The discussion focuses on your fertility history, previous investigations and treatments. An examination is performed and most often also an ultrasound assessment. To assist with making a diagnosis and to determine the various factors that may contribute to your infertility, certain investigations are performed which may include some of the following:
- Semen analyses
- Hormone and other blood tests on female patients and sometimes male patients.
- Ultrasound scans
- Hysterosalpingogram (HSG)
- Recurrent miscarriage screen
- Semen analyses
- An ejaculatory sperm sample is to be obtained and handed in for analyses by the scientists (andrologists). The four main factors that are analyzed include:
- Sperm count
- Morphology (appearance of the sperm)
- Motility (movement) of sperm and progression (speed at which the sperm moves.)
- Anti-sperm antibodies (immunological defects on the sperm that result in poor function of sperm.)
- Hormone tests on female patients
- Rubella immunity (female patients)
- Chromosome analyses are advised in certain cases of severe male factor infertility, though not routinely. It is also applicable in couples with recurrent miscarriage loss.
- Ultrasound scan (USS)
It allows for direct vision of the uterus and ovaries and shows up abnormalities such as ovarian cysts, fibroids, large polyps inside the uterine cavity, etc. From a fertility perspective it enables one to see the development of follicles inside the ovary, which is a fluid-filled structure in which a single egg is maturing. The ultrasound cannot identify the egg itself, as it is too small and can only be viewed under a microscope. However there is a similarity between the size of the follicle and the maturity of the egg and by measuring the follicle’s growth throughout the menstrual (treatment) cycle we can conclude when an egg is ready to be released.
USS is also used to evaluate a pregnancy and give valuable information from an early stage. Pregnancy scans can normally be performed between 2 – 3 weeks after a positive pregnancy test.
- Hysterosalpingogram (HSG X-Ray)
This is a very useful investigation, which involves taking x/rays of the pelvic area in which the uterus and Follapian tubes can be assessed. Contrast dye is inserted through the uterine passage, which enables the cervical canal, uterine cavity and Follopian tubes to appear on the x/ray. The shape and outline of the uterine cavity can be assessed, and also the cervix and any malformations including cervical incompetence. Conditions such as a septum in the cavity, or fibroids and polyps can be diagnosed this way. As the dye passes through the left and right Fallopian tubes, not only can patency of the tubes be confirmed but can the rate at which the dye passes through give some indication of tubal function. This procedure is also performed by the gynaecologist together with the radiographer
This procedure evaluates the cervical and uterine cavity by using fibre optic scopes that are inserted through the vagina into the cervix. The picture is then transferred from the fibre optic lenses to a colour monitor where it can be viewed under direct vision. Surgery can be performed on the cervical or uterine cavity by means of hysteroscopy in which case it requires the patient to be asleep under general anaesthetic. Patients are therefore admitted to hospital and discharged a few hours after their procedure.
This procedure involves a general anaesthetic and is performed as day-case surgery in a hospital. A fibre optic scope is inserted through the abdomen and with the aid of more instruments that are inserted through other ports (openings) in the abdomen; surgical procedures and evaluation of the female pelvic anatomy can be performed. Patients are admitted as a day-case at the hospital and discharged within a few hours following their surgery. Albeit the procedure is quite simple with very few risks, the technology nowadays makes it possible for skilled gynaecologists to do extensive pelvic surgery with very little post operative discomfort to patients.
As an investigation for causes of infertility, the benefit of performing a laparoscopy is indispensable. It gives a direct, 3-dimensional overview of the abdominal and pelvic structures and can confirm possible anatomical distortion of these structures and diagnose the presence of certain diseases including endometriosis. These conditions can also be treated at the same time and therefore the diagnostic benefit also becomes therapeutic at the same time with no need to return for follow-up surgery at al later stage.
- Recurrent miscarriage screen
Due to the complexity of this condition, there are various tests and investigations that need to be performed in order to diagnose, or exclude certain underlying contributory factors. Some of the basic investigations include blood tests, analyses of the immune system, excluding certain medical conditions including genetic disorders and finally, evaluation of the uterus.
Having completed various investigations, patients are then seen during a follow-up consultation to discuss the results to date, possible factors influencing their infertility and a diagnosis and appropriate treatment can be planned. For all other patients who had already been through treatment at the practice a follow-up consultation is often recommended as it allows for a more in depth discussion about their situation and response.
Surgery, depending on the underlying condition, could potentially offer a good solution as it makes an improvement to the underlying cause of infertility in both the short and long term. However it should not be seen as a permanent cure for all conditions, as some conditions can return in due time, i.e. uterine fibroids. The surgery itself can either be done with endoscopic procedures such as hysteroscopy and laparoscopy, or alternatively an open abdominal procedure called laparotomy. Surgery can be applied for various conditions including endometrioses, tubal problems, fibroids of the uterus, distortion of the normal pelvic anatomy, adhesions with scar tissue formation, etc.
Azoospermia is the term given to men with no sperm in their ejaculate sample and this can be classified as primary or secondary testicular failure.
- Primary testicular failure is where the problem is directly in the testis and can be due to obstructive or non-obstructive causes.
- Obstructive causes are characterized by a blockage of the vas epididimys, which is the tube responsible for the outflow of sperm directly from the testis. This can be as a result of previous infection, severe trauma to the testis and scrotal area, male sterilization (vasectomy) and genetical, i.e. absent vas in cases of Cystic Fibroses. This type of azoospermia has the best prognoses as in 95% of cases sperm can directly be obtained from the testis by means of a minor surgical procedure, also known as SSR (surgical sperm retrieval.)
- Non-obstructive causes imply that the vas epididimys is open; however the cells in the testis itself are not functioning correctly and as a result sperm are not being produced. In the majority of cases this is genetical in origin and the man has simply been born with abnormal / no cells responsible for the production of sperm.
- Secondary testicular failure is due to factors outside the testis, including hormonal causes, whereby there is no development of sperm. Quite often this can be corrected with the administration of various hormones and other medication.
DIAGNOSIS AND TREATMENT
In up to 97% of cases a diagnosis can be made. In all cases there are treatment options available to suit the needs of a specific couple. With advancing technologies, such as PGS (pre-implantation genetic screening), which minimizes the risk of recurrent failed IVF treatment and miscarriage, more and more patients can nowadays benefit from treatment.
Treatment options include the following:
- Cycle monitoring
- Intra-uterine insemination
- In vitro fertilization
- Sperm and egg donation
- Cycle monitoring
This involves frequent ultrasound scans to determine when an egg is ready to be released from the ovary. Once the follicle (structure housing an egg inside the ovary) has reached a certain size, the egg is then released from within the ovary and patients are then advised when to have intercourse. Treatment can either be in a natural cycle, i.e. no administration of any medication, or alternatively on a stimulated cycle whereby hormones are taken to increase the number of eggs. By having more than one egg one maximizes the chance to conceive though there is risk for a multiple pregnancy and this can be discussed during consultation. This treatment can only be offered if there is confirmed tubal patency, minimal pelvic disease, e.g. endometrioses and finally, the quality of the sperm meet with a minimum standard as required.