INFERTILITY
DIAGNOSTICS
Advanced diagnostic techniques can be used to identify the cause
of an individual's infertility and indicate the best way to treat
it. Even when no specific problem is identified, today's advanced
reproductive techniques may help the childless couple start a
family. This is certainly a welcome news for couples who are unable
to achieve pregnancy.
In order to understand why pregnancy doesn't occur, we need to
examine the four critical areas which are needed to make a baby -
eggs, sperm, fallopian tubes, and the uterus. The tests, which often
seem endless, will actually fall into one of these areas. In 40% of
cases, the problem will be with the male, in 40% with the female,
and in 10% both partners will have a problem. In some cases, about
10%, no cause can be identified (unexplained infertility) even after
exhaustive testing.
Before starting with tests, the doctor takes a detailed medical
history from the couple, and also performs a physical examination
for both of them, to determine if this can provide clues as to the
cause of the problem. The doctor will need to find out details about
your menstrual cycle, as well as your sexual habits and past history
of surgery or illness, so you should be prepared to answer these
questions. Many clinics give patients a form to fill out, so that
they can provide all this information. A physical examination can
also provide the doctor with useful information, and he will look
specifically for important clinical findings such as abnormal hair
growth, excessively oily skin, or the presence of a milky discharge
from the breast.
However, for most couples, investigations are needed to establish
a diagnosis. These specialized tests constitute the infertility
workup and they can be completed efficiently in one month. Timing
the procedures properly during the menstrual cycle is important and
we have found the following strategy useful in our practice.
The first day the bleeding starts is called Day 1, and the semen
analysis can be done at this time. The wife's blood hormonal tests
for Prolactin, LH, FSH, TSH can be done between Day 3-5 of the
cycle; followed by a hysterosalpingogram (X-ray of the uterus and
tubes) between Day 5-7. Ultrasound for ovulation monitoring is done
between Day 11-16 ; and this is used for timing the PCT (postcoital
test) as well, during which time the cervical mucus is assessed
also. A serum progesterone level is then measured on Day 21, about 7
days after ovulation, and this provides information about the
quality of ovulation. The laparoscopy or hysteroscopy with
endometrial biopsy can be performed in the same month (Day 20-25) if
desired.
With this strategy, time is not wasted, and couples can be
reassured that a possible reason for the cause of the infertility,
if it exists, will be detected within one month.
The workup should not stop when a problem is discovered - it is
still important to complete the testing, since it is possible that
infertile couples may have multiple problems. Many diseases, such as
pelvic inflammatory disease ( PID) which can cause the tubes to get
blocked, can be "silent", so that the patient may have absolutely no
signs or symptoms.
A single test abnormality does not necessarily mean that a
problem exists and the test may need to be repeated, to confirm that
it is a persistent problem.
Unfortunately, it is very common to find that tests are done
piecemeal - or sometimes, not done at all. Often treatment is
started before coming to a diagnosis. Conversely, some doctors take
so long to do the tests that patients get fed up - after all, they
want treatment!
The couple must be seen together and the first test which should
be done is a semen analysis. Sadly, sometimes the wife will have
undergone innumerable tests (sometimes repeatedly); and the
husband's semen analysis (where the problem lies) has not been done
even once.
It is only after the workup has been completed, that a treatment
plan can be formulated - and you will now need to make decisions
about treatment options.