What is fertility window?
- The best fertility advice in terms of frequency of intercourse is – every day or every other day “around ovulation”.
- Ovulation is usually on day 14 – if the menstrual cycle length (from day 1 to day 1) is 28 days, or on day 16 if periods are 30 days apart.In other words, ovulation usually occurs 14 days before the next period comes.
- The egg only lives about 12-24 hours, while the sperm (if normal) will live in the female’s reproductive tract for up to 2-5 days – while maintaining the ability to fertilize an egg.
- Therefore, the best fertility advice would be to have sex on the day of ovulation, or the day before ovulation (or both).
What causes infertility?
No one can be blamed for infertility. In rough terms, about one-third of infertility cases can be attributed to male factors, and about one-third to factors that affect women. For the remaining one-third of infertile couples, infertility is caused by a combination of problems in both partners or, in about 20 percent of cases, is unexplained.
The most common causes are:
- Ovulation problems
- Tubal infertility
- Sperm problems
- Unexplained infertility
- Female age issues
- Egg quantity
Less common causes:
- Uterine problems
- Previous tubal ligation surgery
- Previous vasectomy surgery
What is Polycystic Ovarian Syndrome?
PCOS, short for polycystic ovarian syndrome, is a common cause of anovulation. It is also sometimes referred to as PCO (polycystic ovaries) or PCOD (polycystic ovarian disease).
In woman with PCOS:
- Do not release an egg (ovulate) regularly
- Have ovaries that contain many small cystic structures, about 2-9 mm in diameter
How is Infertility Diagnosed?
Couples are generally advised to seek medical help if they are unable to achieve pregnancy after a year of unprotected intercourse. The doctor will conduct a physical examination of both partners to determine their general state of health and to evaluate physical disorders that may be causing infertility.
If no cause can be determined at this point, more specific tests may be recommended. For women, these include an analysis of ovulation, x-ray of the fallopian tubes, uterus and hormones. For men, initial tests focus on semen analysis.
How does normal ovulation work?
In a normal menstrual cycle with ovulation, a mature follicle – which is also a cystic structure – develops. The size of a mature follicle that is ready to ovulate is about 18 to 28mm in diameter.
About 14 days after ovulation the woman would be expected to get a period if she is not pregnant.The basic difference between polycystic and normal ovaries is that although the polycystic ovaries contain many small antral follicles with eggs in them, the follicles do not develop and mature properly – so there is no ovulation.Since women with polycystic ovaries do not ovulate regularly, they do not get regular menstrual periods
Can I conceive with PCOS?
The good news is that the chance of getting pregnant with polycystic ovarian syndrome using fertility treatments is very good. The great majority of women with polycystic ovarian syndrome will be able to have a baby with fertility treatment.
For young women under age 35 with polycystic ovaries, the real question is more about which treatment will be effective – and not so much whether any treatment can ever work.
What is unexplained infertility?
Infertility cases in which the standard infertility testing has not found a cause for the failure to get pregnant. Unexplained infertility is also referred to as idiopathic infertility.
What if I don’t respond to the drugs for ovarian stimulation?
A response to ovarian stimulation depends on a number of different factors, the most important include available eggs, appropriate hormone levels, proper administration of any medications and lifestyle/environmental factors.
In order to respond to ovarian stimulation, a woman must have eggs available to respond; this is sometimes referred to as ovarian reserve. If a woman has diminished ovarian reserve (identified by a high blood levels of follicle stimulation hormone (FSH), low blood levels of anti Müllerian hormone (AMH) or a low antral follicle count on ultrasound), she may not have a good response to stimulation.
It is possible that a woman does have the necessary eggs but lacks the appropriate pituitary hormones to respond. In this case, using a different medication- one which may contain both FSH and luteinizing hormone (LH) may allow for an optimal response.
Lifestyle factors can also affect a woman’s response to stimulation. Optimizing weight, diet and stress can also improve a response to ovarian stimulation.
What is HSG?
