Q:When should a couple worry
A:Ordinarily, if a couple stays
together for 6 months without using contraceptive
methods unable to conceive, it may be time to investigate for
infertility. If the
woman has grossly abnormal menstrual periods, investigations
may be started much earlier.
Q:What is the normal physiology
A: Normally, a woman produces
ova from her ovary. The ova are extruded out
every month at about the 14th to 16th
day of the cycle. This process is called ovulation. These ova are picked up by finger
like tubular organs attached to the womb (uterus)
called fallopian tubes. The ovum travels through
the fallopian tube to reach the uterus.
The sperm from the man enters the woman’s vagina , uterus
and from there, goes into the fallopian tube to
meet the ovum to form a zygote, which is the smallest form of the beginning
of human life. This zygote
then enters the uterus and lodges there to develop
into a foetus and gradually grows there till the woman
delivers the baby.
does conception not occur in the first cycle after marriage in all
A: All couples
who cohabitate together do not conceive immediately after
marriage even if they have not been using contraception for
the following reasons:
may not ovulate in all cycles.
may not meet the ova in spite of being near it.
The zygote may not lodge properly in the uterus.
is important to remember in patients with infertility. When a couple starts infertility
treatment, they should not be disappointed unduly
in case they do not get positive results
in the first or second cycle of trying for a conception.
What are the causes of infertility?
causes of infertility are:
quality of the husband’s sperms. Normally there are
20million sperms per ml of
semen. Decrease or absence
in count, motility etc of sperms may result in infertility.
meaning lack of regular ovulation occurring from
the woman’s ovary.
Usually such women have irregular periods.
in the fallopian tubes due to birth defects or infections.
in the cervix which is the mouth of the uterus.
5. Some immulogical problem, by which the
man or the woman may produce antibodies
against the sperms or ova which render them ineffective.
Q: What are the social causes
A: 1.Poor quality of sperms can
be worsened by smoking and alcoholism.
heat can be a deterrent for the production of sperms.
weight gain as well as excessive weight loss in
the female can lead to
hormonal disturbances which can lead to anovulation
women would do well to cut down on sweets and fatty
foods and to
regularly . These simple and cheap measures could go
a long way in
causes a lot of mental tension. Mental tension
can affect the hypothalamus,
an organ in the brain which controls the production
of all female reproductive
necessary for proper ovulation and conception.
This is the reason why a lot
of women conceive spontaneously
when they are not on any treatment and are not
actively for conception. The
tension release in these months probably
any hypothalamic block that may be posing a problem
5.Long working hours prevent
couples from cohabitating normally, thus causing
apparent infertility. Similarly,
husband is staying abroad, or in another part of
the country also suffer from apparent infertility.
for conception in the 2 or 3 months that the husband
is in station, which may prove inadequate for normal
conception. This leads to over treatment for
infertility as fertility has to be artificially
enhanced in the months that the
is in station.
are the basic evaluations a couple will have to undergo in case of
A: The basic evaluations in a
case of infertility are
history and examination
50% of infertility is caused due to poor quality of semen, a
semen analysis is mandatory in all cases of infertility. If
there are abnormalities in the semen, the man should by
evaluated by way of history and physical examination. History
might reveal noxious factors like smoking, alcoholism, working
in an overheated environment,erectile dysfunction, etc, which
could be remedied. Physical examination may reveal enlarged
veins near the scrotum which is called varicocoel. The presence
of significant varicocoel may mandate surgical correction.
main points in clinical history of a female are menstruation,
coital history and history of abnormal vaginal discharge.
Menstruation: Irregularities in menstruation could be an indication of
hormonal imbalance. Hormonal imbalance results in anovulation,
where the ovum required for fertilisation is not released by the
Regular coital history: Infrequent coitus may lead to infertility if the couple co-habitate
in the nonfertile periods of the cycle. This is particulary
important in couples with different working hours or couples who
stay separately and meet only occasionally. Care should be
taken to see that the couple are together in the fertile period
of the cycle.
