to achieve successful pregnancy {which will be explained later}.
For additional information you can visit the American College of Obstetrics and Gynecology and the American Society for Reproductive Medicine.
Step 1: How am I feeling right now?
Being able to name our feelings seems like an easy task, but how many times have you ever just stopped and took the time to identify your emotion? Most of us are not aware of how we are feeling and what impact it is having on our daily lives. Identifying and communicating, “I am angry, anxious, frustrated, ect.” reduces the intensity of our experience. Also notice emotions and situations that bring you comfort and a sense of safety. All your feelings are important! Labeling actually changes our brain and allows us to process emotions and make more conscious decisions.
After you identify your emotion, remember to validate those feelings, no matter how illogical you think they are.
NOTE TO SELF: All feelings are ok!! Sit with your uncomfortable feeling, without judgment, realizing that they are anticipated as this journey is fraught with a rollercoaster of emotions.
Hysterosalpingogram (HSG)
Sonohysterogram (SHG)
What it Diagnoses:
A sonohysterogram can be used to determine the causes of abnormal bleeding and recurrent loss. This ultrasound enables your doctor to closely examine your uterus, specifically the inside of it (uterine cavity), and to measure the depth, shape and size. The cavity is assessed for possible growths, such as fibroids or polyps, and other abnormalities such as adhesions, retained tissue from a recent miscarraige or other problems with your uterine lining. Sometimes an assessment of fallopian tube patency is done at the same time, but typically this is done separately, at the time of HSG.
When to schedule your appointment:
This test must be done after you stop bleeding but before you ovulate.
Bring along with you:
1. Come prepared with a pad, there will be liquid discharge and this procedure could cause some spotting or light bleeding.
2. Most people do not feel much, but some may experience cramping from this procedure. (It is typically less crampy than the HSG.) Confirm with your Doctor prior to the visit what type of pain relief medication you are allowed to take. With your doctor’s permission, in order to reduce the chance of pain, take the pain relievers 45 minutes prior to the procedure.
For additional information you can visit the American College of Obstetrics and Gynecology and the American Society for Reproductive Medicine.
Step 2: Be proud of what we have accomplished:
Begin by taking pride in all the milestones that you have achieved on this journey. Each step you take is a big accomplishment that took a lot of bravery and courage. Applaud yourself for persevering. There may be a lot yet ahead of you, but it is important to take stock of what you have already achieved and not only focus on what lays ahead.
Try to identify a few things that you have done right. Focus on what you have accomplished in relationships, marriage, professionally, and successes in daily living such how you are surviving a global pandemic and handling social distancing. Manage your expectations, and determine whether they are realistic or setting you up for failure.
Take note of your inner critic, the rule of thumb is, if you wouldn’t say it to a friend, then don’t say it to yourself. To counter that harsh, condemning voice, can you identify some areas of your life that are working or where you feel successful?
Hysteroscopy
Hysteroscopy is a procedure used to diagnose and treat uterine problems using a special instrument called a hysteroscope. A hysteroscope is a thin telescope attached to a camera that is inserted into the vagina, through the cervix and inside of the uterus. Typically a saline solution will be put through the hysteroscope into your uterus to expand it to enable your doctor to evaluate the uterine cavity.
This is an outpatient procedure that can be performed either in your specialist’s office or in the hospital. It is sometimes done under local anesthesia and other times with sedation. It is often done as a follow-up if an abnormality was found in the uterine cavity by HSG or SHG.
What it Diagnoses:
The most common issue that a hysteroscopy is used to diagnose is abnormal bleeding. Abnormal bleeding can refer to heavy, elongated, short or infrequent menstrual cycles, as well as bleeding in between cycles. Additionally, a hysteroscopy can be used to help diagnose the cause of recurrent miscarriage. The most common findings include polyps, fibroids and adhesions (scar tissue).
What it can Treat:
Inserted through the hysteroscope, surgical instruments can be used to remove adhesions, polyps, fibroids, as well as perform a biopsy.
