It is common to think that it is easy to get pregnant, but it isn’t. The chance of achieving a pregnancy in a healthy couple who have sex on the day of ovulation are 20%.
This probability is lower as the woman’s age advances, especially after age 35. One in 7 couples may have trouble conceiving, but most achieve their goal when they consult an infertility specialist. A timely intervention gives couples the best chance of achieving pregnancy.
Infertility diagnosis
If you and your partner have had unprotected sex for more than a year and have not been able to get pregnant, you are likely to have infertility and it is recommended to consult the specialist. If the woman is over 35 years old it is recommended to consult after 6 months if the same situation occurs in order to avoid delaying any treatment that is necessary. Other indications of earlier consultation are the presence of irregular menstrual cycles which would indicate ovulation disorders, history of ovarian or uterine (womb) surgeries for fibroids, endometriosis or if you or your partner has known fertility problems. If you are planning to seek a pregnancy and the woman is over 37 you should consider an immediate consultation with an infertility specialist.
Infertility work-up
Causes of infertility are found in men up to 40% of the time, in women in 40% and in 25% of the time, causes of infertility are found in both partners.
That is why it is necessary to evaluate both partners initially by means of an interview where they will be interrogated by antecedents or symptoms and a physical examination with the objective of detecting the 3 main causes of infertility:
- Alteration in number or functionality of spermatozoa
- Ovulation disorders
- Fallopian tube obstruction or blockage
Evaluating the male partner
As the male factor may be involved as a cause of infertility in up to 40-50% of cases, it is essential to include it within the initial assessment of the infertile couple. Find out what tests are performed in these cases.
Semen analysis is part of the basic exams in the evaluation of the infertile couple. This is the test that allows us to discard or confirm if the male factor is involved as a cause of infertility regardless of whether the male had childrens previously.
The test is performed by analyzing a semen sample to determine sperm characteristics such as volume, quantity, motility, and shape that are important to evaluate the ability to fertilize the egg.
The semen sample is obtained by masturbation after a minimum sexual abstinence of 2 days but not more than 7 days. It is ideal to take the sample in the laboratory because certain characteristics of the sperm can be altered by changes in temperature and time that can occur when taking the sample at a distant site. There is a private and comfortable place in our facilities of the Reproductive Medicine Unit to take the sample. One of our assistants will provide you with a sterile container to collect the sample the day of the test.
The result will be delivered the next day and your analysis will determine whether it is normal or abnormal. In the latter case it may be necessary to take a new sample since the characteristics of the spermatozoa can vary and could be normal when the test is repeated a few weeks later. In case of persistent abnormality in the results, additional tests will be done to try to determine the cause and try to correct it or suggest some treatment indicated for such cases as: intrauterine insemination , in vitro fertilization , or ICSI .
Hormones are substances that regulate the functioning of the reproductive system and the production of spermatozoa. An abnormal sperm count may be a result of a hormonal alteration so measurement of blood hormones may be necessary in the assessment of male infertility.
Ultrasound is a test that uses sound waves to create images of parts of the body that are displayed on a screen. The male reproductive system can be evaluated by ultrasound to obtain important information that allows us to diagnose the cause of male infertility. Decreased testicle size, varicose veins (varicocele), and dilatations in the ducts that communicate the testicles with the urethra are some of the findings that may explain alterations found in male with infertility.
Evaluating the female partner
The women evaluation is aimed at answering the following questions:
Is the uterus (womb) suitable for implantation of the embryo and the development of pregnancy?
Is there any obstruction in the tubes that prevents the egg and sperm from being found?
Are the ovaries developing and expelling a mature egg every month?
Are there enough eggs in the ovary to facilitate pregnancy?
Female fertility tests
Trans vaginal ultrasound allows a very close picture of the uterus and ovaries. It is one of the most versatile tools not only for the diagnosis of pathologies in these organs but also to guide and follow many treatments to correct the infertility.
Ultrasound is a test that uses sound waves to create images of parts of the body that are displayed on a screen. It plays a fundamental role in the evaluation of women with infertility and allows visualization of the uterus (womb) and ovaries.
