Determining the cause of infertility

The investigations now available to a couple who have difficulty in achieving a pregnancy have greatly advanced over the past two decades. Whenever a couple think there is a problem in conceiving, they should seek the advice of their doctor (general practitioner or family doctor). Whenever possible couples who perceive problems in conceiving should be seen together as both partners are affected by decisions surrounding investigation and treatment of infertility.Your doctor will review your past medical and surgical events, especially any prior investigations or treatments for infertility, your current health status, including lifestyle and diet and any occupational risks. Your doctor will ask you about birth control, previous pregnancies and sexual practices within your current relationship. The history may reveal clues as to the underlying causes of your infertility so that the doctor can select the specific diagnostic tests that will identify your cause of infertility. The basic infertility workup typically takes a couple of months to complete. The stress of being tested and waiting for the results may add extra pressure to your emotions, your relationship with your partner and your sex life.Some couples will only need assurance and advice about their general health and preconception care. While others will require referral to an infertility clinic where further investigations are usually carried out such as: laparoscopy and dye test, hysterosalpingogram, screening for chlamydia infection etc. Your doctor is likely to transfer you to see a specialist for the following reasons:

  • If the woman's age is 35 years or more, or if the woman has absent or infrequent periods, has had previous abdominal or pelvic surgery or a past pelvic infection or a sexually transmitted disease.
  • If the man's semen analysis showed absent sperm or poor quality sperm or if there is a problem with sexual intercourse e.g. impotence.
  • If the duration of infertility exceeds 36 months.


Preconception care

Improving your chances by preparing for pregnancy

It is important that you and your partner get off to the best possible start for the much wanted pregnancy. Preparing for pregnancy will not only increase your chance of achieving a pregnancy but may also decrease the risk of complications to both mother and fetus. Here are a few suggestions and recommendations:

Weight and nutrition

It is essential to eat a balanced healthy diet with fresh fruits, green vegetables and plenty of water. Avoid eating processed food as it contains flavouring and additives. Reduce coffee intake. Excess caffeine has been linked to miscarriage and low birth rates (Fernandos 1998 and Cnattingius, 2000). Decaffeinated coffee could aggravate the immune system more than caffeinated variety (Mikuls et al 2003). Diet rich in Omega 3 can significantly decrease natural killer cell activity and suppress the production of TNF alpha cytokines (Frank et al 2001; Gazvani et al 2001). Being overweight or underweight can affect normal ovulation, reduce the chance of getting pregnant, increase pregnancy complications and the risks associated with anesthesia etc. If your body mass index is above 30 you need a supervised weight loss program involving dietary advice and exercise. Obese women take longer to conceive and are at higher risk of miscarriage than ordinary women. If your body mass index is less than 20 then you may also need to go on a sensible eating program to correct it. Restoration of body weight may help resume ovulation and restore fertility.

Changes in lifestyle - How to prepare yourself and partner for pregnancy

• Give up smoking, if this is difficult cut down as much as possible. Cigarette smoking is harmful to the woman's ovaries (smoking has been linked to premature ovarian aging. Kinney 2007). Women who smoke reduce there chance of successful pregnancy by approximately 40% compared with non-smokers. Smoking reduce implantation and pregnancy rates (Neal et al, 2005,. Human Reproduction). Smoking also adversely affects live birth rates equivalent to increased female age by 10 years (Linsten et al, 2005. Human Reproduction). Furthermore, pregnant smokers are more likely to have low birth rate babies and premature birth etc. It has also been associated with an increased risk of placenta previa (low lying placenta) and abruption placenta (separation of a normally sited placenta from its attachment into the womb).

• Reduce or eliminate consumption of alcohol as it may affect ovulation. In addition, there is an increasing body of evidence suggesting harm to the fetus from alcohol consumption during pregnancy including increased rate of miscarriage, growth retardation, prematurity, and developmental delay. Furthermore, excess alcohol during pregnancy is associated with fetal abnormalities such as 'Fetal Alcohol Syndrome'. The syndrome can lead to learning and physical disabilities and behavioural problems.

• Do not use recreational drugs e.g. marijuana, cocaine, etc. or antidepressant drugs. The use of Cannabis by women in the year before IVF treatment is associated with a reduction of the number of eggs collected (Klonoff-Cohen et al, 2006. American Journal of Obstetrics and Gynecology).

• Breast self-examination will help to pick up a breast lump. Breast cancer is rare in young women. However, the high levels of hormone estradiol and progesterone produced by the ovarian stimulation drugs could stimulate the growth of a pre-existing cancer. If you find a lump in your breast, your doctor should assess this urgently. He or she will be able to arrange further evaluation and referral to a specialist when necessary.