When to schedule your appointment:
This test must be done after you stop bleeding but before you ovulate (typically cycle days 5-9). Your doctor may dilate your cervix prior to the procedure. If you are a mikvah user (link to Infertility and Halacha), it is helpful to schedule this appointment as close to the last day of your period.
Bring along with you:
1. Come prepared with a pad or panty liner, there will be discharge and this procedure could cause some light bleeding.
2. Many people experience cramping from this procedure. Confirm with your Doctor prior to the visit what type of pain relief medication you are allowed to take. With your doctor’s permission, in order to stay ahead of the pain, take the pain relievers 45 minutes prior to the procedure.
A few more things to keep in mind:
1. Complications from hysteroscopy occur in about 2 of every 100 cases.
2. Risks include bleeding, infection and damage to the uterus or surrounding organs, nerves and blood vessels. Severe complications are very rare.
3. To prevent infection you may be asked to take estrogen or antibiotics following the hysteroscopy.
For additional information you can visit the American College of Obstetrics and Gynecology and the American Society for Reproductive Medicine.
Step 3: Make a checklist of next steps:
Empower yourself. Take note of what you can and cannot control, focus on the items that are within your control. For example, a medical condition which causes infertility is not in your power, but focusing on making appointments and seeking out specialists is.
Always remember that you are your own best advocate. You are a partner in this process. It is ok to stand up for yourself and your needs. Do not be afraid to ask questions or to seek second opinions.
Laparoscopy
Laparoscopy, also referred to as minimally invasive surgery, is a surgical procedure in which a fiber-optic instrument called the laparoscope is used in place of invasive exploratory surgery. For the purposes of fertility diagnostics, these instruments are inserted through the abdominal wall via small incisions in the skin, with a small camera attached to view pelvic anatomy, including the uterus, ovaries, and fallopian tubes. Carbon dioxide gas is used to fill the abdomen to allow visualization.
This surgery is performed in a hospital or ambulatory surgery center. It is an outpatient procedure, though general anesthesia is used.
What it Diagnoses:
This procedure can help doctors diagnose fibroids and other structural abnormalities, adhesions, endometriosis, ovarian cysts and blocked fallopian tubes.
What it can Treat:
In some cases laparoscopy can also be used to treat the above issues. It can also be used to treat ectopic pregnancies.
Bring along with you:
Since a general anesthetic is used, you will need to bring a family member or friend to drive you home.
Note: Many people experience cramping and some discomfort from this procedure. Confirm with your Doctor what type of pain relief medication you are allowed to take and whether a prescription will be provided.
A few more things to keep in mind:
1. As with all surgeries, there are risks associated with laparoscopy. About 2 of every 100 may develop a complication, typically minor. The most common are bladder infections and skin irritation.
2. Adhesions may develop within the abdomen after the surgery.
3. Other risks include the risk of anesthesia, bleeding, infection and damage to the bowel, bladder, ureters, uterus, major blood vessels or other organs.
For additional information you can visit the American College of Obstetrics and Gynecology and the American Society for Reproductive Medicine.
How to do it:
1. Settle into a comfortable position, either sitting tall in a chair or laying down
2. You can open or close your eye
3. Put one hand on your belly just below your ribs and the other hand on your chest
4. Take several slow deep breaths: breathing in through your nose and out through your mouth
Notice which hand is moving ….the one on your belly or on your chest
5. NOW Take a deep breath in through your nose, and let your belly push your hand out. … hold it for a couple seconds.. then breath out through your mouth and let your belly flatten
6. If your mind wanders its ok, try to refocus on your breathing
Try this twice a day, taking 3-10 deep belly breaths.
Step 4: Take a deep breath:
Did you know that focusing on deep breathing reduces stress? But what does take deep breaths really mean?
Pause take notice of your breath see video for techniques you might try:
Belly breathing pulls more oxygen to the brain, which helps us regulate our emotions and make better decisions during stressful times. When we belly breath it slows down the amygdala, the emotion center of our brain, and increases the activity in the frontal lobes, our decision making center. When our brain is depleted from oxygen we can’t think straight, so breathing allows us to make better choices!
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