After some months of trying for a baby, it is very common to begin to wonder if it is going to happen at all. Difficulties are even more unexpected when you’ve already had a baby before without much delay – why should there be a problem this time? It is generally considered reasonable to see a specialist after 12 months of trying, for ‘further investigations’. This article will cover what to expect if you are referred to a gynaecologist or specialist infertility clinic.
Normal conception rates
Even for a normal, fertile couple, the ‘per month’ success rate is around 20%, so it is not at all uncommon for it to take some months to conceive. Overall, around 70% of couples will have conceived by 6 months, 85% by 12 months and 95% will be pregnant after 2 years of trying. Although for a normally fertile couple, the ‘per month’ rate is around 20%, as you might expect for couples where there actually is a problem, this rate is lower. It is useful to know the overall background rate of pregnancy after any given duration of trying, particularly to make sense of success claims of any treatment. Studies have looked at the ongoing success rates after many years and the results are sumarised below:
|Number of months trying||Overall % of couples having not conceived||Monthly success rate (%)||Proportion (%) who will conceive in the next 12 months|
As you can see, ‘infertility’ is really a poor term to use, because this implies that there is no chance of getting pregnant. For most couples who are referred for further investigations, it would be best described as ‘subfertility’, meaning reduced fertility, as there is usually a background fertility rate – it’s just taking longer than they would wish. Of course they will want to exclude an insurmountable cause of subfertility, or one which will definitely require some form of treatment to succeed.
Many people will have tried methods of timed intercourse, detecting ovulation either by temperature changes & cervical mucus production or with urinary ovulation prediction kits. The Royal College of Obstetricians & Gynaecologists advise against this approach as research has not demonstrated that it results in improved pregnancy rates and it is frequently psychologically draining.
Causes of infertility
For conception to occur following normal intercourse, adequate numbers of actively swimming (motile) sperms need to enter the cervix, work their way up the uterus and into the fallopian tubes. At the same time, an egg must be released from the ovary and be able to make its way down the tube to meet the sperm. The egg and sperm combine at fertilisation and the dividing egg makes it way back down to the uterus to implant into the thickened lining of the womb. Any problem along the way may result in problems falling pregnant. The causes of infertility can be considered as follows:
- Ovulation problems 10-15%
- Tubal blockage or endometriosis 30-40%
- Male (sperm) problems 30-40%
- Unexplained 15-20%
These rates are variable for any given population, and are only a guide. When you are seen in the clinic, each of these factors are given consideration, in the discussion before, during the examination and in the investigations subsequently arranged.
What happens in the clinic?
It is important to recognise that although most couples are referred to a gynaecology clinic for investigation of infertility, men should be actively involved – not least because in over one third of cases there is a male contribution to the difficulties conceiving. It is genuinely helpful if both partners can attend the clinic together.
In the discussions which take place, your doctor will want to establish important facts, such as your age, how long you have been trying, how often you have intercourse, if there is any problem with normal intercourse (eg. impotence, penetration problems), and whether either of you have had any pregnancies in other relationships. If you have irregular periods, this may suggest that ovulation is not taking place every month or if they are particularly painful and intercourse is uncomfortable, this might suggest endometriosis. Previous pelvic (PID) or chalmydia infection may be significant with regards to tubal blockage, as might previous pelvic surgery.
On the male partner’s side, it is important to know if there have been any operations or trauma to the testes or a significant infection, such as mumps as an adult, which can be associated with a low sperm count. For both partners documentation of alcohol and smoking habits is important, as both of these are associated with reduced fertility.
Examination will include an internal to check that the uterus & ovaries feel normal and to see if there is any particular tenderness or painful areas. Swabs are sometimes taken to rule out infection. Many men are surprised when they are asked to be examined in an infertility clinic, but it can be helpful. Most clinics do not routinely examine the male partner unless the semen analysis turns out to be abnormal.
What tests will be done?
