Infertility: Causes and Investigation

Infertility refers to inability to conceive or maintain a pregnancy even when couples have regular unprotected sexual intercourse. The usual agreed upon definition of infertility uses one year as a reference. Therefore, if a couple has regular intercourse without using any protection for a year and is unable to achieve a pregnancy, then it will be a good idea to see a fertility specialist and undergo a few tests for fertility assessment. For patients older than 35, the waiting period is usually shorter. Rather than waiting for one year, a couple where the female partner is older than 35, fertility testing will be in order if they cannot achieve a pregnancy within six months of trying. The reason is, patients older than 35 years of age are more likely to have reduced levels of fertility. Therefore, the longer they wait, the more difficult it might become to parent a biological child.

Both male and the female patients need to undergo investigation in order to understand what the underlying problem might be. In some cases, none of the partners may seem to have an obvious problem but they may still need the help of assisted reproductive technologies as conception via natural methods does not occur. Depending on the ages of patients and their test results, our team will identify the right method of treatment and prepare a customized treatment protocol for each couple.

Below you will find information about the initial tests and screening we ask our patients to have when they have not been through any infertility testing and/or fertility treatments. If a couple has already been through infertility testing and/or fertility treatments, then based on previous test results and previous treatment outcomes, further investigation will be performed. However, advanced investigation will be diferent for different people. For instance, a patient who has had 4 IVF failures and a patient who has had 4 positive outcomes but experienced miscarriages will be subjected to different tests and screening. Please do not forget that one prescription does not fit all and we are only trying to give you some general ideas about infertility and testing.

Female Infertility Testing

Our “Female Infertility” section discusses in length the possible causes of female infertility. Briefly, these are ovarian factors, uterine factors, tubal factors and cervical factors of infertility. Ovarian factors refer to inability of producing viable egg cells for natural conception while tubal factors form a barrier between the egg and the sperm. Uterine and cervical factors have to do with implantation and maintenance of pregnancy. Each of these factors should be evaluated before making an informed decision as to how to proceed with treatment. The first round of testing for female patients include the following:

• Hormone testing on day 2 or day 3 of the menstrual period for ovarian and reproductive assessment. These tests include FSH, LH, Estradiol, Prolactin, TSH and AMH hormone tests.
  
• A baseline ultrasound scan, again, on day 2 or day 3 of menstrual period. An investigation into the uterus, cervix and the ovaries will be necessary to make sure that there are no visible problems that can interfere with a successful pregnancy.
  
• If the patient has had previous IVF failures, then further investigations will be needed such as certain transferrable disease tests, infections, genetic testing and more advanced screening techniques.
  
• If the patient has had recurrent miscarriages, then further genetic testing as well as thrombophilia testing will need to be administered for starter.
  
  

Male Infertility Testing

Male infertility assessment begins with a sperm analysis. A sperm analysis indicates many parameters of the sperm sample that relate to sperm viability and the capacity of sperm to fertilize the eggs. While a semen analysis is the most important starting point of male testing, it should be known that a semen analysis cannot possibly reveal everything about the possible causes of male infertility. Sometimes, advanced male testing will be necessary to understand the underlying causes of male infertility. Nevertheless, semen analysis is still a very good starting point. Before having your sperm sample tested, it will be important to have abstinence of 3 to 5 days so that the sperm sample is in its optimal condition. Shorter or longer abstinence periods can negatively affect sperm motility and count, respectively. A sperm analysis shows important parameters regarding sperm quality such as:

• Sperm volume: The total volume of the ejaculate in mililiter.
  
• Sperm count / concentration: The number of sperm cells in the ejaculate per mililiter.
  
• Sperm motility: The percentage of sperm cells that are motile/mobile.
  
• Sperm morphology: The percentage of sperm cells that have normal/expected sperm morphology.
  
• pH level: Measures acidity/alkalinity of the sperm sample.
  
• Round cell count: Elevated round cell count may indicate an active infection.
  
  

These parameters provide us with important information regarding the viability of sperm during fertility treatments. If sperm analysis indicates a value below reference values, then the parameter in question is further investigated and if problem is not too severe, ICSI or microchip sperm selection methods are usually very effective in resolving the problem. If the male patient is diagnosed with azoospermia, then surgical sperm extraction methods can be employed to surgically search for sperm cells. For more information about male related infertility problems, please visit our “Male Infertility” section.

Why Do I need to get tested before an IVF Treatment?

During a normal menstrual cycle, the blood flow marks the beginning of follicle (egg) development. During this stage, the follicles are still very small, and they require Follicle Stimulating Hormone (FSH) in order to grow. This FSH hormone is released by the pituitary gland in your brain. In a natural menstrual cycle, there is only enough FSH release to recruit one follicle for ovulation. During an IVF cycle, we hope to obtain more than one egg so that we can offer you a higher chance of success. Therefore, we prescribe FSH medication externally in greater amounts so that more follicles are recruited for ovulation. This is the reason behind using medication during an IVF cycle. We simply mimic what your body does in a natural cycle, but we do it in a slightly higher doses so that we can multiple eggs, and therefore, multiple embryos.

First of all, before any treatment can be planned or any recommendations can be made, we will be asking you to undergo the female and male infertility testing described above. Female infertility tests are the basic method of screening which will help us make an assessment of your ovarian function and predict your expected response to the medication which we will use during your IVF treatment. Male semen testing gives us a very good idea about the viability of the sperm sample for fertilization.

The precise dosage of medication and the precise protocol will depend on your test results, because these test results will indicate to us what the naturally occuring level of hormones are. Based on these hormone levels, we will be able to design your treatment protocol.

Please contact us for more detail on Infertility Causes and Management.