Infertility

What is Involved in the Fertility Evaluation?

Infertility Tests

History and physical examination – First and foremost, your doctor will take a very thorough medical and fertility history. Your doctor may ask you many of the following questions: How long have you been trying to get pregnant? Do you have pain with menstrual periods or intercourse? Have you been pregnant before? What happened with your prior pregnancies? Have you had any sexually transmitted infections or abnormal pap smears? How often do you have menstrual cycles? These and many other questions will help your physician design a specific evaluation and potential treatment for you. In addition to a careful history, a physical evaluation may also be performed.

Transvaginal ultrasound – Ultrasound is an important tool in evaluating the structure of the uterus, tubes, and ovaries. Ultrasound can detect uterine abnormalities such as fibroids and polyps, distal fallopian tube occlusion, and ovarian abnormalities including ovarian cysts. Additionally, transvaginal ultrasound affords the opportunity for your physician to assess the relative number of available eggs. This measurement is called the antral follicle count and may correlate with fertility potential.

Laboratory testing – Depending on the results of the evaluation discussed above, your physician may request specific blood tests. The most common of these tests include measurements of blood levels of certain hormones such as estradiol and FSH, which are related to ovarian function and overall egg numbers; TSH, which assesses thyroid function; and prolactin, a hormone that can affect menstrual function if elevated.

Hysterosalpingogram (HSG) – This test is essential for evaluating fallopian tubal patency, uterine filling defects such as fibroids and polyps, and scarring of the uterine cavity. Many uterine and tubal abnormalities detected by the HSG can be surgically corrected.

Semen analysis – The semen analysis is the main test to evaluate the male partner. There are four parameters analyzed: 1) semen volume – should be at least 1.5 to 2 ml. 2) sperm concentration – normal concentration should be at least 20 million sperm per 1 ml of semen.; 3) sperm motility or movement – a normal motility should be at least 50%. and (4) morphology, or shape – there are three parts of the sperm that are analyzed for morphology: the head, midpeice, and tail. Ideally, using strict morphology criteria, a minimum of 5 – 15% normal forms leads to a better ability for sperm to fertilize the egg. An abnormal semen analysis warrants a further evaluation..

What are the Common Causes of Infertility?

What Causes Infertility?

1) Advancing maternal age: In our modern era, women are delaying child birth until their thirties and forties, which has lead to the discovery of the adverse effect of advanced maternal age on egg function. In fact, female age-related infertility is the most common cause of infertility today. For unknown reasons, as women age, egg numbers decrease at a rapid rate. And as aging occurs, egg quality, or the likelihood of an egg being genetically normal, decreases as well. Hence the ability to conceive a normal pregnancy decreases from when a woman is in her early 30s into her 40s. A woman is rarely fertile beyond the age of 45. This applies to the ability to conceive with her eggs, but not with donor eggs.

2) Ovulation disorders: Normal and regular ovulation, or release of a mature egg, is essential for women to conceive naturally. Ovulation often can be detected by keeping a menstrual calendar or using an ovulation predictor kit. There are many disorders that may impact the ability for a woman to ovulate normally. The most common disorders impacting ovulation include polycystic ovary syndrome (PCOS), hypogonadotropic hypogonadism (from signaling problems in the brain), and ovarian insufficiency (from problems of the ovary).

3) Tubal occlusion (blockage): As discussed previously, a history of sexually transmitted infections including chlamydia, gonorrhea, or pelvic inflammatory disease can predispose a woman to having blocked fallopian tubes. Tubal occlusion is a cause of infertility because an ovulated egg is unable to be fertilized by sperm or to reach the endometrial cavity. If both tubes are blocked, then in vitro fertilization (IVF) is required. If a tube is blocked and filled with fluid (called a hydrosalpinx), then minimally invasive surgery (laparoscopy or hysteroscopy) to either remove the tube or block/separate it from the uterus prior to any fertility treatments is recommended.