Hysterosalpingography is an X-Ray test to look at the shape of the uterine cavity and to check if the fallopian tubes are patent.
Does having a dye test improve the chance for getting pregnant?
Pregnancy rates in several studies have been reported to be very slightly increased in the first months following a hysterosalpingogram. This could be to the flushing of the tubes opening a minor blockage or cleaning out some debris that was preventing the couple from conceiving.
- Bladder should be empty prior to the procedure
- You will be made to lie down on your back with your legs in lithotomy position
- A speculum will be placed in the vagina to visualize the cervix
- The cervix will be cleaned with normal saline
- The cervix will be held with a vulsellum
- A dye will be injected via a metal catheter placed inside the cervix.
- An x-ray picture is taken as the uterine cavity is filling and then additional contrast is injected so that the tubes should fill and begin to spill into the abdominal cavity. More x-ray pictures are taken as this “fill and spill” occurs.
The procedure takes about 15-20 minutes.You might have some bleeding and slight stomach pain,this will usually resolve within 4-5 days
What is hystero-laparoscopy?
Diagnostic hystero-laparoscopy is a minimal access surgical procedure to visualise the abdomen and pelvis.This gives the doctors a visual impression of the uterus, fallopian tubes and ovaries .A hysteroscopic procedure will give an idea of the uterine cavity and the ostia(internal openings of the fallopian tubes)
Two to three tiny incisions are made on your abdomen and a telescope is passed inside to visualise the pelvis.A dye is injected into the uterine cavity to check if the fallopian tubes are patent. Sometimes if the ovaries are very large, an ovarian drilling procedure is done in the same sitting.
Post operative period is usually uneventful. You might have a slight discomfort for one to two days . You can start eating normally from the very next day and can exercise normally after a week.
Most patients with unexplained infertility spontaneously conceive after a diagnostic laparoscopic procedure.
What is PGT?
Preimplantation genetic testing (PGT) is a technique in which one or more cells is taken from an egg or embryo for testing to provide information about the genetic make-up of the rest of the cells in that embryo. The embryos are tested on day 3 after egg harvest and then implanted back into the uterus on day 5. Alternatively, the embryos can be frozen after the cells are removed for testing and implanted in a subsequent menstrual cycle.
Patients with many inherited familial diseases can have their embryos tested to determine its genetic make-up. Specifically, this would include patients with a history of single-gene disorders (such as cystic fibrosis or sickle cell anemia) and patients with a history of sex-linked disorders (such as Duchenne muscular dystrophy and Fragile X syndrome). In addition, even families in search of a bone marrow donor may be able to use PGT to bring a child into the world that can provide matching stem cells for an affected sibling.
What are the most common tests done and their function?
Blood tests that might be needed include day 3 follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), AMH, prolactin, progesterone (P4), thyroxin (T4), thyroid stimulating hormone (TSH).
If there is a history of recurrent miscarriages (2 or more) a lupus anticoagulant (LAC) and anti-cardiolipin antibody (ACL) are often done, as well as other tests.
FSH: Follicle-stimulating hormone (FSH) helps control a woman’s menstrual cycle and the production of eggs.For women, a FSH test is done on the third day of the menstrual cycle and is used to evaluate egg supply. For men, the test is used to determine sperm count.
Estradiol: Estradiol is an important form of estrogen. An estradiol test is used to measure a woman’s ovarian function and to evaluate the quality of the eggs. Like FSH, it is done on the third day of a woman’s menstrual cycle.
Luteinizing Hormone Level:In women, luteinizing hormone (LH) is linked to ovarian hormone production and egg maturation.
An LH test is used to measure a woman’s ovarian reserve (egg supply). It is done during a woman’s menstrual cycle to see if she is ovulating or to evaluate PCOS patients.
Serum Progesterone: Progesterone is a female hormone produced by the ovaries during ovulation. It causes the endometrial lining of the uterus to get thicker, making it receptive for a fertilized egg.
A serum progesterone test is used to determine if ovulation is occurring. Since progesterone levels increase towards the end of a woman’s cycle, the test is done during the luteal phase of the menstrual cycle (just before her period starts).
