Dr Bell understands that trying to get pregnant can be emotionally draining if it is taking too long. Although he can use IVF if needed (he is an accredited affiliate with Genea), that does not mean that he will push you into IVF unnecessarily.
 
Ideally, with help, you will be able to achieve a pregnancy with minimal or no intervention.
 
Remember, you are not alone!. One in seven couples experience difficulty getting pregnant at some time in their life.
 

Subfertility is common; it affects one in seven couples. The definition of subfertility varies, most couples will undergo some investigations after around one year of trying.

 

About one-third of subfertility cases can be attributed to male factors, and about one-third to factors that affect women. For the remaining one-third of couples, subfertility is caused by a combination of problems in both partners or is unexplained. 

 

The most common male factors include an absence of sperm cells or too few sperm cells. Sometimes, sperm cells are malformed or they die before they can reach the egg.  

 

The most common female factor is an failure to produce an egg each month. Other causes of female subfertility include blocked fallopian tubes, which can occur when a woman has had pelvic inflammatory disease or endometriosis (a sometimes painful condition causing adhesions and cysts). 

 

History and examination

Before any investigations are carried out it is important that we take a detailed history and perform an examination.In the discussions which take place we will want to establish important facts, such as your ages, how long you have been trying, how often you have intercourse and whether either of you have had any pregnancies in previous relationships.

 

Irregular periods may suggest that ovulation is not taking place every month. If periods are particularly painful or intercourse is uncomfortable, endometriosis is a possibility. 

 

On the male partner's side, it is important to know if there have been any operations or trauma to the testes or a significant infection, such as mumps as an adult, which can be associated with a low sperm count. For both partners documentation of alcohol and smoking habits is important, as both of these are associated with reduced fertility.

 

Examination of the woman will include an internal to check that the uterus & ovaries feel normal and to see if there is any particular tenderness or painful areas. 

 

I do not routinely examine the male partner unless the semen analysis turns out to be abnormal.


Essential investigations

Most couples will need to undergo the following investigations.

  • Day 2 hormone profile. This is a blood test that checks whether there is a good reserve of eggs in the ovary and that the hormonal system leading to their release is intact. It is taken on the second day of the cycle (day 1 is the first day of a period). High levels of these hormones are also found in polycystic ovary syndrome, this syndrome may prevent ovulation. 
  • Progesterone test. This will check if ovulation has taken place. It should be taken 7 days before a period, so for a 28-day cycle it is done on day 21. If a period doesn't come 6-8 days after the test, then it will need to be repeated. 
  • Semen analysis. A sample of semen is needed to check the total count, whether the sperms look normal, and if they are moving. It is important to abstain from intercourse for 3 days before the test and to ensure that the sample is transported to the lab without delay when produced. If the first test is low or borderline a second sample is requested to see if this was a one-off result. 
  • Rubella antibody levels. These are checked to see that immunity is present, as this is a good time to repeat the immunisation if not, rather than risk infection during pregnancy, which can cause fetal defects.
  • Thyroid function tests and prolactin - If a woman has irregular or infrequent menstrual cycles, or shows other signs of thyroid disease then it is important check the thyroid gland is working properly. Prolactin is a hormone that is normally involved in production of breast milk and is released from a gland in the brain called the pituitary. An overactive pituitary gland can cause abnormally high levels of prolactin (hyperprolactinemia). This can cause problems with ovulation. 

 

Some patients may need the following investigations

  • Pelvic ultrasound scan – We may suggest this as a part of the initial investigation to check that the uterus appears normal and whether the ovaries have a polycystic appearance. An internal or transvaginal scan is the most accurate.
  • Diagnostic laparoscopy and dye test -  a laparoscopy might be suggested. This involves a general anaesthetic and a telescope look through the umbilicus into the pelvis to see if there is endometriosis.  At the same time some dye is injected to check the patency of the tubes. The chance of couples with unexplained infertility falling pregnant in the first three months after a lap and dye test is about 30%. This may be because mucous or debris in the tube is dislodged and the tube cleared during the test.
  • Hysteroscopy -. A fine telescope is passed through the cervix and the uterine cavity visualised. Hysteroscopy can detect fibroids, polyps, and other factors.

 

Managing female causes of infertility

 Tubal blockage  is diagnosed on laparoscopy.  Laparoscopy also gives the opportunity of taking a close look at the tubes to decide on the usefulness of tubal surgery to open them. If tubal surgery is unlikely to be successful in-vitro fertilisation (IVF) will often be suggested in the first instance. 
 
  • Ovulation problems (Anovulation) Irregular periods strongly suggest that an egg is not being released each month. Sometimes women still cycle but are not ovulating. Treatments for anovulation include;
    • Clomiphene citrate (Clomid) is commonly used to start the ovaries ovulating again. This is sometimes combined with other medications.
    • Ovarian stimulation is a more intensive treatment, which uses injections of hormones on a daily basis and close ultrasound monitoring of the ovary’s response. 
    • IVF  
  • Endometriosis: This is a condition where spots of the lining of the uterus (endometrium) are found inside the pelvis on the ovaries, the back of the uterus and the ligament supports of the uterus.  Extensive endometriosis involving the tubes and distorting the ovary interferes with egg transport and ovulation. It is less clear how mild to moderate endometriosis exerts an effect on fertility. The aim of treatment is to remove all the endometriosis by either cutting it out or burning it away. Mild to moderate endometriosis can usually be managed laparoscopically, but more severe cases may require open surgery. 
  • Tubal blockage  is diagnosed on laparoscopy.  Laparoscopy also gives the opportunity of taking a close look at the tubes to decide on the usefulness of tubal surgery to open them. If tubal surgery is unlikely to be successful in-vitro fertilisation (IVF) will often be suggested in the first instance. 
  • Unexplained infertility. Apart from being terribly frustrating, unexplained infertility means that treatment is not directed at any known cause. One useful treatment option is direct insemination of prepared and ‘optimised’ sperms from the partner (IUI). This involves insemination around the time of ovulation. Pregnancy rates are typically 15% per cycle. Sometimes this technique is combined with ovarian stimulation. If this is unsuccessful after 6 cycles then IVF is usually advised. 


Treatments available for male infertility 

  • Intrauterine insemination (IUI). For various reasons this is much less popular today.
  • Intracytoplasmic insemination (ICSI).  ICSI is a type of in vitro fertilisation (IVF) where one sperm is injected directly into one egg to fertilise it. This is useful for men with even very low sperm counts. Sometimes it is possible to retrieve a few sperm from men who have none seen on semen analysis, by taking a testicular biopsy under anaesthetic. 

 

In conclusion

Remember that infertility is a relative term. It would probably be better to talk about subfertility.  This is particularly true for those couples where no cause for fertility problems is found. Their chance of falling pregnant per cycle is less than that of the average couple but it is not a zero chance. IVF is emotionally and physically draining and it is not risk free for the women. It is not always successful. The decision to go ahead you need is one you need to make as a couple.

Fertility- Getting pregnant or concerns