Infertility work up
Dra Maria Zweig MD
What happens when your trying to get pregnant and nothing happens?
When is it time to worry and do something about it?
It’s a general rule that you should give it at least six month if you are actually trying. Which means that you are consistently being sexually active during the time of ovulation, you are having regular monthly periods and are both relatively healthy. In medical terms we describe infertility if the couple has not gotten pregnant after a year of unprotected sex.
Even though, we think that infertility is on the rise, in actuality it has stayed constant or slightly decreasing at about 6 – 9% of couples throughout time. Maybe, what we are perceiving is that infertility treatment is rising because there are more options available to couples having infertility issues, when in the past there weren’t many. Witch is actually good news for couples struggling to get pregnant.
Is there really a clock ticking away in female fertility?
Yes, unfortunately after 35 a woman’s fertility starts decreasing, especially so after 40.
Rate of miscarriages also start increasing with increased maternal age, as do genetic abnormalities.
This also happens with men but at an older age.
The average time to get pregnant if you have a couple in there 20’s is 4.5 month. If you have the same 25-year-old woman and a 40-year-old man the average time to pregnancy is 2 years.
Thereafter, with increasing male partner age, time needed to conceive keeps taking longer. You also get an increased rate of miscarriages if the father’s age is over 45.
So, when is the time of ovulation during the cycle?
I know that there are apps now available to help a woman know when she ovulates or when her most fertile period is happening, and they do help, but there are somethings you need to know.
- An ovum or egg survives for about 24 hours and sperm survive for 48 hours.
- Ovulation slightly varies from cycle to cycle, so you have to give yourself some leeway.
- Ovulation occurs 14 days before your period. The fist part of your cycle is more variable.
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Simple way to see this is to average your cycles from first day of your period to the next, subtract 14 and that is the probable day of ovulation. If your typical cycle last 30 days, then you ovulate on the 16th day of your cycle. You count the first day of your cycle as the first day of your period. You want to give yourself 3 days either way and at least have sex every other day during this time. I should point out that normal ovulatory cycles are usually shorter than 35 days.
I took all the correct steps to try to become pregnant but it still didn’t work, then its time to work it up.
It takes two to make a baby so we usually try to work up both potential parents to see where the problem may lay.
We need to evaluate to see if the woman is ovulating, passing an egg, every month adequately. That the hormonal milieu around the woman’s cycle is working normally. This includes thyroid, pituitary and ovarian hormonal function testing. We can do these things with blood test, sonograms and/or through endometrial testing (a biopsy of the uterine lining).
We need to know that enough sperm, usually around 70 million per ejaculate are being produced. They need to be motile, have normal forms and that there are no incompatibilities between the couple (allergies). There are many obstacles and a long distance to travel between where the sperm is deposited in a woman’s vagina to where fertilization occurs (fallopian tube).
So, we need strong sperm that have the ability to survive through the woman’s reproductive passageway; successfully swimming towards, and fertilizing the woman’s egg.
We usually ask the man for a semen analysis, a lab test, and/or we do a post-coital test on the woman. In both, we are analyzing the sample for quantity and quality at the time of ejaculation and in vivo after a few hours after sex respectively.
Obstruction between ovum and sperm maybe present, causing the problem. The biggest culprits are previous infections, surgeries, endometriosis or anatomical abnormalities such as fibroids.
Ultrasound evaluation or a special dye evaluation of the reproductive organs, a hysterosalpingogram, may be ordered to checkout the possibility of an obstructed passageway.
Sometimes we order a blood test that raises the suspicion of endometriosis being present. Endometriosis is a condition where even if obstruction is not present, it may be affecting the ability of sperm and egg to travel adequately through the passageway and create problems anyways.
This is usually the last step we perform if needed. This is an invasive surgical procedure. Performed under general anesthesia, usually in a go-home the same day type of setting.
It may be used to evaluate a woman’s reproductive organs more directly, but is usually reserved for when treatment of a problem is anticipated. For example, when endometriosis is suspected and needs to be removed. Also, in the case of obstruction of the passageway due to adhesions or fibroids which also need to be resolved for fertility to be restored.
A common sense approach to infertility testing must be performed and a problem-solving plan must be formulated to resolve fertility problems. This can be trying time for couples, but keep in mind that many advances have been made and many treatment avenues have been opened to couples, that were previously not available.