Diagnosis and Treatment:

Overview:

The monthly potential for achieving a pregnancy in the average fertile couple having unprotected intercourse is only ~ 25%. This percentage will not increase even if you have intercourse daily and it reflects human fertility potential or fecundity. Over a period of one year the chance of a successful pregnancy is usually between 80 to 85% so that 7 out of 8 healthy couples will be pregnant within one year. The remaining 15% of the couples failing to conceive are classified as infertile. Infertility is divided into primary and secondary, the former defined as failure to ever achieve pregnancy while the latter denotes a difficulty in achieving pregnancy following a previous success.

The most important influences on fertility are chronological age, frequency of intercourse, duration in which a couple has attempted to achieve a pregnancy and presence of a fertility problem.

When to Seek Medical Advice:

If you have been having unprotected sexual intercourse two or three times a week at the time of ovulation, for a year or more and you are not pregnant you meet the definition of being infertile. From the statistical point of view, pregnancy can still occur however the chances continually decrease with time and you may now want to start thinking about seeking medical assistance.

This definition applies to patients who have "regular" cycles, meaning periods every twenty-three to thirty-five days. There will be some conditions that warrant consultation sooner such irregular periods, history of previous pelvic surgery or pelvic infections, a history of multiple miscarriages, or chronological age greater than 35 years. For the male partner, men who have had medical illnesses or infections in the reproductive system and men who do not feel their testes in the scrotum. Remember that there are some commonsense issues that need to be evaluated before you seek medical advice in regard to your fertility. Body weight, diet and exercise are important influencing factors as well as smoking, alcohol consumption and certain medications. We do know that women who are severely underweight or overweight have difficulties conceiving.

The Infertility Work-Up

On average, the distribution between male and female related infertility is evenly distributed at ~ 40%. Ten percent of the time both partners contribute to the problem and in ~10% of cases the problem is unidentified and is termed unexplained infertility. Before commencing any testing a detailed history is taken from the couple and a comprehensive physical is performed on the female. Once the work up is complete, a treatment plan is formulated.

Evaluation of the Female Partner

The following tools for assessment must be carefully scheduled according to the menstrual cycle. Please contact the nursing staff should any details need clarification and refer to the baseline testing instructions for cycle day specifics. For all intensive purposes the first day of your period is considered cycle day 1.

Hormonal Studies

Blood tests will be performed during various phases of your menstrual cycle to determine any hormonal imbalances that may affect your fertility. Hormones controlling ovulation, endometrial thickness and implantation will be assessed as well as those which may interfere with these processes. Blood tests assist in diagnosing the cause of your infertility. Analytes measured can include estradiol, progesterone and androgens. Pituitary, thyroid and adrenal function is also assessed in this fashion. The results of the hormone tests usually take two to three weeks.

Endometrial Biopsy

An endometrial biopsy is a microscopic evaluation of the endometrial tissue, which lines the inside walls of the uterus. This test is performed after ovulation to assess the thickness and pattern of the endometrium, which has responded to the estrogen and progesterone produced earlier in the cycle. You must avoid conceiving a pregnancy this cycle as an endometrial biopsy may inflict harm to an early pregnancy. The doctor will insert a speculum inside your vagina and insert a small catheter inside the uterus. You may experience mild cramping and spotting after a piece of the endometrium is sampled. The biopsy is sent to a Pathologist for interpretation. Results will be available in approximately two weeks.

Hysterosalpingogram

A hysterosaplingogram or (HSG) is a radiological test that evaluates the uterus and patency of the fallopian tubes. Tubal blockage or abnormal growths (polyps, fibroids, or scar tissue) can prevent fertilization or implantation. The HSG assesses the anatomy and the potential function of the female reproductive tract. This test is performed directly after the conclusion of your period. The HSG is performed on an out-patient basis in the Radiology Department. A speculum is inserted into the vagina and a special dye is delivered to the uterus through a thin plastic catheter placed in the cervix. The dye should fill the uterus and spill out of the fallopian tubes during which time an x-ray is taken. The patient may experience mild cramping and some spotting during and after the test. Complications may include infection, bleeding and discomfort. Preparation for the test includes a prophylactic antibiotic and over-the-counter pain medicine. Results can usually be determined immediately.

Vaginal Ultrasound

Ultrasound is a diagnostic tool that uses high frequency sound waves to create images of the abdominal organs. The ultrasound is performed vaginally at which time the physician will record images of the ovaries and uterus. Ultrasound may help to diagnose such things as fibroids, pelvic masses, early pregnancy and polycystic ovarian syndrome. Results are usually available immediately.

Hysteroscopy

Hysteroscopy is a minor procedure that may be performed in the physician's office or operating room and with very little anesthesia in some cases. Hysteroscopy can be used to confirm the results of the HSG such as polyps, fibroids, or scar tissue within the uterus. After dilation of your cervix, the hysteroscope is inserted and passed into the uterus. The inside of the uterus is expanded with a solution that is pumped through the scope. This provides visual access the uterine cavity and openings of the fallopian tubes. Patients may experience some cramping and discharge.

Laparoscopy

A laparoscopy is a short surgical procedure performed on an out-patient basis which allows diagnosis and immediate treatment of certain causes of infertility. Adhesions (scar tissue), endometriosis, tubal blockages and deviations in functional anatomy can be observed. A small fiberoptic telescope is placed through a small opening in the naval providing visual access to the ovaries, tubes and uterus. Gas is pumped into the abdominal cavity prior to insertion of the scope. The expansion of the cavity allows the physician to view the reproductive organ more clearly. A tool called a probe is also inserted into the abdomen to lift organs to view hidden areas. Patients may experience fatigue after the procedure and pain in the shoulders or diaphragm.

Evaluation of Male Partner - Click Here for Information

Treatment

Minimal interventions such as timed intercourse or ovulation induction with intercourse are viable options for some couples. The following addresses the more aggressive therapies available to assist in conceiving

Reproductive Surgery

Ovulation induction

Fertility drugs stimulate multiple follicular development within the ovaries thus increasing the chances of conception following intercourse, artificial insemination or IVF. Ovulation induction regimens vary depending upon the treatment modality employed but may be as simple as oral administration of Clomid. More aggressive therapy involves the injection of FSH, which stimulates the ovary directly, combined with blood and ultrasound monitoring before ovulation is triggered.

Intrauterine insemination (IUI)

Intrauterine insemination or artificial insemination can be performed during an ovulation induction cycle or with the use of an ovulation predictor. The process bypasses the normal cervical mucus/sperm interaction by directly depositing the washed sample in the uterine cavity. Fallopian tubal patency is necessary since the sperm still need to travel into the tubes to interact with the oocyte(s).

Semen from the partner or anonymous donor is prepared in the laboratory to concentrate a highly motile fraction. The sample is loaded into a specialized catheter that is introduced through the cervix into the uterus. The procedure is typically very quick with minimal discomfort.