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What do you mean by infertility? What should I expect on my visit to your clinic?

Infertility is a condition where a couple fails to conceive after about a year of regular unprotected intercourse.

If you have been cohabiting for more than a year or if you are more than 35 years of age and have been cohabiting for more than 6 months without conception, you should visit an infertility clinic.

Today there is hope for many such couples in the form of improved diagnostic tools (laparoscopy, hysteroscopy, sono-hysterography among many others ), assisted reproductive techniques ( IUI and test tube baby) and a better treatment options for diseases like fibroids, endometriosis and polycystic ovaries.

On your first visit to our clinic, we would take your case history and examine the female partner and advise you to carry out certain basic blood tests (usually routine tests and sometimes hormonal tests) for the female partner and a semen analysis of the male partner.

If all of these are within normal limits, further evaluation is carried out to check whether the woman’s ovaries are producing eggs (ovulation) regularly and whether her fallopian tubes are open.

What are the reasons some couples find it difficult to conceive?

Depending on the results of the various tests, the couple may fall into any or more of the below mentioned categories:

Male factor infertility (the husband’s semen shows poor sperm count or low motility)
Tubal factor infertility (one or both of her fallopian tubes is blocked or diseased) – This may happen in cases of pelvic infection, tuberculosis, endometriosis or adhesions due to previous surgery
Anovulation (the ovary does not release the egg every month) e.g. Polycystic ovaries, chocolate cyst, obesity
Uterine factor infertility (the uterus may have fibroids, septum, tuberculosis, adhesions)
Cervical factor infertility (the cervical mucus is thick and may not allow the partner’s sperms to penetrate) e.g. vaginal and cervical infection
Multiple factor infertility – In some patients, there may be more than one cause for failure to conceive. For e.g. tuberculosis, endometriosis. Sometimes both the partners may have a problem.
Unexplained infertility – In many cases, all tests yield normal results, yet conception does not occur in reasonable amount of time. Such couples often benefit with assisted reproductive techniques (ART).

Understanding tests for fertility:

Semen Analysis:

This is the most basic test for assessment of the male partner. Semen testing should be done preferably in a specialized lab. If the report shows any abnormality, the test should be repeated for confirmation.

Sonography – Sonography of the female pelvis can detect any abnormality such as tumor of the uterus or ovary or hydrosalpinx (when the fallopian tube is filled with fluid).

Follicular study – Sonography is an invaluable tool for studying ovulation. Sonography is done from the ninth day of the menstrual cycle on alternate days till ovulation is detected (on day 14th or 15th usually). Follicular study helps to detect defects in ovulation and also whether the uterine lining is ready for implantation of the fertilised egg.

Advanced sonography (using Doppler blood flow testing) can assess the amount of blood flow to the uterus and ovaries.

Hysteroscopy – It is a surgical procedure to be done under local or general anaesthesia. An endoscope is inserted into the uterus through the vagina and a magnified view of the inside of the uterus is seen. It helps to detect small internal fibroids, polyps, septum or adhesions ( bands ) and to assess the endometrium ( uterine lining ) and cavity. Any defects of the cavity such as double uterus, very small (hypoplastic uterus) or T-shaped uterus. The doctor may combine it with a D&C (dilatation and curettage) to take biopsy of the uterine lining.

Laparoscopy – Under general anaesthesia, an endoscope is inserted through the umbilicus into the abdomen and a magnified view of the abdominal cavity is obtained. It is an excellent tool to evaluate the uterus, tubes and ovaries and their relationship to each other. It can diagnose tuberculosis, endometriosis, pelvic inflammatory disease, etc. and treatment may be carried out at the same sitting. In experienced hands, this is a very safe and cost-effective procedure to diagnose and treat the cause of female infertility. It is almost always combined with hysteroscopy.

Hysterosalpingography (HSG) – An Xray of the uterus and tubes taken after injection of a suitable dye into the uterus . Since it is performed without anaesthesia, it may be a little painful. It gives a fairly good idea of the uterine cavity and tells us whether tubes are open. However, it may miss endometriosis and early tuberculosis and will not tell us the cause of tubal blocks.

Sonohysterosalpingography– Saline is injected into the uterus and sonography is performed. This gives similar information as HSG, and gives better information about endometrium. However, it requires expertise and is not commonly performed.

What if all my reports are normal?

We call such a situation ‘unexplained infertility’. In such cases, we induce ovulation (using medicines) and grow more than one egg (controlled ovarian hyperstimulation) to increase chances of fertilisation and then perform IUI (intrauterine insemination) in the same cycle.

What is IUI (intrauterine insemination)?

Intrauterine insemination (IUI) is the instillation of selected highly motile sperms directly into the uterus. This is usually the first line of treatment in women with open tubes and sperm counts above 15 million.

Are there any side effects to fertility treatments?

Apart from being extremely stressful, various treatments may have specific side-effects.

Notable among those, is hyperstimulation of the ovaries, which may happen during ovarian stimulation especially in the course of IVF or ICSI treatment. Here the ovaries become large with multiple cysts and fluid leaks in the abdomen. It may become life-threatening in severe cases. Fortunately, with advanced protocols of management, the incidence of this condition has become far less common.

Another common problem is multiple pregnancies (twins or triplets) due to maturation of many eggs in one cycle.

Surgical treatments have their independent risks as well.

Counselling prior to start of treatment as well as through it, is very important to help couples understand what they are going in for, as well as supporting them emotionally.

When should couples opt for fertility treatments?

There is no hard and fast rule about when to start the process of fertility testing and treatment. It would depend on the age of the couple (esp the woman’s) as well as the couple’s attitudes towards this issue. Medically, infertility is defined as inability to conceive after a year of regular, unprotected intercourse. However, for older couples or couples who have other associated conditions which could affect fertility, it would be wise to start early treatment, whereas for younger couples with no risk factors, we could wait a little while longer. In general, if the couple is anxious to conceive, we do initiate early testing.

How long should couples try to conceive using these treatments?

Again, there is no cut-off to stop trying. It would depend on the age of the couple, their resolve, their attitudes towards the issue and their financial and psychological state. After 40, fertility undergoes a sharp decline, and most clinics prefer to use ‘donor eggs’ for IVF or ICSI.

It is interesting, however, to note that many couples conceive spontaneously after stopping treatment! Possibly, the sense of ‘letting go’ relieves stress and things just fall back into place naturally.

How do I prepare myself for test tube baby (IVF or ICSI)?

Most of the couples enquire about the costs and the success rates. But there is much more to it than meets the eye. For example:

  • What are the tests you would need to undergo before starting on the program?
  • How many times would you be needed to visit the IVF clinic during one cycle?
  • What injections would be used to grow the follicles ( eggs ) ?
  • What is hyperstimulation syndrome ?
  • Why do ICSI or IVF pregnancies not have a 100% success rate?
  • Why do some cycles have to be cancelled ?
  • What is prenatal diagnosis?
  • What are the factors to look at when choosing an ART clinic ?
  • What is cryopreservation of embryo ?
  • What is sperm banking and what is surrogacy?