Standard medical textbooks define infertility as the “failure to conceive following one year of unprotected sexual intercourse.” For young and healthy heterosexual couples having frequent intercourse, about 85 per cent will be pregnant after one year of trying and about 93 per cent will be pregnant after two years of trying to conceive. While this is the “classic” definition of infertility, you may label yourself as infertile if there is “failure to conceive following one year of unprotected intercourse if under 35 years of age or six months if over 35.”
You should approach a fertility unit for help if the female partner is.
– Under 35 years of age and trying for more than 1 year.
– Between 35 and 39 years and trying to conceive with adequately timed intercourse for a period of 6 months or more.
– 40 years or more and attempting a pregnancy for 3 months or more.
We do this because we recognize that female age is one of the most important predictors of subsequent conception.
When female age is a factor, moving more aggressively towards completing the evaluation and initiating treatment can help to maximize the chances of pregnancy.
At the beginning of the menstrual cycle, an egg begins to develop in the ovary. After approximately two weeks of growth, the egg is released or “ovulated”. Following ovulation, the ovary produces the hormone progesterone to prepare the lining of the uterus for implantation of the embryo (baby).
After ovulation, the egg survives for approximately 24 hours. Which means that a woman can get pregnant only once in the month. Therefore, it is extremely important to ascertain the time of ovulation.
There are various methods for detection of ovulation. The following are a few:
– Basal body temperature charts are an inexpensive means of ovulation detection but are inaccurate.
– Ovulation can now be predicted by at-home kits that measure luteinizing hormone (LH) in the urine.
– Midluteal phase (a week before menses) measurement of serum (blood) progesterone concentrations remains the simplest and most accurate method of detecting ovulation.
– Serial pelvic ultrasounds (follicle study) are currently the most accurate noninvasive method of ovulation detection. But even ultrasound is not the perfect test due to the variable ultrasonic appearance of the ovary after ovulation and documentation of retained oocytes in follicles that have collapsed on ultrasound.
In the beginning of the menstrual cycle (cycle days 1-5), the pituitary gland in the brain secretes Follicle Stimulating Hormone (FSH) to stimulate to ovaries to select and grow an egg for the cycle. Measuring the levels of FSH and Estradiol (estrogen) on cycle day 2 or 3 (first day of FLOW is cycle day 1) provide us with an assessment of the quality of the eggs. Newer tests like Inhibin B may be suggested for a few patients.
In case you are not ovulating, there are various tablets and injections, which can help to make your eggs grow. However, you have to be monitored with the help of follicle studies to assess the growth of the eggs and detect the day of ovulation.
The following are a few ways to evaluate the status of the Fallopian tubes:
- A hysterosalpingogram (HSG) is an X-ray test that determines whether there is a blockage in the fallopian tubes, which would prevent the union of a sperm and egg. It may also be used to detect irregularity or scarring of the lining of the uterus. The HSG is performed between the 8th and 10th day of the period to make sure that you are not pregnant during the procedure.
- The test involves lying on an X-ray table, in the same manner as for a routine pelvic examination. A small catheter is placed snugly in the cervix. The catheter is connected to a syringe that contains the HSG ” dye”. It is this dye that shows up on the X-ray.
- An HSG takes 5-10 minutes to perform and may have some cramping associated with it, but it is not necessary to miss work. You may take an analgesic an hour or two before the procedure if desired.
- A sonosalpingography is similar to the HSG, but is done with the help of saline (instead of dye) and sonography (instead of X-ray).
- Laparoscopy is the direct visualisation of the pelvis (inside of lower abdomen), with the help of a scope and camera. This procedure is routinely done as a day care procedure at our centre. (Insert image) A number of fertility related procedures can be done with the help of Laparoscopy, including treatment of cysts, endometriosis, opening of tubes etc.
Certain kind of blocked tubes can be corrected with the help of a surgery, which may be performed laparoscopically. In other conditions, we have to consider by passing the tubes with the help of IVF.
Sperms are evaluated by a simple semen analysis which is the measurement of 4 different properties of a single ejaculate:
- Volume is the amount of the ejaculate measured in cc’s.
- Count is the concentration of sperm, measured in million of sperm/cc.
- Motility is the percentage of sperm that are moving, i.e. living.
- Morphology is the percentage of sperm that are normal in shape
The “normal” values for these parameters are greater than 2cc in volume, 20 million/cc in concentration, 50% motility, and 50% normal morphology. The presence of white blood cells in the semen may indicate an infection of the prostate or urethra, even if no symptoms are present.
At our centre, we insist on abstinence of 2 to 5 days in order to evaluate the semen accurately. The collection can be done by masturbation and the sample should be collected in the container provided by the centre. For the comfort of our male patients, we provide a comfortable collection room, offering complete privacy. In case you wish to collect the semen at home, it must reach the centre within half an hour.
If the semen analysis is persistently abnormal, a urological exam, more specific sperm testing and hormonal testing are recommended. The urological examination by our andrologist, will check for the presence of anatomical abnormalities (varicocele, congenital absence of the vas deferens). More specific sperm testing might include more stringent morphology testing (Kruger morphology), or testing for the presence of white blood cells or antibodies. Hormonal testing includes measurement of Prolactin, FSH and Testosterone.
Depending on the quality of the sperm you may be offered an IUI (intra uterine insemination) or ICSI (Intra cytoplasmic Sperm Injection).