Investigating infertility

WHEN SHOULD WE SEEK HELP?

The answer to this is not as simple as six months, 12 months or any particular length of time. The standard definition of infertility is the inability to conceive within one year of regular intercourse without the use of contraceptives. Most couples should seek medical help after one year. For many, it may even be appropriate to wait longer than that. Up to 90 per cent of normal fertile couples will be pregnant at the end of one year and up to 95 per cent by two years. However, couples with a complex problem or increasing age may need to seek help more rapidly than this. Initially a couple should see their own GP who will be able to assess their situation, arrange some of their preliminary tests and advise about whether referral to a local or specialist fertility clinic is indicated.

SHOULD WE USE THE NHS OR GO TO A PRIVATE CLINIC?

Most NHS clinics can provide a comprehensive range of basic investigations to establish why you can’t conceive. They will also provide some fertility treatments such as tubal surgery or ovulation induction. An increasing number provide in vitro fertilisation (IVF), in line with guidelines of the National Institute for Health and Clinical Excellence (NICE) (see later), although the numbers treated may be limited by the funding available.
Private clinics generally provide a range of treatments – some are purely IVF centres whereas others provide full diagnostic and thera­peutic services. The Human Ferti­lisation and Embryology Authority (HFEA) who are responsible for licensing all IVF clinics also provide information about successful pregnancy rates. When you are selecting a private fertility clinic, you need to find out the cost, the range of facilities that are available, whether you could be seen quickly or at unsocial hours, and the experience and qualifications of the doctor who will be seeing you.

There are several other ways of finding out information about private clinics. The decision to attend a particular clinic often depends on sheer practicalities, such as ease of access and location. If there are several clinics within driving distance, contact them first for the information leaflets or booklets that they will provide for prospective patients. Your GP or hospital consultant may also recommend a particular clinic. Patient support groups in your locality can probably put you in touch with people who have attended these clinics and may give invaluable help based on personal experience (see ‘Useful addresses’). For more on NHS and private treatment (including costs), see ‘Assisted conception’.

WHAT TESTS WILL WE NEED?

The number of fertility tests that you will require generally depends on the complexity of your problem. It is impossible to generalise and cover all the possibilities. Outlined below are some common investi­gations that provide a basic diag­nosis for most couples.

Blood tests

You will need to have a test to assess your rubella (German measles) status. German measles is a fairly mild illness in women, causing a slight rash, swollen glands and aching joints, but it can damage an unborn baby if it is caught during early pregnancy. If you are not immune, you will be offered an
immunisation. You should avoid pregnancy for four weeks afterwards, which is when the test should be repeated to confirm that the immunisation has been effective.
A full blood count will assess your overall health and will make sure that you are not suffering from anaemia. Additional blood tests will be needed to check your hormone levels and some of these samples will need to be taken at specific times in the woman’s monthly cycle. Follicle-stimulating hormone (FSH) and luteinising hormone (LH) levels are usually measured at the beginning of the woman’s period and give an indication of the reserve supply and quality of the eggs that are ripening in her ovaries. Progest­erone is measured about a week before her period is due, to assess whether a woman is ovulating (releasing eggs) normally. Thyroid hormone levels may also be measured. These control the rate at which the body’s cells work (the metabolic rate). If a woman’s thyroid gland is underactive, this can interfere with the quality of eggs that she releases and can also increase her risk of miscarriage.

You may also be tested for evidence of a previous infection with Chlamydia, which can damage or block a woman’s fallopian tubes. If high levels of chlamydia anti­bodies are present, both partners will be treated with a suitable antibiotic. Treating a couple at this stage will not correct tubal damage that has already occurred, but it will prevent further reactivation of Chlamydia, which may occur during a laparoscopy or other pelvic surgery.
Recent guidelines issued by the Human Fertilisation and Embryology Authority recommend that couples undergoing assisted conception are screened for hepatitis B and C, and for HIV. Screening for these infections has several purposes. One is for the patient’s own health screening. The second relates to concerns about the safety and health of the staff handling blood or tissues from these patients. The third relates to the difficulties encountered if blood, tissue, sperm or embryos from patients need to be frozen for future use. Currently, the technology used for freeze storage cannot give complete reassurance that there is no risk of spread of the viruses that cause these infections from sample to sample. Therefore couples, men or women, who have one or other of these infections would not normally have their tissues frozen because of this.

Ultrasound scans

At your first visit to a specialist, he or she may arrange for you to have an ultrasound scan of your pelvis. An ultrasound scan is painless and only involves a short, outpatient appointment. It produces an echo image using sound waves. As the waves bounce off different parts of your body, the echoes form a picture.
An ultrasound scan enables the specialist to assess the health of your ovaries and uterus, and to see how well your ovaries are working. It is possible to assess whether follicles are developing or whether there are any abnormalities, such as polycystic ovaries. In addition, your uterus is examined for the presence of a normal endometrial lining, which is appropriate for the stage of your monthly cycle, and any medical problems, such as fibroids (non-cancerous growths in the uterus) or developmental abnor­malities. However, an ultrasound scan generally cannot diagnose conditions such as endometriosis (where tissue resembling the lining of the uterus is found in the pelvis) or blockages of the fallopian tubes.

In a few specialised centres, additional ultrasound techniques may be available. Studies of the developing follicle and blood flow around the ovaries (Doppler flow studies) are sometimes used to investigate infertility. Another technique called contrast ultrasound involves passing a fluid into the cavity of the uterus. The fluid is of a particular consistency so that it shows up clearly on ultrasound. Its flow along the fallopian tubes can be traced in this way, and any blockages revealed.