4) Uterine fibroids: Fibroids are very common (approximately 40% of women may have them) and the mere presence alone does not necessarily cause infertility. There are three types of fibroids: 1) subserosal, or fibroids that extend more than 50% outside of the uterus; 2) intramural, where the majority of the fibroid is within the muscle of the uterus without any indentation of the uterine cavity; and 3) submucosal, or fibroids the project into the uterine cavity. Submucosal fibroids are the type if fibroid that has clearly been demonstrated to reduce pregnancy rate, roughly by 50%, and removal of which will double pregnancy rate. In some cases, simply removing the submucosal fibroid solves infertility.

5) Endometrial polyps: Endometrial polyps are finger-like growths in the uterine cavity arising from the lining of the uterus, called the endometrium. These abnormalities are rarely associated with cancer (<1% in a woman before menopause), but polyps are can decrease fertility by up to 50% according to some studies. Removal of polyps by the minimally invasive procedure hysteroscopy is associated with a doubling of pregnancy rate. In some cases, simply removing the polyp solves infertility.

6) Male factors affecting sperm function: Male factor infertility has been associated as a contributing factor causing infertility in 40-50% percent of cases, and as the sole cause for infertility in 15-20% percent of cases. If a semen analysis is found to be abnormal, generally it is first repeated to confirm the abnormality. Once confirmed, the male partner is referred to a reproductive urologist, especially if the abnormality is severe. In some cases, the semen function can be improved by recommending certain lifestyle changes, by hormonal treatments, or by surgery. In most cases however, sperm function may not improve and therefore any attempts at pregnancy may require additional treatments or procedures.

A. Intrauterine insemination is a process by which sperm is washed and prepared for placement into the uterine cavity, therefore bypassing the cervix and bringing a higher concentration of motile sperm closer to the tubes and ovulated egg. At least one open tube is required for IUI, and the sperm abnormality cannot be severe otherwise the sperm will not be able to swim to and fertilize the egg.

B. Intracytoplasmic sperm injection is a process by which semen is washed and prepared for direct injection of one sperm into each egg collected during the IVF process. In order to perform ICSI, an egg is held via a small suction pipette, while one sperm is injected into that egg using a very fine glass needle. This process bypasses the normal fertilization process, which may be compromised due to poor sperm function. Your doctor will analyze your semen analysis carefully and help you decide if ICSI is an appropriate treatment for you.

7) Endometriosis: Endometriosis is a condition whereby cells very similar to the ones lining the uterine cavity, or endometrium, are found outside the uterine cavity. It is found in approximately 10-50% of reproductive-aged women and can be associated with infertility as well as pain during intercourse and/or menstrual periods. Endometriosis causes infertility by producing inflammation and scarring, which can result in not only pain but also potentially detrimental effects on egg, sperm or embryo. Endometriosis can only be confirmed by surgery, usually laparoscopy. If endometriosis is found, it can be surgically removed by various methods, and its removal may lead to a decrease in pain as well as improvement in the ability to conceive naturally. Your doctor will determine if you are at risk of having endometriosis based on a careful history, physical exam, and ultrasound.

8) Unexplained/other: Sometimes a full evaluation does not reveal the cause of infertility. This occurs approximately 15% of the time. Thankfully, even when the cause of infertility is not known, various fertility treatments can overcome the unknown road block that was preventing pregnancy and eventually lead to delivery of a healthy baby.

Vaginal Infertility:

• Your uterus is removed through an incision at the top of your vagina. There is no external incision.
• Most commonly used in cases of uterine prolapse and other non-malignant (or noncancerous) conditions.
• Fewest complications and fastest recovery (up to four weeks) and is considered the preferred approach.
• Patients often go home the same day/next day of surgery.

Laparoscopic Infertility:

• A laparoscope (a thin tube with a video camera on the end) is inserted in the lower abdomen through a small incision in the belly button.
• Surgical tools are inserted through several other small incisions.
• Your uterus can be removed in small pieces through the incisions in your abdomen or through your vagina
• Some people go home the same day or after one night in the hospital.
• Full recovery is shorter and less painful than an abdominal Infertility.

Abdominal Infertility:

• Your uterus is removed through a six- to eight-inch-long incision in your abdomen.
• The incision is made either from your belly button to your pubic bone, or across the top of your public hairline. The surgeon will use stitches or staples to close the incision.
• Most commonly used when cancer is involved, when the uterus is enlarged or when disease spreads to other pelvic areas.
• It generally requires a longer hospital stay (two or three days) and a longer recovery time.