Tests that might be arranged are directed at checking each of the steps on the way to conception. This typically includes:
A hysterosalpingogram (HSG). This is an outpatient procedure, carried out in the x-ray department. A speculum is passed (like when having a smear test) and a small amount of dye is injected through the cervix. A series of x-rays are taken and this will demonstrate whether the tubes are open or blocked.
Day 2 LH/FSH – this is a blood test that checks whether there is a good reserve of eggs in the ovary and that the the hormonal system leading to their release is intact. It is taken on the second day of the cycle (day 1 is the first day of a period). LH and FSH are hormones that stimulate egg development and release.
Day 21 progesterone – this will check if ovulation has taken place. Low levels of progesterone in a cycle suggests that it hasn’t.
Semen analysis – a sample of semen is needed to check the total count, whether the sperms look normal and their motility. It is important to abstain from sex for a few days before the test and to ensure that the sample is transported to the lab without delay when produced. If the first test is low or borderline a second sample is requested to see if this was a one-off result – was this the best or worst?
Rubella antibody levels – these are checked to see that immunity is present, as this is a good time to repeat the immunisation if not, rather than risk infection during pregnancy, which can cause fetal defects.
These are the baseline investigations, following which it is usually possible to decide what may be contributing to the delay and plan treatment, when and if appropriate. If there is a significant degree of pain with intercourse or painful periods then a laparoscopy might be suggested instead of a HSG. This involves a general anaesthetic and small telescope look into the pelvis to see if there is anything causing the pain (eg. endometriosis). At the same time some dye is injected to check the patency of the tubes. This is also done if an initial HSG suggests that there might be a problem with the tubes, as a HSG alone can’t give all the information.
What treatment might be suggested?
Ovulation problems – a first-line treatment is usually clomiphene, a fertility drug which stimulates the ovary into regular ovulation. It is taken for 5 days at the beginning of a cycle and is usually monitored with a repeat day 21 progesterone the first month to check that it is working. Sometimes a scan is done to check on the developing egg. If this doesn’t work, injections with a stronger hormone is the next step. This is called controlled ovarian stimulation and requires daily injections for the first fortnight of the cycle, with closer monitoring by scan and hormone tests.
Tubal blockage – the treatment for this depends on how damaged the tubes are, after checking at laparoscopy. Small areas of blockage may be amenable to surgery to remove this, but where there is a widespread problem, in vitro fertilisation (IVF, or test-tube baby) is the only option.
Endometriosis – the best treatment for mild to moderate endometriosis is destruction of the lesions at the time of diagnosis through the laparoscope with diathermy (heat) or laser. Severe endometriosis might require more extensive surgery as a separate, planned procedure either laparoscopically, or by open surgery. Medical (drug) treatment is of limited use when fertility is a concern. For more severe disease IVF is sometimes the only option if other treatments have been unsuccessful.
Sperm problems – there is no medical treatment that will correct low sperm counts. Reduction in alcohol, smoking & illicit drug use will improve matters. If the count is very low (<5-10 million) or the motility poor, two other options are available. One is to go straight to IVF (sometimes with direct injection of a single sperm into the egg – intracytoplasmic sperm injection, ICSI). The other option for milder degrees of male factor problems is called intrauterine insemination (IUI). This involves selecting the most motile sperms, concentrating them in the laboratory and injecting them through the cervix at the time of ovulation. It is sometimes combined with controlled ovarian stimulation.
Unexplained infertility – the first-line treatment for this is IUI combined with controlled ovarian stimulation. Clomiphene does not improve pregnancy chances in unexplained infertility.
Although there appears to be a bewildering amount of quite intensive treatments, remember that after only 12 months of trying there is still a reasonable chance of a spontaneous pregnancy without any intervention. Sometimes the outpatient appointment & test results seem to be taking ages to come through. This is not always a bad thing, as many couples find themselves pregnant without any help from us. If it doesn’t happen spontaneously, there is usually something that can be done to improve the chances of success.
Article by Dr Danny Tucker.