When women have had her tubes taken out because she has had previous ectopic pregnancies and both the tubes have been removed or had a laparoscopy where both tubes are clearly damaged – that is when we can say that she cannot conceive naturally. If the woman has infrequent periods, the chances of conceiving are less but not zero. She could have an odd ovulation here and there and there is still a possibility but the decreased frequency of periods suggest that there is much reduced chance of conceiving naturally.
For primary infertility, the first thing I would recommend is to have your ovarian assessment done and that will involve you having a scan. This scan will involve having a complete look at the shape and size of your uterus, presence of any fibroids, presence of any polyps (this scan can sometimes suggest if there are any large polyps) and looking at your follicular count on the ovaries. There is also a blood test which is the Anti Mullerian hormone (AMH) together with the follicle count and the blood test (AMH) we can conclude what your ovarian reserve is. So there may be a reason you have a very good reserve or you have polycystic ovaries and you are actually not ovulating and that could be a reason you are not conceiving. Or on the scan we could find out there are possible endometriotic nodules that you have so on the ovaries we can see some endometriotic cysts, so that could be a reason as to you not being successful. You may be someone who is having premature ovarian failure and your reserve is much lower than expected for your age and that could be a reason why you have not successfully fallen pregnant. So that is the first line of starting how to diagnose or how to start looking for why if you haven’t fallen pregnant.
The second thing would be to check the patency of your tubes and another thing we must establish is that you are ovulating regularly so maybe doing a 2 phase progesterone blood test which we generally do on day 21 in a regular cycle of 28 days to make sure you are ovulating and that tells us okay you have eggs, you are ovulating that is fine and this is the way to go forward. After this would be to check your tubes to see if they are patent. A blocked fallopian tube can be a cause of fluid in the tube, hydrosalpinx can be a reason why you haven’t successfully fallen pregnant. This will be the initial investigation which we do along with AMH and we also do baseline hormones like FSH, LH and estradiol to see if your baseline hormones are fine. In cases of very low ovarian reserve or ovarian failure, we do see higher FSH as well. Readings are only relevant in the first five days of your cycle. From the first day of your period, it must be done within the first five days of your cycle. These are the initial investigations I would do.
Would normally approach a diagnosis of infertility by first taking a detailed history and that should be from the woman and her partner and the history should cover especially as far as the woman is concerned: for menstrual cycles whether they are regular, how frequently she gets periods, what periods are like, are they light or heavy, are they particularly painful. Talking of pain – is there pain at different times in the menstrual cycle, is there pain during intercourse. So the first, I suppose, method of trying to establish a diagnosis by taking a good history. We also should look at the couple’s history. Are they having regular intercourse? Are they trying to time intercourse and if so are they doing the timing right or are they making a mistake and it you’d be surprised how many times couples are using various tests to time intercourse but they’re getting it perhaps slightly wrong and that can actually harm your fertility and of course, we should also be asking the man questions about his general health, his sexual function and any previous fertility that the man has had or and such relevant things.
