BACC GUIDE TO INFERTILITY

The term infertility refers to the inability of a couple to conceive after one year of unprotected intercourse (two to three times a week). For women > 35 years of age, the time limit is 6 months. 

Couples have to take an appointment for a consultation with Dr Kamini Rao.

At the start, one of the assistant doctors will meet with the couple to gather all relevant details pertaining to their past and current problems. This is followed by a clinical examination. The couple then meets Dr Kamini Rao, who will go through the data, and decide accordingly on investigations and treatment.

Evaluation for infertility is spread out, over a short period of time usually 2 - 3 weeks.  The purpose is to detect a cause for the infertility in either the man or woman or both, and plan treatment strategies.

It is important for the couple to be aware that both of them need to go through certain tests, as infertility is a “couple” problem.  Hence work schedules, retionships and sexual practices may be temporarily affected. The couple is encouraged to put forth their queries and doubts to the doctor, who in turn will have reasonable answers to their problems, at the end of the evaluation. 

TESTS MANDATORY TO BOTH PARTNERS 

HIV (human immunodeficiency virus): This is a blood test performed to detect the presence of HIV or AIDS.  HIV has an incubation period of 2-6 months.  This means that if an individual has been recently infected with HIV, it may show up in the blood test only 2-6 months later.  A HIV positive result warrants further confirmatory tests and counseling of the couple. 

HBV & HCV: This is a blood test to diagnose the presence of hepatitis caused by either the ‘B’ virus or ‘C’ virus.  Their presence is a health hazard to medical personnel who can get infected with the same, during handling of blood, tissues or body fluids.  Their presence in either one or both the partners does not exclude them from evaluation or treatment, but only serves to highlight the precautions to be followed by the staff at the clinic/hospital 

FEMALE EVALUATION

Some of the routine tests will be outlined in brief.

Hormonal evaluation – Testing for hormones will assess the normalcy of menstrual cycles or ovulation. This includes the following:

Thyroid: A normal thyroid function is essential to achieve and continue a pregnancy. Hence hormones released by the thyroid such as Thyroxin (T4) and tri-iodothyronine (T3) are measured. In addition, the hormone controlling the function of the thyroid gland i.e. thyroid stimulating hormone (TSH) released from the pituitary gland in the brain is also measured.

These tests can be done at any time of the month with no particular reference to the menstrual cycle. Abnormal levels of the hormone if detected, is usually treated with drugs.

FSH/LH: Follicle stimulating hormone (FSH) and leutinising hormone (LH). These hormones are secreted by the pituitary gland in the brain. FSH is responsible for the development of the follicles within the ovary.  The follicle is a tiny structure that contains the egg or oocyte or ovum, which is the female contribution to conception.  A normal FSH level indicates normal functioning of the ovaries.

LH is responsible for ovulation i.e. release of the mature egg from the follicle by rupture of the follicle. FSH/LH ratio should be in the normal range for normal ovarian function.   

Both these hormones are usually tested in the first few days of the menstrual cycle i.e. D2, 3 or 4.  Abnormalities of the same can be treated with drugs.

Prolactin:  Prolactin is a hormone secreted by the pituitary gland. It plays an important role in ovulatory function.  It can be measured on any day of the cycle. The woman should fast overnight i.e. the test should be done on an empty stomach after 8-12 hours of fasting. High prolactin levels can be treated by medications. If levels are very high then further testing may be required before starting treatment.

Androgens:These include testosterone and dehydroepiandrosterone sulphate (DHEA-S). In the female these hormones are produced by the ovary and adrenal cortex (a small gland on top of the kidney).  They play an important role in ovulation and their levels are diagnostic of certain ovarian or adrenal disorders.

Ultrasound scan: The term ultrasound refers to very high-frequency sound waves, which are above the human hearing range. Ultrasound is based on the principle that when any form of energy is applied to a quartz crystal it vibrates to produce waves. This wave strikes the various tissues and is reflected back to the quartz crystals, which in turn produces a corresponding electric current. This current is further processed by the machine to be displayed as images.  The image is displayed in various shades of gray depending on tissue density e.g. bone appears white and fluid appears black.

An ultrasound scan is done to visualize the uterus and ovaries. Normal tubes cannot be seen on a scan. The scan is usually done via the vagina i.e.transvaginal scan (TVS). The woman is instructed to pass urine prior to a scan.  The patient lies on the examination table with her legs bent at the knees or held against her abdomen.  The probe is covered by a condom or rubber sheath. Contact gel is first applied to the probe tip and even on the outside. The probe is gently introduced into the vagina. There is very little discomfort to the patient. It is not done in cases where the hymen is intact. Read more

Diagnostic procedure

This may include one or more of the following procedures:

·        Hysteroscopy

·        Laparoscopy

·        HSG

Sonosalpingography -
In this test, under ultrasound guidance one can observe the passage of fluid i. e. saline (injected into the cervix via a syringe attached to a catheter), through the uterus into the tubes and finally spilling around the ovaries into the pouch of Douglas. This is an outpatient procedure.

MALE EVALUATION

This includes semen analysis, and semen culture and sensitivity.

Semen analysis A semen sample is collected from the male by masturbation into a sterile wide-mouthed container provided by the laboratory. Prior to the collection, the man must abstain from sexual intercourse or masturbation for a period of 3-5 days. The sample is analyzed for various parameters to assess the normalcy of the semen.

Semen culture and sensitivity is done to test for the presence of any infection in the semen. If present, it is treated by a course of antibiotics.

Hormonal assays. If the semen sample shows significant abnormality then hormonal tests such as FSH, LH and testosterone may be advised as these hormones play an important role in sperm production.

After the above basic evaluation the couple are advised to take an appointment with Dr Kamini Rao. At this visit they will be given a copy of all the evaluation reports. The doctor will interpret the results for them, and based on the findings a treatment plan will be outlined.