Introduction

Infertility is typically defined as the inability to achieve pregnancy after one year of unprotected intercourse.

You should consider seeing a doctor if you have been trying to conceive for a year or more. However, if you are 35 years or older, you should begin the infertility evaluation after about six months of unprotected intercourse rather than a year, so as not to delay potentially needed treatment.

Also, if you have a reason to suspect an underlying problem, you should seek care earlier. For instance, if you have very irregular menstrual cycles (suggesting that you are not ovulating or releasing an egg), or if you or your partner has a known fertility problem, you probably should not wait an entire year before seeking treatment.

If you and your partner have been unable to have a baby, you’re not alone. At least one out of seven couples has trouble conceiving. During this time, it is normal to experience feelings of frustration, jealousy, anger and stress. However, once you begin to explore your medical options, you’ll find that fertility treatments offer hope for a successful pregnancy.

The Initial Visit

Both you and your partner should try to attend the first meeting since infertility is a shared experience and is best dealt with as a couple. During this visit, you’ll begin to understand the degree of commitment and cooperation that an infertility investigation and treatment requires.   It is important that you communicate freely between each other as well as with your doctor.

Your doctor will review your history and ask you and your partner questions to help identify potential causes for your difficulty in conceiving. He or she will ask about the frequency and regularity of your menstrual period, pelvic pain, abnormal vaginal bleeding or discharge, history of pelvic infection, and medical illnesses. Expect questions concerning prior pregnancies, miscarriages, operations, and methods of contraception.

Your partner will be asked questions concerning prior genital injury, surgery, infections, drug and/or medication use, history of fathering other children, and medical illnesses. You’ll be asked how long you’ve been trying to conceive, how often you have sexual intercourse, and if anyone in either family has birth defects.

Your doctor will need to know the complete reproductive histories of you and your partner, including any former relationships. Since at least 25% of infertile couples have more than one factor causing infertility, it is very important to evaluate all factors that may affect both you and your partner.

A physical examination of you and your partner may follow the initial review. The occurrence and extent of the examinations will depend upon whether or not any factors impacting your fertility are found early in the evaluation. Then, you and your partner might undergo a series of tests. Sometimes this may require a significant amount of time and energy on your part, but the results are invaluable. These tests may include:

  • Hormone bloodtests: Testosteron in the male and Estrogen, Progesterone and FSH in the female partner. Other hormones possibly of influence include Thyroid hormone and Prolactine
  • A sperm test (semen analysis) of the male partner
  • Blood test for both partners to screen of sexually transmitted diseases and HIV
  • Possibly other tests, depending on any other symptoms that you may have. For example, an ultrasound scan and or x ray of the womb,

During the first visit, you may discuss the emotional stress of infertility, a subject that is often difficult for you to share with family and friends. You should always feel free to make your doctor aware of your concerns and frustrations and you should ask your doctor questions whenever you need clarification.

The Process of Conception

In order to understand the fertility tests and treatments you may be offered, it is important to understand how conception naturally occurs. First, your ovary must release (ovulate) an egg. This usually occurs once a month, approximately mid-way through the menstrual cycle. The egg must be picked up by the fallopian tube. Sperm must travel through the vagina, into the uterus, and up into the fallopian tube in order to fertilize the egg. The fertilized egg, or embryo, then travels down the fallopian tube to the uterus, where it implants in the uterine lining and develops (Figure 1). A problem in any part of this process can lead to infertility.

Fertility Factors

The Male Factor

In approximately 40% of infertile couples, the male partner is either the sole or a contributing cause of infertility. Therefore, a semen analysis, or sperm test, is important in the initial evaluation. To prepare for a semen analysis, your partner will be asked to abstain from ejaculating for at least 48 to 72 hours. The semen specimen is examined under a microscope to determine the volume (amount), motility (movement), and morphology (appearance and shape) of the sperm. In general, two or three semen analyses may be recommended over two to six months, since sperm quality can vary over time. Other hormonal and genetic tests may be recommended as well depending on the type and severity of abnormalities found.

Several factors may affect sperm production and male infertility:

  • Current or past infection of the testes.
  • Growth of the testes
  • Side-effects of some medicines and street drugs.
  • Certain hormonal problems.

Treatment for male factor infertility may include antibiotic therapy for infection, surgical correction of varicocele (dilated or varicose veins in the scrotum) or duct obstruction, or medications to improve sperm production. In some cases, no obvious cause of poor sperm quality can be found. Intrauterine insemination (IUI) may then be recommended.

