Sunday 21 October 2018

What fertility tests can you trust and when should you take them?

It has long been looked to as one of the key indicators of fertility in women, but a recent study has thrown the reliability of testing for the hormone AMH into doubt. So what are the fertility tests to trust? Who should be taking them, and when? Jessie Collins weighs up the options

There are several ways to get indicators about your fertility
There are several ways to get indicators about your fertility

We've all heard the stories (though some seem to veer close to urban myths) - the couple who were diagnosed as infertile naturally and magically, nine months later, welcome a bouncing new baby. Or the woman who was told she had next to no eggs yet finds herself conceiving naturally within months of meeting Mr Right. However, new research published in the Journal of the American Medical Association could provide answers, and has been welcomed by many as a possible reset to the long-held ideas about how fertility is judged.

What is fertility testing and how does it work?

There are several ways to get indicators about your fertility. The most simple and basic test for women is an AMH test. AMH, or anti-Müllerian hormone, is secreted by growing follicles, the sacs that house each egg, so is a good indicator as to the health of an ovary. It is a simple blood test that can give you results within days.

The second medical marker for women is their FSH level. FSH, or follicle stimulating hormone, is what is responsible for developing an egg in a woman's menstrual cycle. It works on a positive and negative feedback system so if a woman is producing lots of eggs, the FSH level will be low; if they are running low on eggs, their FSH is going to be higher as the ovary will be sending a signal for more FSH, for more of a stimulation package. The FSH level in menopausal women and women in their 70s and 80s is typically high, and so is one of the core blood tests for discover whether you are menopausal or not.

For men, the tests are still fairly rudimentary, in that it is a sperm test. In the instances of a clinical testing this involves taking a semen sample and examining it at microscopic level, measuring the quantity of sperm and also their shape, their functionality and mobility. Home testing involves a more simplified look at the mobility of the sperm, or their numbers, but it will not be able to determine their quality.

A wider diagnosis

Beyond the first level of testing, as in blood and semen tests, if you go to your doctor or a specialist for a complete fertility check-up you will more then likely also be getting several other insights. Most clinics also test for TSH (thyroid stimulating hormone), an excess of which can cause high levels of the prolactin hormone. Prolactin is the hormone produced to promote breastmilk, and too much of it can prevent a woman ovulating altogether.

Your GP and a fertility specialist will take a full medical history, and take your lifestyle and general health into account, something Dr Declan Keane of Repromed says is the most important part of looking at your fertility fitness.

"Almost 70pc of the information we need is based on taking a history: Have you been pregnant? What medicines you are taking? What surgeries have you had? And information about a woman's menstrual cycle."

So what's new?

A woman's AMH level has historically and widely been held as the key indicator of her reproductive health, but new research published in the Journal of the American Medical Association has thrown that very much into question. The study followed 750 women between the ages of 30 and 44 who had been trying to conceive for three months or less and found that during the 12-month trial, those with low AMH values were not less likely to conceive than those who had normal AMH values. It has thrown the validity of AMH testing, specifically the hormone looked for in any home fertility testing kit, into question.

Quantity Versus Quality

"AMH has been popularised as this blood test you can do which tells you if you are fertile or not," explains Dr John Kennedy of SIMS IVF clinic in Dublin.

"No, it doesn't. AMH is not a marker of your egg quality, and your egg quality is the biggest indicator of your fertility. It is a marker of your egg quantity, of how many apples you have left. The theory was that as you run out of apples, the proportion of good to bad apples changes, so if your AMH is low then maybe you've got a diminished quality as well.

"What we have determined, though, is that there are loads of people walking round with no issues getting pregnant, who are completely fertile with low AMH. Your AMH doesn't tell you if you can get pregnant or not; age and history are much more important indicators of that."

Dr Keane agrees, saying: "I've met people in our clinic where words like barren have been used to them, even from their GP, so many of them will go for donor eggs, but actually 2pc to 5pc of them will get pregnant even when their AMH limits are below the lowest level that the machine can detect, because you still have eggs in there."

What determines a 'normal' AMH level is also something very specific to what region you are being tested in.

"The population in Asia will have a different AMH reference range to those in New York," explains Dr Keane, "or in Ireland as it is something very specific to each region."

AMH can be useful for diagnosing polycystic ovaries, but it is mostly useful for diagnosing the general health of the ovary and also in predicting someone's possible response rate to follicle stimulation, says Dr Keane.

"AMH also tells me how loudly the clock is ticking. You could be 28 with a lovely AMH but it doesn't tell me anything about you, you could still have polycystic ovaries, you could be not menstruating. In isolation it's no good. That's the vulnerability of AMH on its own."

Who Should be Getting Tested?

An AMH test, says Dr Kennedy, will do two things.

"It can instruct and direct me on dosages and protocol to use when someone is going through a fertility treatment. The second thing from a patient perspective is if your AMH is low then you need to be more proactive about your fertility because statistically you are more likely to run out of eggs at a younger age then your peers. Where people get confused is that they take an AMH as a diagnostic test, it isn't. It's a screening test. It maybe points you in a general direction but it is not a diagnostic test."

