• In general, infertility is defined as not being able to get pregnant (conceive) after one year of unprotected intercourse.
• As aging occurs, egg number, egg quality, and the likelihood of an egg being genetically normal, decreases. Therefore we recommend a fertility evaluation if a couple has been attempting pregnancy for 6 months or more when the woman is 35 years of age or older.
• A woman’s body must release an egg from one of her ovaries (ovulation).
• A man’s sperm must join with the egg along the way (fertilize).
• The fertilized egg must go through a fallopian tube toward the uterus (womb).
• The fertilized egg must attach to the inside of the uterus (implantation).
• Infertility may result from a problem with any or several of these steps.
• No, infertility is not always a woman’s problem. Both men and women can contribute to infertility.
How do you find the cause of Infertility?
• History and physical examination – First and foremost, a very thorough medical and fertility history will help us design a specific evaluation and potential treatment for you. In addition to a careful history, a physical evaluation may also be performed.
• Transvaginal Ultrasound – Ultrasound is an important tool in evaluating the
structure of the uterus, tubes, and ovaries. Ultrasound can detect uterine
abnormalities such as fibroids and polyps, distal fallopian tube occlusion, and
ovarian abnormalities including ovarian cysts.
Additionally, transvaginal ultrasound affords the opportunity for your physician
to assess the relative number of available eggs. This measurement is called
the antral follicle count and may correlate with fertility potential.
• Laboratory Testing - The most common of these tests include measurements of blood levels of certain hormones such as estradiol and FSH, which are related to ovarian function and overall egg numbers; TSH, which assesses thyroid function; and prolactin, a hormone that can affect menstrual function if elevated.
• Hysterosalpingogram (HSG) – This test is essential for evaluating fallopian tubal patency, uterine filling defects such as fibroids and polyps, and scarring of the uterine cavity (Asherman syndrome). Many uterine and tubal abnormalities detected by the HSG can be surgically corrected.
The semen analysis is the main test to evaluate the male partner. Infertility in men can be caused by different factors and is typically evaluated by a semen analysis. When a semen analysis is performed, the number of sperm (concentration), motility (movement), and morphology (shape) are assessed by a specialist. A slightly abnormal semen analysis does not mean that a man is necessarily infertile. Instead, a semen analysis helps determine if and how male factors are contributing to infertility
What increases a man’s risk of infertility?
• Age. Although advanced age plays a much more important role in predicting female infertility, couples in which the male partner is 40 years old or older are more likely to report difficulty conceiving.
Disruption of testicular or ejaculatory function
• Varicoceles, a condition in which the veins on a man’s testicles are large and cause them to overheat. The heat may affect the number or shape of the sperm.
• Trauma to the testes may affect sperm production and result in lower number of sperm.
• Unhealthy habits such as heavy alcohol use, smoking, anabolic steroid use, and illicit drug use.
• Use of certain medications and supplements.
• Cancer treatment involving the use of certain types of chemotherapy, radiation, or surgery to remove one or both testicles
• Medical conditions such as diabetes, cystic fibrosis, autoimmune disorders, and certain infections may cause testicular failure.
Hormonal disorders
• Improper function of the hypothalamus or pituitary glands may result in low or no sperm production.
Genetic disorders
• Genetic conditions such as a Klinefelter’s syndrome, Y-chromosome microdeletion, myotonic dystrophy
What are the advices for semen collection for lab testing?
• Answer: The quality of the semen analysis is highly dependant on the method of collection. The ideal number of days to wait after sex to give a semen analysis is three to five days. Giving a semen analysis in less than three days after an ejaculation produce a small volume low count semen sample.
• Collection at the laboratory with specified container is recommended for accuracy.
• The actual technique for the collection of the sample is very important.
• The best way to obtain a sample is through masturbation. It is the easiest way to collect the entire ejaculate into the sterile collection container.
• It is very important to collect the entire sample, especially the first part of the ejaculate as it contains most of the sperm.
• Please do not use any lubricants, lotions, gels, etc for the collection of the sample as these items will alter the sample.
• The specimen must be kept at room temperature and promptly brought to lab within 30-40 minutes.
• Sperm samples can be adversely affected by heat, air- conditioning and extreme temperatures.
• It is best to keep sample near body temperature on the way to the office and this can be achieved by placing sample cup in between your legs.
COLLECTION CONDOM OPTION:
• If collection by masturbation is not the preferred method, you may also use a sterile collection condom.