AMH (Anti-Mullerian hormone levels):Blood levels of the hormone AMH are often used by fertility specialists and gynaecologists as part of the evaluation of ovarian reserve and the response of the ovaries to stimulation with injectable gonadotropins (FSH).
This is not really a “test” that we do to help us determine egg quantity and quality – it is part of a treatment for infertility.
The table below has AMH interpretation guidelines from the fertility literature and from our experience. Do not get carried away with the cutoff values shown here. For example, the difference between a 0.9 and a 1.1 ng/ml test result puts a woman in a “different box” in this table – but there is very little real difference in fertility potential. In reality, it is a continuum – and not something that categorizes well.
AMH Blood Level:
- High (often PCOS)
- Over: 4.0 ng/ml
- Normal: 1.5 – 4.0 ng/ml
- Low Normal: 1.0 – 1.5 ng/ml
- Low: 0.5 – 1.0 ng/ml
- Very Low: Less than 0.5 ng/ml
High AMH levels correlate with low cancellation rates, retrieval of more eggs, higher live birth rates and a high chance for freezing of leftover embryos. Low AMH levels (alone) do not predict low IVF success rates in women under 35Couples should not be excluded from attempting IVF due to low AMH values alone because live birth success rates were reasonable in these cases.
Prolactin:Women with unexplained elevations of prolactin over about 50-100 (normal prolactin is below about 20-30, depending on the lab) should have CT or MRI scans of the area of the pituitary gland and sellaturcica at the base of the brain.
Usually, MRI scans are done to get the best images – without radiationImaging is done to look for any tumor, and to measure anything that is found Future scans can then be done to look for significant tumor growth or shrinkage
Larger tumors (such as greater than 1 cm. in size) might eventually require surgery if there is not enough response to medication
High prolactin can cause reduced FSH levels which then results in ovulation problems. The ovulation and fertility problems are treated with drugs to reduce prolactin levels back to normal so that regular ovulation will resume.
Transabdominal ultrasound:For general assessment, doctors often choose transabdominal ultrasound. It is routinely used to evaluate the condition of the uterus and ovaries, and it’s helpful in the detection of cysts.
For transabdominal ultrasound testing, all of the action will happen on your lower belly. To prepare, you may be asked to drink up to six glasses of water an hour before the test, since a full bladder will push the intestines out of the way of the other organs.
Once you’re face-up on the table, the technician will apply gel to your abdomen. This will facilitate the movement of a small, hand-held device called a transducer. The transducer sends reflected sound waves to a nearby computer, producing images on the monitor. You’ll remain still as the transducer is moved gently but firmly over the skin.When you’re done, the gel will be wiped away, and you can empty your bladder and get dressed.
Transvaginal ultrasound:A directed physical exam that may include a pelvic ultrasound should be performed.Ultrasound can help us discover abnormalities with the uterus, fallopian tubes and/or ovaries. We can sometimes see evidence of pelvic scarring, such as when an ovary appears to be stuck to the uterus. We get information regarding the woman’s potential for adequate ovarian stimulation with medications by counting antral follicles.
More often, doctors request higher-resolution images, the kind that can be obtained with a transvaginal ultrasound. It may sound daunting, but it’s not so bad. The transvaginal ultrasound is performed with a small, very thin, sometimes chilly transducer that is covered and lubricated. If you’re allergic to latex, be sure to mention it to the technician before the exam so that a latex-free cover is used.
It’s used for monitoring endometrial development, follicle development, and ovulation, particularly for women who are taking fertility drugs. For these monitoring exams, your reproductive endocrinologist will be present to check your progress, and the good news is that these ultrasound check-ups only last about five minutes.
Doctors also employ ultrasound to guide medical instruments during surgical procedures, such as egg retrieval for IVF. If early pregnancy is detected, ultrasound is commonly used to confirm the location of the pregnancy and assess the gestational sac. And when fertility treatments have succeeded, an ultrasound is frequently used to detect the heartbeat of a fetus, or two!
