Infertility investigation in practice – finding the reasons

As months go by, lives of many couples get infiltrated with a sneaky, uneasy kind of anxiety which could become the greatest fear for those who are seriously planning to have a child together. Infertility gets more and more realistic, thus more and more dreadful, even to an extent anxiety and horror themselves become one of the reasons for delayed conception. Good news is, if we choose to look for the reasons instead of hiding the fear in ourselves, in most cases, we will find a way to address the problem with the help of modern medicine. But when should we start to get suspicious and what to do then?

First of all, we should define when should we start to think about that something is going wrong? 85% of couples (where the female partner is 35years old or below) would start to think about looking for reasons after 12 months of delayed conception despite having regular sexual intercourses. If the female partner’s age is above 35, then the couples are advised to look for the reasons after 6 months of ineffectual trying, since age-related problems should be identified and treated without further loss of time.

Even before the first meeting, couples would like to check on some lifestyle elements that could be changed and thus improve the situation. Smoking and alcohol consumption for both men and women should be avoided – although for guys up to 3-4 units of alcohol per day could be okay. BMI over 30 affects the probability in both sexes and ladies under BMI 19, especially with irregular menstruation cycles could also be negatively affected by their body weight, however, these factors could fortunately be addressed with a proper diet. Some occupations also could have a negative effect: frequent exposure to radiation, heavy metals, or chemical solvents may have a negative outcome and asymptomatic or overlooked sexually transmitted diseases (STDs) also can hide in the background. Couples may want to take care of these factors before starting the process of – according to the National Collaborating Centre for Women’s and Children’s Health official guideline – having a “vaginal sexual intercourse every 2 to 3 days”. (1)

But what to do when the 12 months are over? Infertility specialists, skilled obstetricians, gynecologists, andrologists, and endocrinologists will help you find out the root(s) of the problem. After a specialist consultation – which sometimes can provide solutions as a standalone treatment, eg. via discussing the proper ways, timing and frequency – a series of examinations could be performed on both members of the couple. We cannot emphasize enough that infertility is not a gynecological disease. It’s a condition that given couples have, and that should be addressed together.

After discussing both person’s record on former conceptions with other partners, former diseases that could affect fertility (eg. sexually transmitted infections) and family history, the following investigations could take place:

• physical examination: please note that not every deviation from normal is obvious for a non-professional.
• Transvaginal ultrasound and a Hysterosalpingogram (kind of local X-ray) – these would give a clear image on possible uterine polyps, endometriosis, PCOS, scarred or obstructed fallopian tube, or insufficient ovarian reserve and other possible reasons
• Endometrial Biopsy
• Blood tests provide the specialists information about sex hormone and thyroid hormone levels, e.g. estradiol and FSH (ovarian function and overall egg number reporters), TSH (thyroid function marker) and prolactin (menstrual function marker). Some sexually transmitted disease tests are also made from blood samples.
• Smear analysis/culturing helps the differential diagnosis in case of STDs
  
• Semen analysis, where it is important to investigate the following values:
  • Semen volume: 1.5 mL or more, pH: 7.2 or more
  • Sperm concentration: 15 million spermatozoa per mL or more
  • Total sperm number: 39 million spermatozoa per ejaculate or more, Total motility (percentage of progressive motility and non-progressive motility): 40% or more motile or 32% or more with progressive motility, Vitality: 58% or more live spermatozoa
  • Total sperm number: 39 million spermatozoa per ejaculate or more, Total motility (percentage of progressive motility and non-progressive motility): 40% or more motile or 32% or more with progressive motility, Vitality: 58% or more live spermatozoa
  • Sperm morphology (percentage of normal forms): 4% or more

These investigations take place in a sequence that is the most helpful for the specialists’ understanding and should be performed in the least stressful manner for the physical and mental condition of the couples. It’s important to understand that more tests don’t mean bigger problems: with every result, the picture becomes clearer and the solution closer. (1,2)

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References:

1. Fertility: assessment and treatment for people with fertility problems. National Collaborating Centre for Women’s and Children’s Health (NCC-WCH), 2004 Feb (revised 2013 Feb)
2. Infertility: Symptoms, Treatment, Diagnosis. UCLA Obstetrics and Gynecology