The Ovulation Factor

Problems with ovulation are common causes of infertility, accounting for approximately 25% of all infertility cases. Ovulation involves the release of a mature egg from one of your ovaries. This usually occurs every month, about midway in your menstrual cycle. After ovulation, the ovary produces the hormone progesterone. During the 12 to 16 days before menstruation begins, progesterone prepares the lining of your uterus into an optimal environment for implantation and nurturing of the fertilized egg. If you have regular menstrual cycles, you are probably ovulating. Cycle lengths of approximately 24 to 34 days (from the beginning of one period to the beginning of the next period) are usually ovulatory. If you only have a period every few months or not at all, you are probably not ovulating or are ovulating infrequently.

In a normal cycle, progesterone levels are highest about seven days after ovulation. Your physician may perform a blood test to measure the level of progesterone in your blood at this time. Generally, blood progesterone is tested on day 19 to 23 of a 28-day menstrual cycle. An elevated progesterone level helps to confirm ovulation and the adequacy of ovarian hormone production.

If you are not ovulating, your doctor may order special tests to determine the reason and then prescribe certain drugs to induce ovulation. Your medical history and physical exam will help determine which tests are appropriate. Both oral and injectable medications are available to help induce your ovulation.

The Tubal Factor

Because open and functional fallopian tubes are necessary for conception, tests to determine tubal openness (patency) are important. Tubal factors, as well as factors affecting the peritoneum (lining of the pelvis and abdomen), account for about 35% of all infertility problems. A special x-ray called a hysterosalpingogram (HSG) can be performed to evaluate the fallopian tubes and uterus. During an HSG, a special fluid (dye) is injected through your cervix, fills your uterus, and travels into your fallopian tubes. If the fluid spills out the ends of the tubes, they are open. If the fluid does not spill out the ends, then the tubes are blocked.

If the tubes are found to be blocked, scarred, or damaged, surgery can sometimes correct the problem. But surgery does not guarantee that the tube, even if opened up or cleared of scar tissue, will function properly.

The Cervical/Uterine Factor

Conditions within the cervix, which is the lower part of the uterus, may impact your fertility, but they are rarely the sole cause of infertility. It is important for your doctor to know if you have had prior biopsies or surgeries of the cervix, or abnormal pap smears. Cervical problems are generally treated with antibiotics, hormones, or by IUI.

The HSG test, often used to investigate the fallopian tubes, can also reveal defects inside the uterine cavity, which is the hollow space inside your uterus where an embryo would implant and develop. An HSG is typically done after your period stops and before ovulation. Possible uterine abnormalities that may be identified include scar tissue, polyps (bunched-up pieces of the endometrial lining), fibroids, or an abnormally-shaped uterine cavity. Problems within your uterus may interfere with implantation of the embryo or may increase the incidence of miscarriage.

The Peritoneal Factor

Peritoneal factor infertility refers to abnormalities involving the peritoneum (lining of the surfaces of your internal organs) such as scar tissue (adhesions) or endometriosis, a condition where tissue that normally lines the uterus begins to grow outside the uterus. This tissue may grow on any structure within the pelvis including the ovaries and is found in about 35% of infertile women who have no other diagnosable infertility problem.

Endometriosis is found more commonly in women with infertility, pelvic pain, and painful intercourse. Endometriosis may affect the function of the ovaries, your ovarian reserve, the function of the fallopian tubes, as well as implantation..

The Age Factor

Fertility declines with age because fewer eggs remain in your ovaries, and the quality of the eggs remaining is lower than when you were younger. Blood tests are now available to determine your ovarian reserve, a term which reflects your age-related fertility potential. In the simplest of these tests, the hormones follicle-stimulating hormone (FSH) and estradiol are tested in your blood on the second, third, or fourth day of your menstrual period. An elevated FSH level indicates that your chances for pregnancy may be lower than routinely expected for your age, especially if you are age 35 or older. Abnormally high FSH levels do not mean that you have no chance of successful conception. However, they may indicate that success rates may be lower, that more aggressive treatment may be warranted, and/or that higher medication doses may be needed.

Older women tend to have a lower response to fertility medications and a higher miscarriage rate than younger women. The chance of having a chromosomally abnormal embryo, such as one with Down syndrome, also increases with age. Because of the marked effect of age on pregnancy and birth rates, it is common for older couples to begin fertility treatment sooner and, in some cases, to consider more aggressive treatment than younger couples.