It is part of the initial evaluation of the woman with infertility and allows evaluating alterations such as fibroids in the uterus or cysts in the ovaries. It helps the doctor measure the thickness and appearance of the endometrium (inner layer of the uterus where the embryo is implanted) during the initial evaluation or during the preparation of the recipient’s uterus to perform a frozen embryo transfer or during an egg donation procedure. It is used during the treatment phase to monitor the growth of follicles during a natural or stimulated cycle in order to decide the most appropriate time to have sex (timed intercourse), schedule an intrauterine insemination , or decide the appropriate time to retrieve the eggs during an in vitro fertilization procedure. It is also used to count the follicles (cystic structure where the eggs are found in the ovary) as a method to evaluate the ovarian reserve (number of eggs remaining in the woman’s ovary).
Trans vaginal ultrasound requires an empty bladder. You will be taken to the examination room and you will be asked to undress from the waist down. A lubricated and covered vaginal transducer will be inserted through your vagina. The procedure is not painful. Sometimes, to better evaluate the uterine cavity (site where the embryo will develop) the ultrasound is supplemented by the instillation of liquid (sterile saline solution) with a catheter (small plastic tube) through the cervix (part of the womb that communicates with the vagina) in order to separate its walls and detect lesions such as polyps or fibroids that may interfere with the implantation of the embryo and cause infertility or treatment failures. This procedure is called sono histerography.
Depending on the reason for which the ultrasound is being performed, you will be informed of the result immediately but sometimes and especially during cycle monitoring, it is necessary to complement the findings with the result of hormonal tests requested simultaneously. In this case only the complete information will be given in the afternoon after knowing the result of the hormonal tests.
It is a very important test that allows evaluating simultaneously the form of the uterus and the tubes status. It is a fundamental part of the initial evaluation of women with infertility.
Learn more about this test, which is full of myths.
Hysterosalpingography (HSG) is an x-ray exam that involves inserting a liquid with iodine (contrast media) through the cervix (the part of the womb that communicates with the vagina) which you can see as a white color with x-rays. The medium contrast draws the inner contours of the uterus and shows the trajectory of the fluid through the tubes confirming that they are not obstructed when the liquid is seen to exit through them into the pelvic cavity.
HSG is recommended in couples with infertility to ensure that the uterine cavity is normal and to discard the presence of lesions such as polyps, fibroids, or scar tissue (adhesions) that may interfere with the implantation of the embryo and causes infertility, failed treatments or recurrent miscarriage. Also to ensure that the tubes are not obstructed or if they present dilation (hydrosalpinx) that can interfere with the results of a treatment as in the case of in vitro fertilization
The HSG is programmed within the first 12 days of the menstrual cycle (before ovulation) in order to avoid exposing the body to x-rays or invading the uterus during a period in which there may be a pregnancy that has not yet been diagnosed. Once you arrive at the site you will be asked to lie down on the x-ray table, the doctor will introduce a speculum to visualize the cervix in order to place a cannula through which the contrast media will be inserted. Simultaneously an x-ray machine will take pictures of your pelvis to observe how the fluid goes through the uterus and the tubes. Some mild to moderate cramps may occur during the procedure so it is recommended to take medication for menstrual cramps one hour before the procedure.
The doctor can give you a preliminary report but the definitive result is after reviewing the images carefully in the office. In case of alterations in the uterine cavity, a hysteroscopy or a laparoscopy will probably be recommended in case of suspected tubal obstruction in order to confirm the findings and try to correct them with surgery. In some cases the results may indicate that the alteration of the tubes may be secondary to an irreparable damage and you will be recommended in vitro fertilization .
Laparoscopy is a procedure in which much progress has been made in the history of modern surgery. It plays an important role in the diagnosis and treatment of diseases and alterations that affect fertility.
Laparoscopy is a minimally invasive surgery that allows visualizing the pelvic organs by inserting lens through an incision no larger than 1 cm, usually through the navel. It is used to diagnose some causes of infertility, and also can be used to correct many pelvic disorders by surgery introducing thin instruments such as scissors, grasping instruments, biopsy forceps, electrosurgical or laser instruments, and suture materials through additional pelvic incisions (no more than 2 or 3) usually no more than 5 mms. This procedure requires general anesthesia but is done on an outpatient basis (does not require hospitalization)
In the patient with infertility and depending on certain special conditions it is recommended to diagnose and to operate some alterations that can cause infertility when these are suggested by previous fertility test like the HSG or antecedents in the past medical history. Partial or total obstructions of the fallopian tubes, pelvic adhesions and ovarian cysts are pathologies that can be operated by laparoscopy. It is also used for the diagnosis and treatment of endometriosis in patients with infertility who also present pelvic pain or severe menstrual cramps.