Hysterosalpingogram (HSG)

This is an X-ray picture to check whether the cavity of your uterus is normal and whether your fallopian tubes are open. It is often carried out in addition to a laparoscopy (see below) because it also gives information about the delicate lining inside the tubes. Passing a dye into the uterus, which shows up white on the X-ray films, gives information about any blockage or kinking of the tubes. It will also reveal whether there is a collection of fluid at the blockage (a hydrosalpinx). This procedure usually involves a short, outpatient appointment and is sometimes uncomfortable.

Laparoscopy

This is usually a day-case procedure under a general anaesthetic. It involves making a small cut in your abdomen, usually just under your navel so you won’t have any noticeable scarring. A laparoscopy allows careful inspection of your ovaries, uterus and fallopian tubes, and can identify polycystic ovaries and uterine fibroids.
A blue-coloured dye is injected through the cervix and uterus, and can be clearly seen by the surgeon as it passes through your fallopian tubes and spills freely from the ends of the tubes if they are open and healthy. The blue dye is completely harmless and will be passed out in the woman’s urine within a few hours. If your tubes are scarred or distorted, the tubal lining may be damaged. Further evidence for this may come from elevated antibody levels in the chlamydia blood test, which suggests that chlamydia infection may still be active. Adhesions (bands of scar tissue) and endometriosis may be distorting your fallopian tubes or ovaries; this is best treated by surgery. Medical treatment of endometriosis is of little value in improving the chance of pregnancy. For more on this, see ‘Treating infertility’.
A hysteroscopy (direct exam­ination of the interior of the uterus with a viewing instrument) may be advised at the same time as a laparoscopy to check the cavity of your uterus and the openings into the inner end of your fallopian tubes. This may allow any adhesions or polyps (growths) in the cavity of the uterus to be seen and, if necessary, removed.

Other tests

• Seminal fluid analysis:

This is carried out on a sample of semen, which is examined under a microscope. The technician can count the number of sperm in a measured volume of semen. The sample is usually produced by masturbation. Generally, two to three days’ abstinence from inter­course is recommended before the test. A diagnosis of a sperm problem should never be made from a single sperm sample. If the first test result shows low numbers or complete absence of sperm, it should be repeated.
Sperm analysis can also be used to assess the motility (swimming ability) of sperm and whether there are any abnormalities present (involving a count of the number of physically normal and abnormal sperm). Every man, even the most fertile, will still be producing some sperm that are non-motile or abnormally formed. Some men produce anti-sperm antibodies, which can cause the heads of the sperm (or occasionally the tails) to stick together, if they are present in seminal fluid. This reduces sperm motility and severely reduces the chance of fertilisation. Anti-sperm antibodies can also be produced by some women in their cervical mucus.

• Postcoital testing (PCT):

This may be done if the sperm count appears to be normal and ovulation has been confirmed. It is occasionally undertaken instead of a seminal fluid analysis. It detects whether sperm survive normally within the woman’s cervical mucus. Using a syringe, a sample of mucus is taken from the woman’s cervix shortly before ovulation. The sample is taken about 12 hours after the couple have had intercourse, and is then examined immediately through a microscope. If more than three motile (moving) sperm are seen in each field of view under the microscope, this is termed a ‘positive test’. If no sperm or no motile sperm are seen, this may indicate a problem with sperm function – either in their ability to penetrate the woman’s mucus or in their survival capacity. A woman’s cervical mucus could also be abnormal, containing antibodies against sperm.
Many clinicians do not routinely advocate the use of the PCT. In our experience, it acts as an important surrogate marker for sperm func­tion, and a positive PCT correlates well with the likelihood of that sperm fertilising an egg.

WHAT MAY THE TESTS SHOW?

The most common causes of infertility in women are ovulation failure and blockage or damage of the fallopian tubes. Ovulation failure may be evident from infrequent or absent menstrual periods. However, in some women, it will be diag­nosed only by means of a blood test to measure their levels of proges­terone. Endometriosis and cervical mucus disorders are less frequent causes. It is not certain that endo­metriosis causes infertility – it may be present only because it is more common in women who have not been pregnant for some time. In men, poor sperm function or a very low sperm count is more common than a complete failure of sperm production. In about 15 per cent of cases, subfertility has more than one cause.
In almost a third of couples, the results of all their investigations will be normal. This situation is called unexplained infertility, and is frustrating for couples who want to know why they can’t conceive. In many cases, there will not be a problem at all and the couple will simply have been unlucky. In others, subtle or minor factors will be impairing their fertility, but their chance of achieving a pregnancy will still be realistic without resorting to active, and possibly stressful, intrusive or expensive, treatments.

Couples with unexplained infertility who have been trying for a pregnancy for more than three years, or where the woman is over 35 years of age, need to consider active fertility treatments. There are a number of options. Tablets or injections of fertility drugs (ovulation induction) may improve their chance of pregnancy by stimulating the release of more than one egg each month. Intrauterine insemination in combination with ovulation induction may give a higher chance of pregnancy (15 to 20 per cent per cycle).
In vitro fertilisation (IVF) treatments offer the best chance of pregnancy, equivalent or better than the chance of natural con­ception for normal fertile couples. However, they also involve the greatest commitment and expense for the couple concerned. For more on these treatments, see ‘Treating infertility’.