There comes a time when a couple who have been trying unsuccessfully to start a family decide to seek medical attention. The timing of this decision varies; some may present to the clinician after just a few months of trying while others do so much later.
On empirical grounds one can advise 12-18 months, knowing that it may take up to 12 months or so for the majority of couples to become pregnant naturally. Some clinicians may advocate a period of two years afterwards. However, such advice should take into consideration the individuals in question and factors such as the woman’s age, the presence of symptoms suggesting underlying cause for their infertility, whether the couple would wish to have infertility treatment at that time or whether they wish to wait for some more time before having any evaluation or treatment.
The most important step in the management of infertility is the evaluation of the couple to determine whether any cause for the condition can be found. It is only after this is completed that issues relating to treatment can be realistically discussed. It is recommended that both partners are seen at the same time. Neither of the partners in infertile couples can be assumed to be free of a cause for the problem. Each will have to be assessed using standard procedures. The discovery of a problem in one partner does not absolve the other form being properly assessed, as in about 20% or more of infertile couples both partners will have an identifiable problem. The evaluation of infertile couples is in four stages namely: clinical history, physical examination, routine infertility investigations and additional investigations.
As most couples are already burdened with work pressures and monetary constraints, the present day approach to evaluation is a comprehensive, economical and stream lined one. In ordinary circumstances the entire work up should be over within a month so that the appropriate treatment can be started quickly.
Clinical History
The clinical history is obtained and physical examination carried out when the couple first present at the infertility clinic. Several questions are asked, aimed at finding out any obvious cause for the infertility.
The questions are quite extensive and probe all aspects of each partner’s social medical and sexual life. In fact some couples may find some of the questions embarrassing but they are being asked in a constructive manner and seek to find the best way of helping the couple.
Physical Examination
Just as in the clinical history, examination of the female is aimed at finding out if there are features that will point to a cause for the infertility. At the same time the woman is assessed for her suitability to have any of the infertility treatments and whether she is fit to have an operation involving general anaesthesia. The sequence of examination is usually as follows:
Height and weight measurement and calculation of the body mass index (BMI). The BMI is a way of assessing an individual’s build to determine whether he or she is overweight, underweight or normal weight. It is derived by dividing the weight (in kilograms) by the square root of the height (in metres) i.e. BMI=weight (kg)/ height. The BMI should ideally lie between 20-25. Values above this range indicate obesity while those below the range suggest under weight.
Assessment of body hair distribution. There should be a satisfactory growth of hair in the pubic region and armpit. Excessive growth of hair on the face and body may suggest the presence of polycystic ovary syndrome (PCOS) although this is by no means invariable.
Gentle squeezing of the nipples to see whether milky fluid can be expressed(galactorrhoea). The presence of galactorrhoea may mean that the patient has hyperprolactinaemia.
Examination of the abdomen with a view to finding out if there are any tumours or tenderness.
Vaginal and pelvic examination to check on the state of the external genitalia, vagina, cervix and uterus. The ovaries usually cannot be felt unless they are enlarges. The presence of tumours in the pelvis is checked for. Any tenderness on pelvic examination is noted.
Investigations
Basal Body Temperature monitoring (BBT)
This test is based on the fact that post-ovulatory levels of progesterone raise the body temperature slightly. The woman checks her temperature with a thermometer everyday, usually before getting out of bed in the morning, and notes the reading on a chart. Following ovulation the corpus luteum begins to secret progesterone and the thermometer should register a rise in the body temperature. The increase in temperature is usually maintained for about 10 days before it falls to normal levels in those who do not become pregnant. The pattern that emerges when this temperature change is plotted on a graph during that month is said to be ‘biphasic’
The test does not tell the patient when ovulation is going to occur in future. It just tells her that ovulation probably occurred a day or two prior to the temperature rise. This information will not be useful to the couple who whish to have intercourse at the fertile part of the menstrual cycle because by the time the temperature is elevated the oocytes is likely not to be fertilizable. Furthermore, it does not necessarily mean that a woman whose chart does not show a temperature rise has not ovulated.
In summary, BBT measurement is not accurate, can be easily affected by other factors and does not predict the occurrence of ovulation. Most importantly it can increase the stress to which infertile couples are subjected. BBT is not advocated nowadays for these reasons
Pelvic Scan
Ultrasound has revolutionized the management of infertility and, as will be seen in later chapters, it is an indispensable tool in the treatment of infertility especially using assisted conception methods. If possible, a patient should have an ultrasound scan at the stage of investigation of infertility. It will assist in the diagnosis of a wide range of infertility-associated pathology such as uterine malformations, fibroids, endometriotic cysts, polycystic ovaries and hydrosalpinges. It will also provide baseline information such as the size of the uterus and ovaries and allow the thickness and reflectivity of endometrium to be measured.
Ultrasound scanning of the pelvic organs can be carried out with probes placed on the abdomen or in the vagina. A full bladder is required for the abdominal approach since this straightens out the uterus and moves it upwards so as to be nearer the ultrasound probe placed on the anterior abdominal wall. The woman is asked to drink a lot of fluid (up to one litre) two to three hours before the appointment and not to empty her bladder during that time. This can be quite uncomfortable. A full bladder is not required for the transvaginal approach. The transducer is covered with a fresh disposable rubber sheath to prevent cross-infection. It is gently introduced in to the vagina and the pelvic organs are usually seen clearly on the screen. There are certain situations where the abdominal approach is preferred and other where the transvaginal approach is better.