After the laparoscopy you will have a follow up appointment in the office where the findings and results of the procedure will be discussed. Depending on the case, you will be advised to: wait for a reasonable period of time for pregnancy as a result of the intervention, consider a complementary treatment such as ovulation induction and intrauterine insemination or go directly to in vitro fertilization.
Hormones play an important role in human reproduction, in women regulates the development and expulsion of the eggs each month (ovulation) and prepare the uterus to be receptive and suitable for the implantation of the embryo product of the fertilized egg.
Some hormonal imbalances can cause ovulation disorders that prevent pregnancy. Measurement of certain hormone levels give adequate information about whether this process is being carried out correctly or why, if not.
To confirm whether you are ovulating during the initial infertility work-up process.
To investigate the causes of ovulation disorders diagnosed by abnormal results at baseline, history of irregular menstrual cycles or findings at physical examination that may suggest hormonal disorders.
For ovarian reserve testing.
Measurement of hormone levels is done by taking a blood test. Usually it is not necessary to be fasting for your measurement but depending on the hormone to be measured this may be necessary. It is recommended to be at rest for at least 30 minutes before measuring some hormones, keep in mind this factor to calculate your time spent in the laboratory. Depending on the hormone you are going to measure you will be scheduled to take it at a certain point in your menstrual cycle.
The ovarian reserve is a term that refers to the number of eggs left in the ovary. This affects the reproductive capacity of the woman and the response to certain treatments.
The woman is born with a certain number of egg, these are spent as the life goes on from the womb to the menopause. Having an idea of how many eggs remain is important in assessing the woman with infertility and in making decisions regarding the type of treatment that is most convenient.
It is recommended to test the ovarian reserve in women who plan to become pregnant after the age of 35, when there is a family history of early menopause, when there is only one ovary, history of ovarian surgery, history of chemotherapy or radiotherapy, unexplained infertility, poor response to stimulation of ovulation with injectable hormones and when there is an indication of in vitro fertilization.
Through blood tests that measure levels of some hormones such as Estradiol, FSH and LH between the first and third day of the menstrual cycle or any day of the menstrual cycle in case the hormone to be measured is Antimullerian Hormone. The ovarian reserve can also be measured by trans vaginal ultrasound, by counting antral follicles (cystic structures where the ova are) in each ovary.
When the results are normal you can opt for basic treatments ranging from timed intercourse to intrauterine insemination. In cases where the results show a decrease in the ovarian reserve, it is recommended to move quickly to treatments that guarantee a greater probability of success such as in vitro fertilization or eventually egg donation or embryo donation.
Causes of Infertility
It is very important to know the infertility causes. Through a rapid and effective evaluation it is possible to establish a diagnosis and choose the most appropriate treatment for each case. The most common causes of infertility are described in this section.
Male Infertility Causes
Alterations of the male factor are responsible for up to 50% of the causes of infertility. These changes can affect the production and transport of sperm from the testicle to the urethra, their motility, shape and their ability to fertilize the egg.
They are produced by factors that directly affect the testis where sperm are produced.
Congenital abnormalities (from birth) such as the presence of the testicle in the inguinal canal, varicocele (varicose veins in the testicles), infections, trauma, hormonal maladjustment, exposure to some toxic substances or radiation, chemotherapy, and some medications may alter the spermatozoa production.
A medical history, physical examination by the urologist, semen analysis, ultrasound, and a hormonal assessment may determine if you have an alteration in sperm production.
When the cause of the problem is found it is possible to establish some type of medical treatment with good results as in some cases of hormonal imbalances. An improvement can also be achieved in cases where the varicocele is operated, especially when it is moderate to severe and the alteration produced in the parameters of the semen analysis is slight. In many cases the cause of the problem is not found and the treatment is aimed at trying to achieve pregnancy through procedures such as intrauterine insemination , in vitro fertilization and ICSI .