Unexplained Infertility

In approximately 10% of couples trying to conceive, all of the above tests are normal and there is no easily identifiable cause for infertility. In a much higher percentage of couples, only minor abnormalities are found that should not be severe enough to result in infertility. In these cases, the infertility is referred to as “unexplained”. Couples with unexplained infertility may have problems with egg quality, fertilization, genetics, tubal function, or sperm function that are difficult to diagnose and/or treat. Fertility drugs and IUI have been used in couples with unexplained infertility with reasonable success.

Lifestyle

For both men and women a healthy lifestyle will contribute to your chances of conceiving.

  • Tobacco and alcohol are known to have a negative effect on the fertility of both men and women, as well as on the development of a fetus in pregnancy.
  • You have a reduced chance of conceiving if you are very overweight or underweight
  • Stress has been known to negatively influence libido in men, and the menstrual cycle in women.
  • In general it is advised to keep a healthy diet and have some regular physical exercise.

Vaginal douching

Vaginal douching is a commonly used method to wash out the vagina with water or a mixture of water and soap, dettol or other solutions. Douches that are sold in drugstores and supermarketsncontain antiseptics and fragrances.

Besides making them feel fresher, women say they douche to get rid of unpleasant odors, wash away mentrual blood after their period, avoid getting sexually transmitted diseases and prevent a pregnancy after intercourse. However, health experts say douching is not effective for any of these purposes. On the contrary, it can actually increase the risk of infections, pregnancy complications and other health problems.

Regular vaginal douching changes the delicate ballance of vaginal flora (organisms that live in the vagina) and acidity in a healthy vagina. These changes can cause overgrowth of bad bacteria which can lead to infection. Douching itself can push existing infections further up into the uterus, fallopian tubes and ovaries. Possible effects of vaginal douching include:

  • Vaginal infection (bacterial vaginosis) Which can increase the risk of preterm labor and endometriosis
  • Pelvic inflammatory disease (PID) An infection of the uterus, fallopian tubes and/or ovaries
  • Pregnancy complications  Women who douche more than once a week have more difficulty getting pregnant than those who don’t. Douching may also increase the risk of ectopic pregnancy (pregnancy outside the womb) by as much as 76%.
  • Cervical cancer  Douching at least once a week has been linked to a possible increased chance of developing cervical cancer.

It is strongly advised you should avoid vaginal douching. Having some vaginal discharge is normal however, if you noticea very strong odor, it could be a sign of infection. The acidity of the vagina will natually control bacteria, and simply washing the outside of the vagina with warm water and mild soap is enough to keep clean.

Fertility Treatment

Sometimes the factors affecting your fertility are easy to detect and treat, but in many cases a specific reason for infertility may be difficult to identify. After a full evaluation, your physician can give you a reasonable idea of your chances of achieving pregnancy with various treatment options.

Possibilities for treatment are:

  • Ovarium stimulation and Ovulation induction.  A hormonal treatment with which the menstrual cycle is regulated   and ovulation will be either detected with LH tests or induced with medicines
  • IUI, Intra Uterine Insemination.  This is a procedure in which processed sperm is placed directly high in  the uterus.
  • IVF, In Vitro fertilization. This technique involves fertilization of an egg cell outside of the body after which an embryo is transferred into the uterus.

The choice of which treatment to pursue, if any, is strictly a personal one. Side effects, costs and expected success rates are important factors to consider when choosing a treatment plan.

It is helpful when beginning fertility treatment to develop a long-term plan with your doctor so that you will have an idea of how long to pursue a particular treatment before moving on to more aggressive therapy or stopping treatment. Each couple has a unique set of circumstances, and the chances of treatment success vary widely.

Your initial treatment may provide additional answers as to the cause of your infertility. It is therefore important to continually re-evaluate your plan by discussing treatment results with your doctor.

Psychological Implications

Infertility is a medical condition that has many emotional aspects. Feelings such as anger, sadness, guilt, and anxiety are common and may affect your self-esteem and self-image. You may find it difficult to share your feelings with family and friends, which can lead to isolation. It is important to know that these feelings are normal responses to infertility and are experienced by many couples. Although a doctor will describe various treatments and realistic odds of success with treatments, you must decide how far you will go in your attempts to conceive. Coming to a joint decision with your partner about goals and acceptable therapies is important.