When should I see a fertility specialist?
Per American Society for Reproductive Medicine, infertility is a disease defined by failure to achieve successful pregnancy after 12 months or more of regular unprotected intercourse. Earlier evaluation and treatment may be justified based on medical history and physical findings and is warranted after 6 months for women over age 35 years.
Female age is a very important component of natural fertility. Apart from this, female infertility can be caused by ovulatory dysfunction (anovulation), tubal/uterine and peritoneal factors and some other unusual or unexplained factors.
Disorders of timely oocyte (egg) production are the most common causes of female infertility. These disorders range from anovulation, oligo-ovulation, to ovarian aging. Anovulation and oligo-ovulation are typically associated with cessation of regular menstrual cycles or longer time periods between menstrual cycles greater than 35 days. Many diseases are associated with anovulation and infertility.
Anovulatory Disorders are approached as classified by World Health Organization (WHO).
- WHO Group 1: Hypogonadotropic hypogonadism or hypothalamic amenorrhea
Causes related with central nervous system, stress, eating disorders, exercised induced ovulatory dysfunction are included in this category. About 35% of adult-onset anovulation may be related with dysfunction of hypothalamus, the region of brain controlling reproductive events, 15% of them may be related to pituitary diseases such as small adenomas of the pituitary gland located just below hypothalamus secreting excessive milk hormone, prolactin. Apart from detailed history and physical examination and hormonal tests, the work-up may include MRI scan of the hypothalamus and pituitary region of the brain. If the life stressors, eating disorders or strenuous exercise are the culprits, life style interventions may result in high success rates in conception after all other causes like male factor were ruled out.
- WHO Group 2: Normoestrogenic or hyperandrogenic anovulation
This group includes women with polycystic ovary syndrome. These patients should also be screened for other causes of increased male hormones and also for metabolic disorders associated with the condition such as lipid profile abnormalities and diabetes. After assessment the management for sub-fertility may include life style modifications, ovulation induction agents like clomiphene citrate (Clomid) tablet or in some cases injectable gonadotropin preparations. Individual decisions may be made for an outpatient surgical procedure to enhance ovulation (ovarian drilling) or some case may need IVF if cannot succeed in conceiving with other methods.
- WHO Group 3: Hypergonadotropic hypogonadism or premature ovarian failure (POF)
May present as diminished ovarian reserve initially. It is called premature ovarian failure (POF) when the menopausal state occurs before 40 years of age, which require a certain test to assure general well-being of the patients. The most realistic chance to conceive for otherwise healthy patients with POF would be through egg donation.
- Gonorrhea / Chlamydia infection or septic miscarriage,
- Abdominal diseases like appendicitis,
- Prior tubal or ovarian surgery, or
- Severe endometriosis.
Some women may have a history of surgical sterilization procedure through bilateral tubal interruption. Through laparoscopy micro-surgical techniques can be applied to restore the issues with the fallopian tubes. If it cannot be treated surgically then In Vitro Fertilization will be the only option to conceive. Some women who underwent surgical sterilization may desire their tubes to be reconstructed. This procedure is called tubal reversal.
Female age is the most important parameter when it comes to natural fertility. We encourage couples to keep their “biological time clock” in mind, while planning to start a family.
Unexplained infertility is diagnosed when the couple has completed a through evaluation without finding a cause for infertility. Some unexplained infertility factors can be uncovered during an IVF cycle observing a low fertilization rate by conventional insemination. Many cases are probably related to multiple factors like somewhat advanced female age of above 35 or 37, semen analysis in low-normal range or advance male age of above 50 years. The treatment for these couples includes life style modifications, superovulation with or without intrauterine insemination and in vitro fertilization.
Understanding reproductive issues in men and women
In couples, about 50 percent of infertility problems are due to female factors; including ovulation dysfunctions, such as anovulation and other menstrual cycle abnormalities, as well as tubal, uterine and peritoneal factors, such as endometriosis. Male infertility accounts for about 30 percent of infertility in couples and the other 20 percent of couples may have a combination of both male and female gender-related factors. A specific reason cannot be identified using current technology for many patients with infertility problems. Fortunately, the majority of these couples with unexplained infertility will eventually have a successful pregnancy with a variety of treatment options.