Female Infertility

When to Seek Help?

After 6-8 months of trying to conceive without pregnancy, you might begin to wonder whether you should seek professional help. While the answer to this question mostly depends on the woman’s age-YES, if you’re 35 or older- other factors should prompt you as a couple seeks help sooner.

We encourage you to take a proactive approach in diagnosing the causes of their infertility by paying attention to their menstrual cycle and medical history. So let us go through the interview:

How long have you been trying to conceive?

If the answer is three years or longer, and especially if your menses are regular, the cause of your infertility is probably severe. Severe male factor, tubal damage, pelvic adhesions, and advanced endometriosis are often involved in chronic infertility, and these conditions require the most aggressive treatment such as IVF.

As can be seen below, most couples (93%) will achieve pregnancy after two years of trying. There is only a minimal increase in pregnancy rate (to 95%) when trying on your own for another year. After three years of infertility, you should seek professional help.

What is the duration of your menstrual cycle?

  • The length of the cycle is measured from the first day of normal flow (not just spotting) to the first day of the next menses. The standard cycle length is 28-32 days.
  • A history of long cycles (longer than 32 days) can mean that your follicle is developing too slowly. Stress (physical or mental) can impair the release of FSH (follicle-stimulating hormone) from the pituitary. FSH is essential for follicle growth, and low FSH release can result in a follicle with insufficient support cells to nourish the egg and to produce progesterone after ovulation to prepare the uterine lining for implantation.
  • A history of short cycles, on the other hand, is more worrisome because it can suggest a low egg reserve. Short cycles (26 days or shorter) occur when the ovaries receive intense stimulation from a high level of FSH, which in turn hastens follicular maturation. Ovulation tends to occur earlier- on day 9-10 instead of the usual day 12-13. The presence of hot flash is particularly worrisome as it reflects a state of low estrogen as often seen during the early phase of menopause. Women who smoke tend to have lower egg reserve.

Do you have milky breast discharge or excessive hair on the face and abdomen that requires weekly removal?

  • Milky nipple discharge can be a sign of excessive prolactin, which is a pituitary hormone that acts on the breast to produce milk for lactation. A high level of prolactin can suppress the release of FSH and cause delays in follicle growth. Occasionally, a pituitary tumor can lead to excessive production of prolactin. Thyroid conditions can also lead to excessive secretion of prolactin.
  • Excessive facial or abdominal hair that requires removal at least once a week can be a sign of excessive male hormone production, which can inhibit follicle growth. Polycystic ovary syndrome (PCOS) is a common condition that is associated with elevated production of testosterone.

Have you been diagnosed with hypothyroidism or polycystic ovary syndrome?

  • Patients with thyroid conditions or PCOS can have delayed follicle growth or suboptimal ovulation and would benefit from taking ovulation induction medications to ovulate better.

Have you ever had abdominal surgery?

  • Myomectomy (surgery to remove fibroid tumors from the uterus) nearly always results in pelvic adhesions that can impair the ability of the tubes to find or pick up the egg after its release from the ovulating follicle.
  • Tubal surgery for ectopic pregnancy or tubal adhesions implies existing tubal damage and co-existing pelvic adhesions.
  • Bowel surgery for appendicitis or other conditions can result in significant pelvic adhesions.

Have you ever been treated for any STD (Chlamydia, Gonorrhea, HIV, HPV, herpes, syphilis)?

  • Gonorrhea and chlamydia are well known to cause infertility by damaging the tubes and causing pelvic adhesions. Chlamydia can cause infertility without any symptoms. Treatment is often delayed due to late detection.
  • HPV can cause abnormal changes in the cervical cells that may necessitate surgical treatment of the cervix, such as LEEP or cryosurgery, which in turn can lead to cervical stenosis (constriction of the cervical opening), impairing the movement of sperm into the uterus.

Do you have painful intercourse or severe pain with menstruation?

  • Painful intercourse can suggest the presence of endometriosis, which can cause pelvic adhesions, impairs egg pick up, and reduce the chance of fertilization.
  • While most women experience cramps during menstruation, severe menstrual pain can suggest endometriosis or uterine fibroids.

Have you had two or more miscarriages?

  • Most miscarriages that occur during the first 12 weeks are due to suboptimal ovulation and abnormal embryos. Occasionally, thrombophilia (hereditary tendency to form clots) or abnormality in the chromosome of either biological parent can be the cause of recurrent early miscarriages.
  • Miscarriages that occur after the 12th week can suggest structural abnormalities such as fibroids, uterine septum, and other malformations of the uterus.

Does the male partner have the following?

  • Male surgery- vasectomy reversal, varicocele repair, or testicular surgery can suggest sperm problems (low count and low motility). Surgery can also lead to the formation of sperm antibodies that can impair fertilization.
  • Infections of the male organs (such as prostatitis and epididymitis) can lead to the formation of sperm antibodies and impairment of sperm function.
  • Heavy smoking can lead to damage to sperm DNA.
  • Low semen volume or watery semen can suggest retrograde ejaculation.

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