Infertility or subfertility

A couple is defined to have difficulty in conceiving after 12 months of unprotected regular intercourse. It could affect 1 in 7 couples, and in 20% cases, male factors could be the issue. Around 85% couples conceive within a year of trying.

For older women (>35 years) or couples with known risk factors for infertility, we generally investigate if there is no pregnancy after six months of trying.

by Dr Astha Dayal

The most common reason for subfertility is stress and anxiety. It leads to decreased libido, further complicating the problem, and the treatments and tests offered are equally stressful.

How do we evaluate fertility in men?

  • A detailed history of a man's past health and medical history are important
    • Childhood growth and development
    • sexual development during puberty
    • sexual history
    • illnesses
    • infections
    • surgeries
    • medications
    • exposure to environmental agents like alcohol, radiation, steroids, chemotherapy, toxic chemicals any previous fertility testing
  • Examination of the male partner, mainly
    • Height and weight
    • Skin and hair pattern-loss of facial and body hair could mean testosterone deficiency
    • Examination of the genitals and breasts to look for any decrease in the size of the testis, Varicocele, or absent vas deferens
  • Semen analysis
    • This is the most important test in male evaluation. It can be given in a laboratory within one hour of collection. One should avoid ejaculation (sex and masturbation) for two to seven days before providing the sample.
  • Hormonal tests like FSH LH Testosterone, Prolactin may be needed if sperm concentration is low
  • In some special cases, genetic or chromosomal tests may be needed
  • Ultrasound of the testis if low sperm count
  • DNA fragmentation test if Semen analysis abnormal

How do we evaluate fertility in women?

  • A detailed history of the women's medical health, including
    • childhood development
    • sexual development during puberty
    • sexual history
    • illnesses and infections
    • Surgeries
    • Medications used
    • exposure to environmental agents like alcohol, radiation, steroids, chemotherapy, and toxic chemicals
    • any previous fertility evaluations
  • Menstrual history of the woman is very important
    • Absent menstrual periods could mean an absence of ovulation, which can cause infertility.
    • Oligomenorrhea, or irregular menstrual cycles can be a sign of irregular or absent ovulation
  • Physical examination including
    • a general examination
    • any signs of hormone deficiency or excess (such as facial hair)
    • a pelvic examination
  • Blood tests
    • Hormonal tests like follicle-stimulating hormone (FSH), estradiol, and anti-müllerian hormone (AMH) level to assess how well the ovaries are functioning,
    • TSH to test thyroid function
    • Prolactin to assess the presence of a benign pituitary tumor.
  • Tests to confirm ovulation, or egg release. This can be done by
    • Blood tests like LH levels, progesterone
    • Basal body temperature monitoring (measured before getting out of bed in the morning) A woman's temperature usually rises by 0.5ºF to 1.0ºF after ovulation.
    • Ovulation kits to check LH levels in urine
    • Ultrasound Follicular monitoring for an accurate evaluation of follicle development
  • Tests to evaluate the uterus
    • 3D ultrasound to look for any uterine abnormalities like a uterine septum fibroids, polyps and structural abnormalities like bicornuate or arcuate uterus
  • Fallopian tubes can be assessed by
    • Hysterosalpingogram (HSG) It involves inserting a small catheter into the uterus. A liquid dye that can be seen on X-ray is injected through the catheter and fills the uterus and fallopian tubes. An X-ray is taken to outline the uterus and tubes.
    • Scarring and obstruction of the fallopian tubes can happen due to pelvic inflammatory disease, endometriosis, or pelvic adhesions after abdominal infection or surgery.
    • Sonohysterogram This is an ultrasound test to check the tubes, where Infusion of sterile saline into the uterus is done by a thin catheter placed through the cervical opening
  • Hysteroscopy In this test, a small tube containing a camera is inserted through the cervix and into the uterus to directly see the lining of the uterus and the sites where the fallopian tubes enter the uterus.
  • Laparoscopy This is a surgical procedure, done to view the uterus, ovaries, and fallopian tubes under general anesthesia.It can detect damage and blockage of the fallopian tubes, endometriosis, and other abnormalities of the pelvic structures. It helps diagnose and treat endometriosis and pelvic adhesions which can help to improve pregnancy rates
  • In special cases, genetic tests may be recommended where a small blood sampling is done

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Dr. Astha Dayal?