Sometimes the sperm cannot reach the urethra due to obstructions somewhere along the way.
Inflammatory processes from infections, scarring after surgeries, or congenital absence of the vas deferens (a duct that carries the spermatozoa from the testicle to the urethra) may cause obstruction to the passage of spermatozoa and these may not be in the semen or be in very little quantity.
When spermatozoa are not found in the semen analysis (azoospermia), there may be an obstruction. Physical examination and ultrasound studies can help diagnose this type of problem along with confirmation that the production of spermatozoa in the testis is normal through a hormonal assessment.
Although surgery may be an option, it is often more practical to obtain the sperm directly from the testis and to inseminate the eggs in the laboratory through in vitro fertilization and ICSI. Intrauterine insemination with donor sperm is an option for couples who do not consider previous treatment.
There is a barrier in the testis that isolates sperm from antibodies (substances that defend the organism from foreign cells). Sometimes this barrier can be broken for various reasons and the spermatozoa are “attacked” by antibodies.
When antibodies bind to sperm, they affect their mobility and ability to fertilize the egg, causing infertility.
When the semen analysis shows a large percentage of sperm cells linked to each other, they may be affected by antibodies. In this case a measurement of sperm antibodies in the seminal plasma may be required to confirm or rule out this situation.
When anti-sperm antibodies are detected in patients with infertility, the sperm can be “washed” in the laboratory with different techniques in order to perform intrauterine insemination with a selection of spermatozoa without antibodies and with good motility. In vitro fertilization with ICSI may also be performed to ensure fertilization of the egg.
In the woman
Alterations in the female reproductive tract can cause infertility in up to 50% of cases. It describes the most frequent causes.
The uterus or womb is the organ where the embryo is implanted and developed and is the site where the spermatozoa must pass to reach the fallopian tubes. Within the female causes of infertility the problems of the uterus is present in a 5 to 10% of the times. Know what diseases can affect the uterus, how to discover and treat them.
The uterus can be affected by different conditions or pathologies:
Congenital malformations: These are defects of the uterus that originate during the formation of the female fetus even in the womb. They can range from the absence of their formation (agenesis) to complete duplication (double uterus) or septate.
Fibroids: This is perhaps the most common pathology of the uterus. They are benign tumors that originate from the uterine muscle. They rarely cause infertility on their own, but they can grow and disrupt the uterine cavity, making it difficult for sperm to rise or implantation, causing difficulty in achieving or maintaining pregnancy.
Intrauterine adhesions or synechiae: These are scars that form in the uterine cavity secondary to infection or trauma by curettage or surgery. They alter the uterine cavity and its circulation, making it difficult to implant the fertilized egg (embryo)
Chronic inflammation (Endometritis): Caused by infections that rise from the vagina
Polyps: These are benign tumors that originate in the lining of the uterine cavity (endometrium). When they are very large, produce irregular bleeding and inflammatory changes that make implantation of the embryo difficult, causing infertility.
The uterus can be evaluated in different ways, depending on your particular case, which will be the most appropriate method for you. Ultrasound and hysterosalpingography are usually the initial methods for detecting uterine abnormalities. Ultrasound is also used with saline solution (sonohysterography); this method consists of distending or separating the walls of the uterus with this liquid to obtain a better visualization of the cavity with ultrasound. Hysteroscopy is a minimally invasive procedure that allows us to confirm the findings found with previous methods and to correct them with surgery.
Usually the pathologies that affect the uterus and its cavity are corrected with surgery. Most of the time and depending on the case, it is performed by minimally invasive procedures such as laparoscopy in the case of fibroids or hysteroscopy in case of some congenital malformations, myomas in the uterine cavity, synechiae or adhesions and polyps with very good results for the majority of patients.
The fallopian tubes are tubular structures that communicate the uterus with the ovary. It is the site where the egg coming from the ovary after ovulation meets the sperm. The tubes can become blocked or damaged and cause infertility. Learn more about this cause of infertility.
Approximately 25% to 30% of women suffer from infertility due to damage or obstruction of the tubes. This is secondary to infectious processes often sexually transmitted, pelvic surgeries, endometriosis or other inflammatory or infectious processes in neighboring organs such as appendicitis.