Stress: Stress can cause anovulation and a couple desiring pregnancy
should learn to cope up with the stress inherent in the
investigation of infertility. It is easier said than done, as
there is a lot of pressure from social and family circles when
the couple do not concieve for a long time. This coupled with
the tedious investigations and frequent visits to the
gynaecologist can be stressful. However, it is important for
the couple to find some ways to let out their emotions and
remain stressfree, so that they get better results out of their
Abnormal vaginal discharge: At the time of first visit, gynaecologist are generally very
diligent and look for abnormal vaginal discharge and ask for
presence of itching or copious vaginal discharge. The clear
watery discharge coming about 15 days before menstruation is
normal and is helpful for sperms to reach the uterus.. However,
if there is foul smelling discharge, or itching in the private
parts, it is indicative of infection in the vagina or cervix.
This may be harmful for the sperms entering the vagina and will
contribute to infertility. This is usually taken care of by
many gynaecologists by routinely prescribing a course of
antibiotics, antifungal and antitrichomonal agents, which are
tablets which kill organisms causing vaginal infections.
However, when the couple have been infertile for a long time,
this aspect tends to get forgotten. This may be a reason why
when some major factors contributing to infertility have been
treated, the couple continues to remain childless, as this minor
factor is forgotten. Thus it is important for the infertile
couple to report to the gynaecologist any change in her vaginal
secretions, at any point during the treatment for infertiliy.
A good clinical
examination by the infertiliy specialist can detect many
abnormalities, which may then be corroborated with findings of
investigations. Some factors that doctors detect through
clinical examination are as follows:
Improper intercourse: Surprisingly, some couples who come for infertility treatment
are found to not even have undergone normal coitus. This
happens sometimes because, they are either unaware of how
intercourse should be done or sometimes because the man has
difficulty in attaining erection. Embarassment prevents them
from disclosing this to their doctors and in this era where many
doctors rely more and more on investigations and less and less
on clinical examination, this deficit remains undiagnosed,
specially when some glaring deficits like low sperm count or
very irregular periods is present. When gross abnormalities are
present, the onus of investigations shift to correct these
abnormalities and sometimes the lack of intercourse remains
Simple growths like polyps near the mouth of the uterus could be
revealed by a proper clinical examination.
of milk or a watery discharge from the breasts (Galactorrhoea)
could be an indication of increased levels of a hormone called
prolactin , which could cause infertility.
Presence of hair on the upper lip, or a male distribution of
hair on the abdomen, could be an indication of abnormal hormone
levels in the body. However, it must be remembered that not all
women with hair on the upper lip have abnormal hormone levels.
Some could be having just familial hirsuitism.
excessive weight gain, as well as excessive weight loss are
deterrants for normal ovulation .
After a good
clinical examination, investigations will have to be done on
the husband and wife to detect abnormalities which need
attention. The following investigations will need to be done in
the male and the female.
Male infertility affects
almost 50% of infertile couples. A simple semen analysis would
rule out male factor straight away.
Semen should be collected in a clean, dry, wide mouthed
container after 2 days of abstinence. The specimen is collected
after masturbation in the laboratory. Some men prefer to
collect it at home and in that case, the specimen should be
handed over to the labarotary within half an hour noting the
time of collection.
Various tests can be done to find out if a woman is
ovulating or not.
BBT: Basal body temperature:A woman is asked to record her
temperature first thing in the morning, before getting up or
having any beverages. The temperature varies mildly over the
days. If the temperature rises and falls twice in the month,
around midcycle, the temperature chart is said to be biphasic
and indicative of ovulation. However, this is a retrospective
test and can only tell that ovulation has occurred/not
occurred. It cannot predict when ovulation will occur and thus
it is not helpful in planning intercourse.
A woman is asked to undergo ultrasonography every two days
,starting from the 10th day onwards till ovulation is
confirmed. The ultrasonogram documents the growth of the
follicle in the ovaries. The follicle gradually grows from a
size of 8 mm till it reaches 18mm and in a couple of days is
seen no more. This is indicative of ovulation. . Doctors use
this modality of testing quite frequently to know whether a
patient is ovulating , so that intercourse can be timed
appropriately and also sometimes to find out if medications
given for inducing ovulation are working properly or not.
kits: Urine is
tested on alternate days and a special paper is inserted into
it. The change in colour in the dipstick is used to indicate
ovulation. This can be done by the patient at home itself and
avoids the necessity of visiting the doctor every 2 days. But
the overall cost of testing per cycle would be higher than that
of serial ultrasonography done by most sonology centers.
