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From the book
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
In order to understand why pregnancy doesn't occur, we need to examine only 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 examining one of these four 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.
Remember that 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.
The first day the bleeding starts is called Day 1, and the semen analysis to check the husband's sperm count and motility can be done can be done on Day 3-4, after requesting him to abstain from ejaculation for at least 3 days . The wife's blood is then tested for measuring the levels of her four key reproductive hormones: prolactin, LH ( luteining hormone), FSH ( follicle stimulating hormone), TSH ( thyroid stimulating hormone). Since these levels vary during the menstrual cycle, they should be done between Day 3-5 of the cycle. We then do a hysterosalpingogram (an X-ray of the uterus and tubes) for her after the menstrual bleeding has stopped - between Day 5-7, to confirm her uterus and tubes are normal. We then see the couple on Day 9 with all these reports and review the results . These three basic tests allow us to check whether the eggs, sperm, uterus and tubes are normal.
Some doctors will perform further testing during the rest of the month, though we rarely do these tests in our own practise . They include: ultrasound scans for ovulation monitoring between Day 11-16 ; and the scan results can be used for timing the PCT (postcoital test) as well, during which time the cervical mucus is assessed also. A serum progesterone level can be measured on Day 21, about 7 days after ovulation, and this provides information about the quality of ovulation. Some doctors will also performed a laparoscopy in the same month (Day 20-25) ; and combine it with an endometrial biopsy, 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.
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 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.
Sometimes it can be difficult for patients to come to terms with the fact that there is a major problem which presents a significant hurdle to getting pregnant. The truth can be bitter, but it's far better to face up to it and deal with it, rather than live in a fool's paradise ! With today's advanced reproductive technology, we can always find a solution, no matter what the problem - but remember that unless you can intelligently identify the problem, you cannot find a solution !
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.