In my career, I have seen many couples voicing their fertility concerns. One of the most common question asked is “How long should I take to try for a pregnancy before becoming concerned?” This is particularly more prevalent an issue, as couples leave it later in life to try for a pregnancy.
A good general rule of thumb is that up to 12 months of trying is not uncommon for a couple to achieve a pregnancy. Traditionally, it is taught that concerns need not be raised before that time. It will however depend on a couple’s circumstance. For example a couple in their twenties may not be as concerned as one in their late 30’s or early 40’s. They wish to try for a longer period of time. For the latter group, plans for more active management of their fertility may need to be considered earlier. In others, they may wish to be checked earlier, irrespective of their ages.
Whenever, this issue is raised, there are 3 basic components to consider:
ovulation: release of eggs by the ovary
sperm adequacy
tubal integrity – this is where fertilisation occur so tubal integrity is important.
Ovulation:
Women with regular cycles usually make and produce eggs consistently, unlike those who have cycles that are irregular. There can be many causes for irregular cycles with the most common being polycystic ovaries. However, other hormonal causes exist, like thyroid dysfunction, diabetes, being overweight etc. Stress also plays a large part.
The easiest way I find in checking if a woman is ovulating would be to keep a
Menstrual cycle chart and a Basal temperature chart
Using this method, changes in the body temperature over a menstrual cycle can detect if ovulation is occurring. Cheap and easy to do, it only requires a pen, graph paper and a thermometer! This method cannot predict when you are ovulating in a cycle, but it allows you to look back at the previous cycles to confirm that you did indeed ovulate. It can also indicate the timing of ovulation in the previous cycles. For those with regular cycles, this can be helpful going forward.
Other ovulation testing methods are:
Ovulation kits.
These check for hormonal change in the body related to the menstrual cycle. Commonly the hormones LH and estrogen can detected in the urine. The kits test for the concentration of these hormones in the urine. This can be tested for by peeing on a stick. Whilst it may help to indicate the likely timing of ovulation, it is not in my opinion as helpful as a basal temperature chart. It does not confirm ovulation, only indicating the likely time ovulation is going to occur. It is therefore no guarantee of achieving pregnancy. In women who have irregular cycles, such timing will vary depending on the length of the cycle. As you cannot predict each cycle length in advance, using these kits generally are not helpful. It is only in women with regular cycles that they may help in allowing sex to be timed for maximal result. Still no guarantee. And most men find it hard to perform by demand!
Progesterone blood levels.
A more accurate hormone test would be to check for progesterone levels by doing a blood test. This will confirm if you did ovulate in a particular cycle. However, it does not tell you when that happened. Only that it did.
Ultrasound of the ovaries to check for egg formation.
Using ultrasound to track egg development in a cycle can also help to check if the ovary is working well. Sometimes it can help to pin point the timing for ovulation. Used more in IVF to enable hormone injection timing, this is not commonly used routinely. The reason is cost and time required to a patient to go for regular ultrasounds in a cycle.
Sperm adequacy:
One of the hardest test to do. Getting the sample is difficult and usually requires a great deal of arduous negotiation on your part!!! There can be many reasons for this…”too much work”, “not enough time in the day” , “ I have a headache” to “ are you really sure it is absolutely needed?”.
But it is important, as 30% infertility problems relate to sperm issues. We look for a number of things including volume, sperm concentration, motility, % abnormal forms and forward progression. Whilst total lack of sperm is an obvious factor, commonly it is more subtle changes that are present that also contribute to a couple’s infertility.
Tubal integrity:
There is only place where these guys and girls can meet. Not, it is not behind the shed! It is the tubes. The fallopian tubes more correctly. They serve a greater function than simply being a meeting point. The cells in the tubes produce fluid and provide a nutritious environment for the sperm and eggs to meet. When pregnancy occurs and an embryo is formed, they tubes also help in moving it into the womb.
Hence any damage to the tubes can affect this function. It is not uncommon to find blockages or damage to the tubes from various conditions. Endometriosis, infection, previous operations in the pelvis can all cause damage. Some women are born with an abnormality on the tubes or even missing tubes.
A variety of methods are used to check the tubes including ultrasound, and x-rays with dye being passed through the tubes to check for blockage. However, the best method is laparoscopy as it will enable a check for other causes like endometriosis or infection. It can also be used to treat endometriosis, cut scar tissue to free the tubes and drain the cysts in polycystic ovaries if present.
Management of Infertility
The way I look to assist couples worried about these issues is
- Exploring their concerns and providing information
- Initiate investigations
- Consider management
Exploring concerns and providing information
For many, I find this is sufficient especially if they are young and have not been trying for a long time. Taking a detailed history can usually exclude problems like polycystic ovarian disease and other medical conditions. In others who have been trying for a long time, or in the older couple, then I would consider starting investigations earlier.
Investigations
The most basic would be keeping a basal temperature chart, checking the sperm for abnormalities and getting a pelvic ultrasound to look for evidence of tubal damage, polycystic ovaries and severe endometriosis. Hormonal investigations are important to further assess ovarian function, ovarian reserve, thyroid function and hyperprolactinaemia to name a few. Laparoscopy to more fully assess the pelvis is very helpful. I also include in this a hysteroscopy and curette to check the shape of the cavity and the lining of the womb
More detailed investigations may also be required dependent on what is found. Some of these may include checking for sperm antibodies, androgen hormone testing etc.
Options of management of Infertility:
These days most would think IVF – test tube babies.
In fact I would say that many couples do not need IVF. Their fertility can be improved by relatively simple means. Examples include the following:
If ovulation is an issue, then there are medications like clomiphene that can improve ovulation.
Correction of thyroid dysfunction and hyper prolactinaemia are also important.
Management of endometriosis may require hormonal or surgical means. Endometriosis can lead to tubal blockage as well and surgical excision of this may be helpful.
Fibroids can also affect fertility and resection or removal of the fibroids can improve fertility. This is particularly if the fibroid is large, blocking the tubes or causing the cavity of the womb to be abnormal in shape.
Improvement in weight, management of other conditions like diabetes etc, also lead to an improvement in fertility. Alteration in medications can also be helpful.
For men, if the sperm is abnormal, all is not lost. Sometimes, this can be due to abnormalities in the testicle or scrotum that can be surgically corrected.
So there are many things that one can consider before taking the IVF step
IVF. This is the ultimate step in trying for a pregnancy. Its use is getting more widespread due to changes in social norms. Couples trying for pregnancy later in life especially in their 40’s and its importance in allowing genetic screening of the embryo in at risk couples of genetic disorders are contributing to its popularity. It is becoming an option for delaying pregnancy. Whilst a great method for many, it is still procedural, costly and has its own accompanying risk. Furthermore, success is not guaranteed.
Whilst we are improving in our understanding of infertility, we are still a long way off from knowing everything about what is makes a couple tick in achieving success in pregnancy. But we have a large number of options now for people to not lose hope in infertility.
These notes reflect my personal opinion and are intended for general advice only. It should not be relied upon for any one individual case. You should consult your own doctor to determine the appropriate management of your own individual situation.