As mentioned before, the
uterus is connected by two tubes which communicate with the
abdominal cavity. These tubes are responsible for the transport
of the ovum , the sperm and in case of successful fertilization,
the transport of the embryo into the uterus. It is done rather
invasively by vaious modalities.
testing: It is
the local language used for testing the tubal patency by
injecting air into the uterus. The gush of air in the abdomen
in the case of patent tubes can be heard through the
stethoscope. It is a very crude form of investigation . It is
hardly ever performed in full-fledged institutions.
Hysterosalpingogram: In this test, a radio-opaque dye is injected into the uterus.
The path of the dye is recorded on an X-ray film. The dye
normally passes through the uterus into the tubes and finally
into the abdomen proving that the tube is open. This test can
be done on a day care basis, but if there is block in one of the
tubes, it can be quite painful.
Any plain fluid is pushed into the uterus and the ejection of
the fluid into the abdomen is recorded on sonography. Unless
very high resolution ultrasonograhy machines are used, it may
not be as accurate as the hysterosalpingogram.
Laparoscopy: Generally in current practice, laparoscopy is not used as a
routine investigation to test the patency of the tube. But if a
patient does not conceive after a reasonable period of time
inspite of treatment, a laparoscopy is done. A fluid with or
without dye is injected into the uterus and the flow of dye
through the tubes is observed through the laparoscope. Any
abnormalities in the abdomen can be corrected at the same
Laparoscopy in infertility:
Laparoscopy is an important modality of investigation in the
investigation and treatment of infertility. Laparoscopy is used
to diagnose any subtle causes for infertility.
factor that affects the motility or patency of the fallopian
tube can cause infertility. Tubal disease has been implicatedin
15-20% of couples presenting with infertility. The tubal ends
are some times closed because of agglutinations. These can be
released through laparoscopic instruments. Releasing adhesions
between the tube, ovary, and the uterus can improve the motility
of the tube
Sometimes in a condition called the polycystic ovarian disease,
might fail. In such cases making tiny holes in the ovary might
help enhance fertility. Picture on the right shows multiple
punctures made into the ovary of a woman with this problem.
Resection and vaporization of endoetriosis is the most common
indication for laparoscopy in infertility. Laparoscopic
treatment of endometriosis yields a pregnancy rate of upto
puncture of ovaries can cure some cases of Polycystic ovaries, one of the causes of infertility.
the time of laparoscopy itself, a scope is passed into the
uterus to make sure there are no abnormalities inside
the uterine cavity. In
case of blocks in the tubal opening into the uterus,
a cannula is passed into the opening to remove the
Sometimes there are polyps or fingerlike
growths in the uterus, which prevent normal conception.
Presence of adhesions or small flimsy bands in the
uterus can also be picked up using hysteroscopy.
Correction of these abnormalities could lead to
Hysteroscopy is also useful in patients who get
pregnant, but continously have abortions. One of the
reasons could be presence of congenital walls dividing
the cavity, called uterine septum. This can be cut
using hysteroscope. Infections can also cause the walls
of the uterus to stick together and this can be cut
using the hysteroscope.
Q: What are
polycystic ovaries: what are the options available for treatment
develop many follicle, about 8-9mm in her ovaries. One of
them become dominant and ovulate. In women with polycystic
ovaries, none of the follicle are able to attain a size capable
of ovulating. These women also have excess of oestrogen in them.
Most of them are associated with obesity. The androgen
level is quite often high in these women and they have excess
hair on their upper lip and hair may grow in a slightly male
pattern. there may be light pigmentation on the back,
called acanthosis nigricans. Many of them have cells which
are resistant to the hormone insulin, which normally digests
glucose in cells. as a result some of them have excess
glucose in their blood.
options; 1.drugs like Clomiphene citrate can be given for 3- 6
months. giving it for more than 6 months may be harmful .
injections can be given
metformin and Pioglitazone can reduce insulin levels
4. In patients
who cannot concieve on clomiphene, laparoscopic puncture of the
ovaries is an option. This is an alternative to hormone
therapy as hormone therapy is expensive.