Dr Keane concurs. "If you have been offered a job and you are thinking 'I really need to put off having kids for a few years' and you want to know how loudly the clock is ticking, then an AMH test is useful. If you run out of eggs, we can't fix that. I would be one of those people calling for early testing - if you have periods, you presume you've loads of eggs. But let's say you are 28 and you have a low AMH, you might want to freeze your eggs, or maybe not put off motherhood as long as you might have."

The same goes for men. "With a sperm sample it's the same, if you are infertile it doesn't mean you don't have to wear a condom, condoms are a part of general health practice. Maybe look at your diet and your lifestyle."

"I would love to see AMH being done on younger women," says Dr Kennedy, "and if it's normal, fine, go off and live your life. And if it isn't, don't panic, it may mean that leaving it later might not be an option. You need a robust system for discussing those results. Avoiding getting the wrong information is key."

Future hopes and threats

Given that quality is key, it is frustrating that it's the one thing they can't test for.

"The best indicator of egg quality," explains Dr Kennedy, "is a birth, a child, which is little compensation to those trying. The other best indicator is IVF. What most people don't understand is that IVF, the process of taking eggs out and combining them with sperm to make embryos, is telling me as much about the kind of embryos a woman and a couple can make."

However the are developments, particularly in biomedicine that may offer future hope.

"There are loads of biomarker tests now coming out to get a read on the quality of eggs but the problem is that anyone doing these tests is a guinea pig for them. They are expensive and unproven at the moment. But down the line they could be incredibly valuable. I could do a blood test, almost like Gattica, and the next day be able to tell you the percentage likelihood of you having a baby in the next year, but we are way off that."

It's easier to test the quality of sperm, adds Dr Kennedy, and the same genetics testing applying to women are being looked at for men. "We know men hold their fertility longer then women do, but as time goes by we are learning that male age does have a bigger role then we previously thought. The statistical likelihood does seem to see it dropping as you get older."

One of the biggest threats to male fertility, says Dr Keane, is obesity, and bad diet, with men's sperm rate having dropped almost by half in the western world over the last 40 years, this could be a significant issue.

"Obesity is a huge problem here, and diet. We have too much meat - fishy diets are better. As us guys get fat, it really affects our fertility hormones, it decreases quality and quantity of sperm. We now have more research coming out to show that in men with poor diet, the genetic material can often also not be packaged properly. The faultier the sperm packaging, the harder it is to get a healthy egg. And there now even links perhaps to the faulty packaging of genetic material contributing to autism. The reality is the health of your sperm is also a predicator to your longer-term health."

THE HOME TEST KITS

Depending on what fertility kit you use, you are only getting a part of your reproductive picture, and it is recommend that you go to your GP if you are concerned.

"Doing the test alone will give you a result," says Dr Keane, "but it doesn't take any of the other factors into the equation."

That said, there are quite a few options available, of varying prices and functionality.

■ Female Hormone Test by Lets Get Checked, €120, Letsgetchecked.com

This tests for FSH, Lutenising Hormone (LH, acute rises of which cause women to ovulate), Prolactin and Estradiol (the strongest of the three estrogen hormones). You collect a blood sample by pricking your finger before sending it off to be tested. Results are usually turned around within 10 working days, and you can access them online.

■ AMH Home Test, €120, Webdoctor.ie

Again this is a blood test you do at home and send off your sample for analysis; however, you do get an online consultation with a doctor as part of the package.

It states that an AMH test can be done at any time in your cycle, something Dr Kennedy refutes. "I could check your AMH three times across the month, and it could totally vary - you have to be very cautious about how you interpret the results."

■ FertilCheck by Babystart, €21.99, Inhealth.ie

This tests for FSH concentration in urine and contains two tests. If both test results are positive, it says, it is an indicator of reduced fertility.

■ SpermCheck Fertility Home Test for Men, $39.99, Spermcheck.com

There are far fewer options for male home testing; this one, from the US, promises results in just 10 minutes, and to be as accurate as a lab test.

However, the issue with home testing kits for men, says Dr Keane, is that they are not looking comprehensively at the sample.

"If you do a home test it will go a different colour but it doesn't tell you the quality; if you test for the emissions from the tail to see how they are swimming, it doesn't test for the quantity. It's a poor indicator.

"A lot of people are coming in with a good positive sperm test and we are looking at it on the microscope and saying no way, this is a bad sperm sample."

CLINICAL TESTING

■ Sims IVF 'His & Hers' fertility test, €300 for a couple, €160 for women, €150 for men - this tests for AMH, Thyroid Stimulating Hormone and Prolactin hormone, and provides a semen analysis. The tests are performed in a single visit, followed up by a scheduled phone consultation with one of their consultants, with test results issued to you and your GP within 10 working days. Sims.ie

■ Repromed Vhi Health Fertility Benefit Package - repromed are the only fertility clinics here recognised by VHI Health so you can access both fertility testing and IVF through your VHI plan. Individual testing for AMH within a plan comes in at €50, as does semen testing, with an initial consultation costing €50. Repromed.ie

■ Merrion Fertility Clinic Fertility Check, €400 for a couple - they also offer a complete couples' package, with semen analysis, an ultrasound scan, AMH blood test, rubella blood test and a consultation. They also offer individual hormone testing and semen analysis. Merrionfertility.ie

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