• This method will allow you to collect your sample during normal intercourse.
• It is important that the whole sample be contained within the condom and then placed in the sterile collection container.
• Do not attempt to remove sample from condom, simply place condom into container.
• Be careful not to place condom in container so that the sample may leak from condom all over container.
• Try to place condom where the sample is isolated in the tip of the condom where it will remain through your transport of the sample.
• The specimen must be kept at room temperature and promptly brought to lab within 30-40 minutes.
• Sperm samples can be adversely affected by heat, air- conditioning and extreme temperatures.
• It is best to keep sample near body temperature on the way to the office and this can be achieved by placing sample cup in between your legs.
COLLECTION CONDOM INFORMATION:
For sperm collection through intercourse
• NON-SPERMICIDAL: Biologically inert polyurethane condom maintains semen motility and velocity. No mold releases or powders used in condom manufacture.
• PSYCHOLOGICALLY ACCEPTABLE: Allows sample collection at home and eliminates client stress traditionally caused by religious, cultural or emotional objections to masturbation or coitus interruptus.
• COMFORTABLE AND GENTLE: Ultra-thin polyurethane facilitates sensitivity and high sexual stimulation.
Each month, your body has a menstrual cycle where an egg is released from the ovaries. Ovulation is when the egg is released. Ovulation occurs (on average) 14 days before the start of your period. It’s normal for women to ovulate (release the egg from the ovaries) anywhere from 12-18 days before their period starts.
An egg is available to be fertilized by a sperm for only 12-24 hours, and at a given ovulation cycle, it is just one mature egg that is released.
This is the time to have an intercourse to get favorable results. Most women ovulate between day 11th and day 21st of the cycle, counted from the first day of the last menstrual period. However, this is not necessary, and many women may ovulate at different times or different day each month.
Most women ovulate between day 11th and day 21st of the cycle, however many women may ovulate at different times or different day each month.
This is why it is important to track your cycles and hence ovulation. One such method that is adopted by doctors is the transvaginal ultrasound follicular tracking or folliculometry.
What Is A Follicular Study?
Follicular tracking is a series of vaginal scans so as to precisely know when you are ovulating. Generally, these scans will start around day 9th of your cycle and continue till day 16th. The doctor will observe the follicle development occurring in your ovaries.
How Long Does A Follicle Scan Take?
The follicular tracking scan will generally take about 5 to 10 minutes, provided you are cooperative with the doctor.
How Many Scans Per Cycle Are Carried Out?
Because the ovulation window is wide, in each cycle about 4-6 scans will be required. The base line scan will help the doctor know the initial stage of the follicle, and from there the development will be closely followed.
The next scan will be scheduled accordingly. As the cycle progresses, the follicle growth and womb lining will be ascertained.
The scan will give a very clear picture of the developments happening and the right time of ovulation will be arrived at.
Is There Anything Else That Follicular Scan Can Help With?
Yes, as a fact, a follicular study will also detect some other issues that may impede a pregnancy. Some of them are:
• The thickening of the womb lining in conjugation with the follicular release
• Follicles that do not grow at all or do not rupture at the correct time
All these parameters help the doctor and you to know what and when things are happening, and what is not happening. It makes it easier to identify the problems and thus impart treatment or corrective measures.
What is ovulation induction treatment?
Inducing ovulation using medication (ovulation induction) allows an egg to mature and be released by the ovary. The cycle is tracked with blood tests and ultrasound, to confirm the best time to conceive.
Ovulation induction medication
There are two types of medication used to induce ovulation: tablets (oral medication) or daily injections of Follicle Stimulating Hormone (FSH). If you are having ovulation induction at the same time as IUI treatment, either type of medication is suitable.
Is ovulation induction right for me?
Ovulation induction may be the best choice if you:
• don’t have a regular cycle
• don’t have periods at all (in premenopausal patients)
• have healthy tubes
• have unexplained infertility.
• Intrauterine insemination (IUI) is the placing of sperm into a woman’s uterus when she is ovulating.
• IUI is often used to treat
• Mild male factor infertility.
• Couples with unexplained infertility and women with cervical mucus problems.
Insemination is performed at the time of ovulation, usually within 24-36 hours after the LH surge is detected, or after the “trigger” injection of hCG is administered. Ovulation is predicted by a urine test kit or ultrasound.
What is the process of IUI?
In the case of husband insemination, the male partner produces a
specimen, at doctor’s office. The sperm is then prepared for IUI.
