In this session, Dr Emma Adsuar, Gynaecologist at Pregen (UR Vistahermosa) has explained what standard fertility assessment should look like, what to check, when and why.
It is estimated that 85% of couples can conceive after one year of regular unprotected sex intercourse. When this does not happen, consulting a doctor is suggested. Infertility increases approximately with the woman’s age due to the decrease of the ovarian reserve and deterioration of oocyte quality. For that reason, it is recommended for women who are over 35 years old and have a disease such as ovarian syndrome to visit the doctor before 1 year. In some countries, a differentiation between sterility and infertility is done. In the first place, not being able to conceive is termed sterility, while infertility implies being able to conceive yet not having a live birth.
To understand this, it is important to consider the causes of infertility. It was traditionally believed a long time ago that women’s factor was the most prevalent, yet it was proved male factor is equally important. As shown on the graph:
Firstly, a clinical history will be the first thing to be consulted by the doctor, which is called anamnesis. Through guided questions of anamnesis, an idea might start to arise about the couple’s problem of having a life. Why is it so important to have a family history? It is said to be important because some women have a history of premature ovarian failure in the family. Therefore, any information regarding the family’s side is fundamental.
Secondly, a personal history will be consulted. It is crafted with questions about diseases the patient is having:
It’s also important to ask about any past surgeries, such as appendectomy (it is important because the appendix is close to the ovarian tube). You may be asked about smoking or drugs because it is known these diminish the ovarian reserve. Medication is also known for affecting fertility.
It is essential to know when the patient had the first period in her life, which is called menarche, as it can obscure a genetic problem that possibly indicates a shortage of ovarian reserve. The menstrual formula also is being checked, regular means that the period follows a pattern. If a patient has a period every 35 days, it is correct. If the patient is experiencing very painful periods, it could be explained by suffering from endometriosis. Obstetric history also includes information about previous pregnancies, miscarriages, or abortions.
The second step after the first evaluation is the examination, of BMI (Body Mass Index), whether the patient is experiencing hirsutism or acne. Patients with obesity are known for having problems conceiving. For those patients, a nutritious plan will be given to lose weight before starting treatment more easily. Then, within the general examination, the pelvic exam is also included. Why is this important? It is crucial because some patients may have a hymen perforated so complete intercourse does not occur.
Complementary tests include a transvaginal ultrasound scan (only the uterus and ovaries can be seen. Tubes can only be seen if an abnormality is detected) Normal shape of the uterus as well as fibroid and polyps are detectable. In the same way, the status of the ovary can be analysed.
Depending on the moment, regular blood tests will be ordered to check the status of the patient:
In case a disease in genetics is detected with a karyotype test, egg donation, and embryo biopsy will be recommended before transferring). Other complementary tests include cervical culture – Chlamydia, Hysterosalpingography (tubes can be perceived), Hysteroscopy (the shape of the uterus and tubes are seen with an X-ray through a cannula in the cervix. If the tube is not open, eggs cannot go through it. Only the uterus can be seen. A polyp or fibroid can affect the endometrium and these can be removable during the test), and Histerosonography (ultrasound test).
During the first visit, the female, and male both must accompany each other because it will facilitate the procedure.
Firstly, the male part is also going to be asked about family history (anamnesis) as there might be genetic factors that affect the quality of sperm.
Personal history is also checked:
Physical examination includes BMI (the importance of having a healthy weight as being overweight can increase testicular temperature and affect the quantity and quality of sperm) as well as hydrocele (increment of temperature reduces sperm production), varicocele, and cryptorchidism. A blood test is also required, mostly for safety, as manipulation of sperm will be required.
Semen analysis is also performed, FISH test is requested it can be compared to a karyotype test yet specific to the sperm sample. A karyotype test is also necessary as there can be a genetic condition affecting fertility.
Related reading:
As I said, 2-3 days more is completely normal. Irregularity means that it doesn’t follow any pattern. The pattern can be, for example, every 25 days, this is regularity, or if the patient has a period sometimes every 28 days, some other time every 40, this is irregularity.
We use this in Spain. Infertility happens when you can conceive, but you are not able to have a live birth. Sterility is when you cannot conceive at all, you haven’t had any pregnancy.
Yes, it counts as infertility. The most important thing is if those ectopic pregnancies were in the same tube or not. If its different tubes, I would recommend trying for six more months, but not longer. It also depends on age, but not more than six months, and if it doesn’t happen naturally, then I would visit a fertility doctor.
DNA fragmentation is supposed to be recommended in patients wherein the sperm test, you can see less than 4% of normal sperm.
The most important thing is what do you understand about trying actively because some patients get it wrong when they think that, for example, they have been not using any protection for five years, but in the last year, they wanted to have a baby, so they might think they have been only trying to conceive for one year – but they’re wrong. They have been trying to conceive for five years. You should go to the fertility doctor because if you had three years of unprotected sexual intercourse, even though you were not concerned about your cycles, not thinking that when you were ovulating, and you haven’t had any baby, then I would recommend you to go and visit the fertility doctor.
One is enough. Sometimes, you can see that the patient ovulated in the right ovary, and she got pregnant with the left tube. Nature is really smart, and with one tube, you can get pregnant.
It depends on if you are thinking of IUI, then yes. It will also give us more information, but if you are going to go directly to IVF, I think it’s not necessary. REM is done when you are thinking of starting insemination, not when you are thinking of um in vitro.
I would like to tell you that the success rate is 100 %, but it’s not true. Even with PGT-A sometimes, the success rate is like 60-70%. I’m sure your doctor did everything he could. You can use corticoids, you can use intralipids, heparin. There are some therapies that you can add in the following IVF. The most important thing I would say is for the patient to be relaxed and positive because that helps a lot.
Yes, in my slides, I was talking about specific blood tests for infertility. For example, if you have an autoimmune disorder, thrombophilia, or any of you are a carrier disease, it will not allow you to have a live birth.