Hormonal Assay
These tests are necessary to check the levels of the various hormones that are produced at different times of the menstrual cycle and are necessary for stimulating egg development, Ovulation, fertilization and implantation of the fertilized egg in the uterus.
If these hormones that affect fertility are not produced in the right amounts at the right times during the menstrual cycles, the chances of pregnancy may be greatly reduced.
The following are the commonly run hormone tests
- FSH (Follicle Stimulating Hormone) This hormone stimulates the development of the egg.
- LH (Leutinizing Hormone) This hormone stimulates ovulation or release of egg from the follicles.
- E2 (Estradiol) This hormone stimulates the growth of follicles, make the cervical glands produce lots of thin mucus and causes the womb lining to thicken – up as preparation for implantation of the fertilized egg.
- Progesterone This hormone makes the womb lining spongy and helps implantation. It also supports early pregnancy.
Other hormones also evaluated may be
- Thyroid (TSH) – low levels can interfere with ovulation
- Prolactin – stimulates milk production
- Androgens – may be elevated and as a result cause Ovulatory dysfunctions
Assement of Ovarian Reserve
Basal FSH and estradiol
If the FSH level is > 10miu/ml or the estradiol is > 70pg/ml then it could mean that the woman has reduced ovarian reserve. There can be a cycle to cycle variation in the FSH and estrodiol levels but a single elevation is predictive that the ovarian reseve is reduced.
Antral Follicle Count ( AFC)
Antral follicles are those follicles in the ovary that have the potential to grow and yield eggs during a stimulation or natural cycle. A reduction in the number of this follicle count also is predictive of reduced ovarian reserve.
This test is done by transvaginal ultrasound test on Day 3 of the cycle.
AMH or Anti Mullerian Hormone
This hormone is an indicator of the reserves of egg bearing tissue in the ovaries.
HSG
A hysterosalpingogram (HSG) is an xray of the uterus and tubes which allows the doctor to visualize the inside of the uterus and tubes.
If the tubes are healthy and not blocked, the dye will spill out into the abdominal cavity.
This is a good sign but it does not guarantee that the tubes will function normally.
If the cavity of the uterus is uniformly distended with dye it in a good sign, polyps, fibroids or intrauterine adhesions may appear as “defects” in the other wise dye-filled Uterus.
Although the purpose of HSG is mostly to diagnose the tubal conditions, it may also enhance fertility and allow some women to achieve pregnancy following the test without further treatment. This is because the test may dislodge small mucus plugs that may have cause tubal blocks.
It is best to schedule the HSG test between day 7 to day 10 of thecycle. It is a good idea to take an anti inflammatory tablet prior to the procedure. (Eg: Brufen, Crocin etc)
The procedure can be described as mildly un comfortable with cramping sensations.
A small tube will be inserted into the cervix (mouth of the womb) through the vagina and an oily dye is injected in to the womb.
The test can now be done by ultrasound scan and is called sono salpingography (SSG).
An abnormal HSG or SSG test needs further testing by a minimally invasive procedure like Laparoscopy.
Sonosalpingogram
This is a relatively new test of tubal patency that is some what similar to HSG but does not involve the use of X-rays. Instead the ultrasound scanner is used to monitor the flow of a specially compounded fluid medium that is slowly injected into the uterine cavity and fallopian tubes through the cervical canal. Ultrasound scanning is performed using a probe that is placed in the vagina. If the tubes are not blocked the fluid should be seen flowing through them.
Laparoscopy and Dye Test
Whenever possible, a laparoscopy and dye test should performed. This serves the dual purpose of checking for patency of the fallopian tubes as well as providing an opportunity for the pelvis to be examined carefully to diagnose or exclude the presence of endometriosis, adhesions or any other problems that may be causing or contributing to the infertility. Laparoscopy is normally carried out under general anaesthesia. The drugs that are used are short lasting and full consciousness is regained within a short while of completing the procedure.
After establishing adequate anesthesia a needle (called the Verres needle) is pushed through the abdominal wall into the abdominal cavity. About 1.5 litres of carbon dioxide gas are introduces through this needle into the abdomen to distend it an allow easy visualization of the pelvic organs. A small elliptical incision is made just below the umbilicus. A laparoscope is inserted into the abdomen through this incision and used to inspect the ovaries, tubes and uterus. The pelvis itself is also inspected carefully looking for evidence of endometriosis and adhesions. Another incision is made lower down the abdomen for the introduction of intstruments that are used in manoeuvring the pelvic organs around to permit their complete examination.
The dye test is carried out with the laparoscope still positioned in the abdomen. A cannula is connected to the cervical canal and methylene blue dye is slowly injected. If the tubes are not blocked the blue dye will distend the tubes and then flow out of the open end of the fallopian tubes.
At present, laparoscopy is done as a “day care” procedure. Scheduling it just before the weekend is sensible. Some amount of soreness and tiredness or shoulder pain may persist for 2 – 3 days.
Hysteroscopy
This a procedure usually done under general anesthesia / local anesthesia in the hospital / clinic set up.
The Hysteroscope is a small instrument that is inserted through the vagina, into the cervical canal and used to view the uterine cavity. Additional operative instruments can be passed through operative channels and procedures like biopsies of the endometrial lining, removal of small polyps and fibroids or cutting of abnormal tissue (Septum’s, adhesions) within the uterine cavity can be easily performed.
A simple diagnostic hysteroscopy is often mandatory prior to IVF procedures to ensure a smooth and healthy uterine cavity.