Your doctor will probably do tests that include a pregnancy test and a pelvic exam. They might give you an ultrasound to look at your uterus and fallopian tubes.

Treating Infertility

Ectopic pregnancies aren’t safe for the mother. Also, the embryo won’t be able to develop to term. It’s necessary to remove the embryo as soon as possible for the mother’s immediate health and long-term fertility. Treatment options vary depending on the location of the Infertility and its development.

How long does a Infertility procedure last?

The procedure lasts one to three hours. The time can vary depending on the size of the uterus, and the need to take down scarring from previous surgeries, and if other tissue, such as endometrial tissue, and other organs are being removed with your uterus (like your fallopian tubes or ovaries).

What are the most common side effects of a Infertility?

Some of the most common side effects of a Infertility are vaginal drainage (may occur up to six weeks after surgery) and irritation at the incision sites.

If your ovaries were removed at the time of your Infertility, you may experience menopausal symptoms such as:

• Hot flashes.
• Vaginal dryness.
• Loss of libido.
• Difficulty sleeping (insomnia).

Your doctor will discuss treatment options to avoid the side effects of menopause mentioned above.

What happens after a Infertility?

The amount of time you spend in the hospital following a Infertility varies depending on what kind of surgery you had. Your doctor will want to monitor you and ensure there are no signs of complications like blood clots or bleeding. You'll walk around as soon as possible after your surgery to prevent blood clots in your legs.
If you had an abdominal Infertility, you might stay in the hospital for a few days. Vaginal and laparoscopic hysterectomies are less invasive and typically do not require any overnight stay in the hospital.
Your healthcare provider will go over recovery instructions, including restrictions to your day-to-day activities. Be sure to discuss any concerns you have about your recovery or the procedure.

Risks / Benefits

What are the advantages of having a Infertility?

Having a Infertility can help you live a more enjoyable life, especially if you suffer from constant pelvic pain or heavy and irregular bleeding. If you're at a higher risk for uterine cancer, a Infertility can lower this risk and potentially be life-saving.

What are the disadvantages of having a Infertility?

A Infertility is major surgery with a long recovery. It comes with risks and side effects, and is permanent. Depending on the type of surgery you have, you can go into menopause or experience symptoms of menopause. You also won't be able to become pregnant after the procedure.

What are the complications of Infertility?

As with any surgery, there is a slight chance that problems may occur. Problems could include:

• Blood clots.
• Severe infection.
• Bleeding.
• Bowel blockage.
• Torn internal stitches.
• Urinary tract injury.
• Problems related to anesthesia.

Recovery and Outlook

How long does it take to recover from a Infertility?

Most people recover from a Infertility in about four to six weeks. Your recovery depends on the type of Infertility you had and how the surgery was performed. Recovering from a vaginal and laparoscopic Infertility takes less time than recovering from an abdominal Infertility.

You should increase your activity gradually and pay attention to how you feel. If anything causes you pain, you should stop. Talk to your healthcare provider about specific instructions for recovering at home, including what medications to take.

What should I know about recovering at home?

Vaginal and laparoscopic recovery take about two to four weeks. It may take up to six weeks to recovery from abdominal Infertility. Talk to your healthcare provider before going home to make sure you know how to best care for yourself.

Common instructions after Infertility are:

• You can experience light vaginal bleeding for one to six weeks. Use only a light pantiliner or sanitary pad to catch the discharge.
• Do not lift heavy objects (over 10 pounds) for at least four to six weeks.
• Do not put anything into the vagina for four to six weeks, or as directed by your healthcare provider.
• Do not have sex for six weeks after surgery.
• You may take a shower after consulting with your doctor.
• You can drive about two weeks after abdominal surgery or when you are no longer taking narcotics for pain. If you had a vaginal or laparoscopic Infertility, you might begin driving with a few days.
• Resume your exercise routine in four to six weeks, depending on how you feel
• You can usually go back to work in three to six weeks, depending on what kind of work you do.