Sperm from the male partner are “washed” or separated. Separation
selects out motile sperm from the man’s ejaculate and concentrates them
into a small volume.
Sperm washing cleanses the sperm of potentially toxic chemicals which
may cause adverse reactions in the uterus. The doctor uses a soft catheter
that is passed through a speculum directly into the woman’s uterus to
deposit the semen at the time of ovulation.
IUI may be used in conjunction with ovulatory medications and careful
monitoring is essential. Monitoring includes periodic blood tests and
ultrasounds beginning around day 6 of the woman’s cycle.
IUI can also used with specially prepared donor sperm, if indicated and if
consented by the couple. The sperm bank provides the sperm that is
already prepared for IUI.
IUI is a relatively quick procedure and is performed in the doctor’s office
without any anesthesia. It should not be painful, although some women
report mild discomfort.
A complete examination of a woman’s internal pelvic structures can provide
important information regarding infertility and common gynecologic disorders.
Frequently, problems that cannot be discovered by an external physical examination
can be discovered by laparoscopy and hysteroscopy, two procedures that provide a
direct look at the pelvic organs.
These procedures may be recommended as part of your infertility care, depending
on your particular situation.
Laparoscopy and hysteroscopy can be used for both diagnostic (looking only) and
operative (looking and treating) purposes.
Diagnostic laparoscopy may be recommended to look at the outside of the uterus,
fallopian tubes, ovaries, and internal pelvic area.
Diagnostic hysteroscopy is used to look inside the uterine cavity.
If an abnormal condition is detected during the diagnostic procedure, operative
laparoscopy or operative hysteroscopy can often be performed to correct it at the
same time, avoiding the need for a second surgery.
OPERATIVE LAPAROSCOPY
During operative laparoscopy, many abdominal disorders can be treated safely through the laparoscope at the same time that the diagnosis is made.
When performing operative laparoscopy, the physician inserts additional instruments such as probes, scissors, or grasping instruments.
Problems that can be corrected with operative laparoscopy include removing adhesions (scar tissue) from around the fallopian tubes and ovaries, opening blocked tubes, removing ovarian cysts, and treating ectopic pregnancy. Endometriosis can also be removed or ablated from the outside of the uterus, ovaries or peritoneum.
Under certain circumstances, fibroids on the uterus can also be removed. Operative laparoscopy can also be used to remove diseased ovaries and can be performed as part of a hysterectomy
Following operative laparoscopy, patients are generally able to return home the day of surgery and recover more quickly, returning to full activities in three to seven days.
Hysteroscopy is a useful procedure to evaluate women with infertility, recurrent
miscarriage, or abnormal uterine bleeding. Diagnostic hysteroscopy is used to
examine the uterine cavity, and is helpful in diagnosing abnormal uterine conditions
such as fibroids protruding into the uterine cavity, scarring, polyps, and congenital
malformations.
Operative hysteroscopy can treat many of the abnormalities found during diagnostic
hysteroscopy.
Operative hysteroscopy is similar to diagnostic hysteroscopy except that narrow
instruments are placed into the uterine cavity through a channel in the operative
hysteroscope. Fibroids, scar tissue, and polyps can be removed from inside the
uterus. Some structural abnormalities, such as a uterine septum, may be corrected
What is hysterosalpingography (HSG)?
Hysterosalpingography (HSG) is an X-ray procedure that is used to view the
inside of the uterus and fallopian tubes.
It often is used to see if the fallopian tubes are partly or fully blocked. It also
can show if the inside of the uterus is of a normal size and shape. All of these
problems can lead to infertility and pregnancy problems.
During HSG, a contrast medium is placed in the uterus and fallopian tubes. This is a fluid that contains a dye. The dye shows up in contrast to the body structures on an X-ray screen. The dye outlines the inner size and shape of the uterus and fallopian tubes. It also is possible to see how the dye moves through the body structures.
When should HSG be done?
It is best to have HSG done in the first half (days 1–10) of the menstrual cycle. This timing reduces the chance that you may be pregnant.
What should I expect after the procedure?
After HSG, you can expect to have a sticky vaginal discharge as some of the fluid drains out of the uterus. The fluid may be tinged with blood. A pad can be used for the vaginal discharge. Do not use a tampon. You also may have the following symptoms:
• Slight vaginal bleeding
• Cramps
• Feeling dizzy, faint, or sick to your stomach
MD (AIIMS), DNB, FRCS
(UK)
MBBS, MS, DNB
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