When should I do something?
The right time to seek help is when you are concerned about your fertility.
Often simple tests that check ovulation and sperm quality can provide reassurance to a couple so that they are happy to try a little longer before more intensive investigation. On the other hand these simple tests can quickly identify a problem.
A woman's chance of conceiving each month falls with age, especially in the late 30s and early 40s, so age is an important factor to consider. In some case you may be encouraged to wait a while before any invasive tests are performed, for example, if you have been trying for only a few months, the woman is under 35, and there is nothing to suggest an anatomical problem.
Paradoxically, couples that may need longer to conceive because the woman is older, require earlier investigations because there is less time left for conception.
There are circumstances when earlier advice should be sought, such as:
- lack of regular periods
- known low sperm count
- a previous operation to bring down a testis into the scrotum as a child
- previous treatments for cancer in either partner.
What happens when I see a Fertility Specialist?
One of the first jobs for your fertility specialist is to estimate your chance of a spontaneous pregnancy (without medical intervention) in the next 1 to 3 years. To do this your specialist will investigate possible causes of infertility. The common tests are:
- Medical history of both partners
- Semen analysis for the man, to look at the number of sperm ('concentration'), the proportion of sperm moving and the way they move ('motility') and the shape of the sperm ('morphology')
- Ovulation tests, usually blood tests for the hormone progesterone timed 6-8 days before next menstrual period
- Tests of ovarian reserve and function – by blood tests of Follicle Stimulating Hormone (FSH) and oestradiol (E2) on the second day of the period when, normally, the oestradiol should be low (200 pmol/l) and the FSH not be raised (i.e < 10 iu/l)
- Cervical smear and swabs to ensure there is no cancer or pre-cancer, or infection, particularly a chlamydial infection
- Pelvic ultrasound – to determine if ovaries and uterus appear normal
If there are no major factors apparent from initial tests then your doctor may recommend a hysterosalpingogram, a laparoscopy and/or a hysteroscopy to test for inflammation or scarring in the woman’s pelvic organs. This ensures there is no barrier to an egg being picked up from the ovary by the tube and fertilised there by the sperm.
- Hysterosalpingogram – this is a relatively simple test whereby, under X-ray control, dye is passed into the uterus and through the tubes. This is a test to determine only if the tubes are blocked and does not detect important scarring elsewhere in the pelvis, such as around the ovaries or tubes, that might affect normal function
- Laparoscopy is a simple operation in which a type of telescope (called a laparoscope) is inserted under general anaesthetic into the abdomen just below the navel to look at the woman's pelvic organs. Dye is passed through the Fallopian tubes at the same time. Besides testing for tubal patency, a laparoscopy can also detect scarring around the ovaries and tubes either from a previous, often unknown, pelvic infection or endometriosis. Endometriosis is a common disease whereby the lining of the uterus grows inappropriately on the ovaries, tubes, bowel or bladder and causes scarring and inflammation that interferes with normal function. At the time of the laparoscopy it is often possible to also treat endometriosis or scarring
- Hysteroscopy - this is also sometimes advised if there is abnormal bleeding or an abnormality is suspected from the pelvic scan. A hysteroscope is a telescope that is inserted through the cervix to examine the inside of the uterus. This is often done at the same time as a laparoscopy
Sometimes major factors are discovered - few or poor quality sperm, extensive scarring in or around the fallopian tubes or irregular ovulation. The chance of spontaneous pregnancy is very low and the treatment options are clear.
Quite commonly the factors are less severe - sperm quality lower than average, some endometriosis (where cells that usually line the uterus grow in the abdomen) or a combination of mild factors.
In around 20% of couples nothing looks unusual, which is described as 'unexplained infertility'. In these cases the duration of infertility seems to be the most important predictor of the chance of spontaneous pregnancy in the future. The treatment options are often the same as for more severe infertility; the question is when to try them.
You and your specialist will need to map out a management plan - balancing the emotional, physical and financial 'costs' of possible treatments with the chance of success.