Tubal obstruction is detected usually during the initial infertility workup by hysterosalpingography. Laparoscopy is a minimally invasive procedure that allows the evaluation of the fallopian tubes through direct visualization in surgery, as well as identifying if the tubes are obstructed, laparoscopy allows the detection of adhesions or scars that interfere with the movement of the tube and pick the egg up going out the ovary after ovulation. Testing in the blood antibodies against Chlamydia (a microorganism that causes infection in the tubes) allows knowing if the patient has had contact with this germ and also giving correct information on the condition of the tubes.
Tubal obstruction can be corrected with surgery but when the damage is very severe the most recommended treatment is an in vitro fertilization, a procedure that does not involve the fallopian tubes.
Endometriosis is a disease that can be present in up to 50% of women suffering from infertility. Find out what it is and how it is best to diagnose and treat it.
Endometriosis is the presence of tissue that lines the cavity of the uterus (endometrium) outside the uterus, usually in the pelvis, ovaries, or intestines. This tissue has the same characteristics and behavior of the normally located inside the uterus and responds in the same way to the hormonal stimuli, growing during the cycle and bleeding at the time of the period producing pelvic pain, menstrual cramps (dysmenorrhea) and infertility secondary to the cicatricial process (Adhesions) as a cause of inflammation.
While it is true that the history of symptoms and some findings at physical examination may suggest the presence of endometriosis, the only way to detect it accurately is by introducing a special telescope through the navel into surgery to look at the pelvis directly (laparoscopy). Occasionally endometriosis produces cysts in the ovaries (endometriomas) that have a typical appearance on ultrasound and may also be suspected by this method.
The pain associated with endometriosis can be treated with medicines that block ovulation but this treatment does not works to treat infertility. When the patient has infertility and depending on each particular case, minimally invasive surgery (laparoscopy) should be used to remove this abnormal tissue from the ovaries and tubes, or increase the chances of pregnancy through treatments such as intrauterine insemination and in vitro fertilization.
Ovulation is the release of a mature egg from the ovaries, it is critical to the achievement of pregnancy. Up to 25% to 30% of women experience infertility due to ovulation disorders. Learn more about this problem.
Usually women release an egg every menstrual cycle (ovulation), sometimes this process is altered by changes in body weight, alterations in the functioning of other hormones such as prolactin, thyroid hormones and polycystic ovarian syndrome.
When you have very frequent menstrual cycles (less than every 21 days) or prolonged for more than 35 days, you are very likely to have ovulation problems. Some patients who have menstrual cycles within the normal range may also have abnormalities in ovulation and in this case it is necessary to perform hormonal tests such as progesterone measurement or serial ultrasound (follicular follow-up) to confirm ovulation.
There are different medications to treat ovulation disorders but changes in diet and a healthy lifestyle to achieve an ideal weight are essential in the success of the treatment.
Woman age is very important in reproduction. The ease of getting pregnant and the risk of miscarriage and having a healthy baby are affected with age.
The woman is born with a quantity of eggs that is determined genetically, these are gradually losing but during the thirties this loss accelerates until the menopause. This phenomenon that is part of the normal process of aging causes a declining of the ability in achieving pregnancy, increased risk of miscarriages and having babies with chromosomal disorders such as down syndrome. Another factor contributing to the decline in age-related reproductive capacity is the possibility that at an older age, there is an increased risk of advanced diseases affecting fertility such as endometriosis, fibroids or diseases of the fallopian tubes.
When you want to conceive after the age of 37 it is necessary to turn to an infertility specialist as soon as possible in order to optimize the strategy to achieve a pregnancy soon. There are different methods by measuring hormones and ultrasounds to evaluate the number of eggs available at a given age (ovarian reserve testing)
It is not possible to reverse the process of reproductive aging. When a decrease in ovarian reserve is detected, it is recommended to move into a faster and more effective treatment to achieve a pregnancy such as in vitro fertilization, but when there are very few good quality eggs available it may be necessary to use egg donor treatment. When you want to postpone fertility to advanced age, you should consider freezing the eggs at an age when there are still enough good quality eggs (ideally before the age of 33). This strategy is known as fertility preservation.
