Part 2 of the series on infertility

A couple is considered to have difficulty in conceiving if they have had sexual intercourse for a year without using contraception and still have not conceived.

In women who are 35 or older, investigations for infertility may be started after trying for six months.

Investigations for infertility start with a thorough marital history. It is considered natural for a young couple to have intercourse at least two to three times a week.

If the history reveals that the couple is having infrequent intercourse, they may be advised about the best time in the menstrual cycle to conceive and may be reviewed after three to six months.

The next step in the investigation of infertility is a thorough physical examination for the woman.

It is not uncommon to find that the couple has not consummated their marriage out of ignorance, misconceptions about sex, or sexual dysfunction in one or the other partner. Sympathetic counselling will usually solve this problem. Some sexual dysfunction may have to be treated with medication.

The fertile period

The best time to conceive during a menstrual cycle depends on the frequency of the periods. For a woman who has a period every 28 to 30 days, ovulation will usually occur between the 12th and 16th days. (The day the period starts is considered the first day of the cycle.)

To ensure that pregnancy occurs, the couple is encouraged to have intercourse starting from the 11th or 12th day of the cycle, on alternate days, till about the 20th day of the cycle.

These days are considered the fertile part of the cycle. For women who have very irregular cycles, medication may be given to ensure that ovulation occurs at the right time, and the same method is followed.

Investigating the male partner

No investigations for infertility should be undertaken in the woman without a semen analysis for the male partner.

This is a simple test and will rule out a male factor for the infertility. The male partner is advised to refrain from intercourse for four days prior to the test. The test will tell us about the number of sperms, how motile they are and if they are of normal shape and size.

Investigating the female partner

The three things that need to be checked in a woman are:

· Is she ovulating?

· Are her Fallopian tubes blocked?

· Are there other factors preventing a pregnancy?

Investigating ovulation

If a woman is having regular periods, chances are that she is ovulating. If there is a doubt that she is not ovulating, an ultrasound scan may be done in the middle of her cycle to establish whether she is ovulating. Since the egg is released from a follicle, the scan is called a follicular maturation study. Ultrasound studies may also reveal other causes for infertility like endometriosis.

Investigations for the Fallopian tube

The Fallopian tube carries the egg from the ovary to the uterus. The tube is also the place where fertilisation occurs. If the tubes are blocked, pregnancy may not occur.

Hysterosalpingography (HSG) is an X-ray that shows the shape of the uterine cavity and also if the Fallopian tubes are open or blocked. It is done immediately after a menstrual period.

A small amount of dye is pushed into the uterus through a thin tube inserted through the cervix. An X-ray is then taken. The dye outlines the uterine cavity and Fallopian tubes. Spill of the dye is seen if the tubes are not blocked.

Laparoscopy is a procedure that gives more information than a hysterosalpingogram. It allows direct visualisation of the uterus, ovaries and tubes through a small telescope-like instrument that is inserted just below the umbilicus. A dye is pushed through the uterus and the Fallopian tubes are checked to see if they are open or blocked. Laparoscopy also allows the direct diagnosis of endometriosis. Some problems, which could lead to infertility, can be corrected with laparoscopic surgery.

Hysteroscopy is a procedure which lets the gynaecologist look inside the uterus. A thin telescope-like device, called a hysteroscope, is placed through the cervix.

The uterus is distended with a liquid. If there is a minor problem like a polyp or a small fibroid inside the cavity of the uterus, which is causing infertility, it can be removed during hysteroscopy.

The male factors for infertility will be discussed in my next column.