• Stop or reduce the caffeine intake. Caffeine is present in coffee, tea, coca-cola, chocolate etc. and is associated with an increased risk of fetal growth restriction (Care study group 2008 BMJ).

• Keep your mouth as healthy as possible and, if you have periodontal disease, get this treated before you become pregnant. There is evidence that treating periodontal disease reduce the risk of having a preterm baby.

Screening by your doctor or clinic

  • • Check if you are immune to Rubella (German measles) as Rubella puts babies at risk of blindness, deafness and mental retardation. Women who are susceptible to rubella should be offered rubella vaccination before they become pregnant.
  • • Check if your cervical smear (PAP test) is in date.
  • • Check if you have a high blood pressure.
  • • Check if you are anemic.
  • • Check if you are diabetic (indicated by sugar in the urine).
  • • Check If you have got kidney disease (indicated by protein in the urine).
  • • Check if you have got genital infection (many genito-urinary infection are asymptomatic).
  • • Check your dental health.
  • • Request certain tests to check for genetic diseases, if there is a history of genetic disorders.

Occupation

Some occupations may reduce male and female fertility such as bakers, drivers, welders, radiotherapists, agricultural workers and woodworkers. The exposure to heat, X-rays, chemical pesticides, solvents, mercury, phthalates etc. may all contribute to infertility.

Folic acid

It is advisable that woman who are contemplating pregnancy should take folic acid, one tablet a day (400 mcg) till the 12th week of pregnancy. This will decrease the risk of neural tube defects such as spina bifida (a hole in the spine) and anencephaly (absent brain) and hydrochephaly (water in the brain). This dose should be increased to 4 mg daily in women who have previously had a baby with a neural tube defect and women who have epilepsy and are taking medication.If you are not very keen to take folic acid tablets you need to eat food which is rich in folic acid such as spinach, green beans, fortified cornflakes and oranges.

 

Advice for men

• Wear loose fitting boxer shorts and trousers.

• Avoid hot baths and take showers instead.

• Cut down smoking and alcohol drinking or stop altogether. Men who smoke heavily or drink too much appear to have lower sperm motility and a higher proportion of abnormal sperm (Fertility and Sterility, 2007).

• If overweight they should loose weight.

• They should avoid exposure to chemicals and radiations etc.


Counseling (counselling)

 The psychological and sociological implications of infertility on the infertile couples are well recognized. From the minute couples realize that they have difficulty in having a child, every step they make in the pathway to achieve this dream can add to their emotional turmoil and financial and physical strain. Infertility, its investigation and treatment can cause significant stress. Added to this, the social and family pressure. Couples are continually reminded of their inability and sense of failure every month when the woman menstruates. Even simple tasks such as daily measurements of woman’s temperature to detect ovulation can be painful.


Taking the first step towards infertility treatment

It takes a lot of courage for the couples to see their family doctor with request of infertility investigations. The family doctor enquires about the ultimate aspects of your relationship may be stressful. Care and skill needs to be taken and explanation of the purpose of the tests are essential.

 

Infertility treatment

The treatment options available to infertile couples

Discovering that you have an infertility problem can be very stressful. You become faced with many difficult decisions to make. There are usually five options available to choose:

  • To purse having a biological child with infertility treatment such as: ovulation inductionintrauterine inseminationIVFICSIGIFT and surgery, etc.
  • Try to have a child who is biologically related to one partner only e.g. using donated eggs or donor sperm and surrogacy.
  • Try to have a child who is biologically not related to either partner through embryo donation.
  • Adoption.
  • Accepting child-free living (stay childless).

After various examinations and investigations, your doctor may be able to diagnose the problem and offer some form of treatment, taking into account many factors such as: the woman's agecause of infertility, how long they have been trying for a baby, previous pregnancy and the cost of treatment.The decision regarding the management of your infertility is yours and yours alone. But it should be noted that the provision of fertility treatments at public health services varies greatly from country to country and even in the same country from region to region. Before you agree to a fertility treatment, we recommend that you consider the following questions :

  • What is the cause of your infertility?
  • Why and how the treatment will be given?
  • What are the alternatives?
  • What is your chance of achieving a pregnancy and a live birth without treatment and how much will the proposed treatment improve your chances of success?
  • How much will the treatment cost?
  • What are the possible risks and complications?
  • How long will you have to undergo treatment in order to give it a reasonable chance to work?
  • Will the insurance cover the cost?
 

Male Infertility

 

Female Infertility

 

Diagnosis Male

 

Diagnosis Female

   
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