Ultrasound tests for fertility don’t produce exciting, 3-D, look-at-our-baby sonograms, but they are useful and virtually risk- and pain-free. Most importantly, they provide information that can help and your partner achieve your dreams.
Ultrasound became an important help for the diagnosis of infertility by demonstration of the pelvic organs, of growing ovarian follicles, of intrafollicular structures and of cyclic uterine endometrial changes. Ultrasonic particularities of ovaries and their landmarks such as the ovarian artery, are described. Average ovarian blood flow can be measured. In hormone stimulated cycles, the ultrasonic examination is repeated through ovulation, induction and even afterward. The average diameter of the growing follicle is measured. The results of more than 8000 scans allowed the deduction that ovulation induction would be successful if the preovulatory follicular diameter was between 18 and 24 mm. Where two or more follicles of that diameter are present, multiple pregnancy occurs. The risk of overstimulation can be assessed. The importance of ultrasound is even higher than estradiol because it is impossible to differentiate between one big, some medium or many small follicles with hormone assays. It is possible to see the cumulus oöphorus, but not earlier than 1-2 days before ovulation. Following successful ovulation the mature follicle appears to have a more solid than cystic make-up. Signs of a failure of ovulation are given. Cyclic changes in the histology of the endometrium are described and make it possible to predict ovulation within 12 hr. Ultrasound is an important aid in predicting the time of ovulation more accurately than the basal body temperature and faster and cheaper than hormone profiles. Ultrasound plays a role in egg collection and replacement of the embryo. The detection of ovulation is very important in the treatment of infertility. This was only possible for a longtime by hormone profile. Nowadays ultrasound is an accepted method in the diagnostic procedures of this field. It permits the visualization of the position and size of the uterus, Fallopian tubes and ovaries, the exclusion of genital anomalies and the demonstration of physiological changes of these organs during the menstrual cycle. The main points of ultrasound in the diagnosis of infertility are as follows: Demonstration of the pelvic organs (uterus, Fallopian tube, ovary) and vascular structures. Demonstration of growing ovarian follicles (Measurement of their numbers and sizes). Demonstration of intrafollicular structures (Cumulus oöphorus, Corpus luteum). Demonstration of cyclic uterine endometrial changes. Most of the results were first obtained with high-resolution compound scanners, but the new generation of real-time scanners are equally capable
Ovarian reserve testing can tell us quite a lot about the remaining quantity of eggs a woman has, but it tells us little about the quality of those eggs.
What is semen analysis?
The semen analysis is a very important test and should be done early in the evaluation process. If a severe sperm defect is discovered, the testing on the female partner should be modified, and therapy can be immediately directed to the sperm problem.
About 25% of all infertility is caused by a sperm defect and 40-50% of infertility cases have a sperm defect as the main cause, or a contributing cause.
This is a very simple and important test and should be done early in the evaluation process. Sometimes the test should be done 2, or even 3 times to get an accurate reflection of the numbers and their variation over time.
The most important parameters in a semen analysis are:
- Concentration (often called “count”) – how many sperm are in each ml of semen?
- Motility – what percent of them are swimming forward?
- Morphology – what percent of them are normally shaped?
- Cutoff values for normal vary somewhat, depending on the lab and the interpreter.
The World Health Organization’s 5th edition of “normal semen analysis” values are shown below:
- Semen Analysis Parameter Normal Values
- Volume – 1.5 ml or more
- PH > or equal to 7.2
- Sperm Concentration -15,000,000/ml or more
- Total Motility – 40% or more
- Morphology – 4% or more normal forms (Strict criteria)
- Vitality 58% or more live
White blood cells- Less than 1,000,000/ml
What if my eggs do not fertilize?
Most eggs will fertilize either by IVF or ICSI. However,on rare occasions, fertilization does not occur even with ICSI, presumably because of a problem inherent to either eggs or sperm. In these cases, the use of donor sperm or donor eggs will usually result in fertilization