Assessing ovulation
If you have regular periods with a cycle of 21-35 days, this suggests that you are ovulating regularly. If you experience Mittelschmerz (mid-cycle pain associated with ovulation), changes in your cervical mucous and increased temperature mid-cycle, these features also suggest that you are ovulating. However, to be sure that you are ovulating, the key medical investigation is to measure the concentration of progesterone in a blood sample taken seven days before your expected period is due. If you have an irregular cycle, then several samples may be required, each taken a few days apart. Progesterone is only produced in high quantities after ovulation, so a high progesterone level means that you have ovulated. If you are not ovulating, then further hormonal assessments will be required to identify the cause.
Assessing sperm problems
Your partner will be asked to produce a semen sample through masturbation after abstaining from intercourse for at least two days. You should not collect the sample in a condom – most condoms have spermicidal lubricants that make analysis impossible. Nor should the sample be collected by coitus interruptus (withdrawal during intercourse) as much of the sample can be lost – remember that some semen is often released prior to ejaculation proper, which you may not be aware of. Instead, collect the sample in a wide-mouthed plastic specimen pot and promptly transport it to the laboratory, avoiding extremes of temperature. As there is marked variation in semen from day to day and week to week, at least two specimens should be assessed.
A normal semen sample has a volume of 2-4 ml (½-1 tsp) with more than 20 million sperm in each millilitre and a total of at least 40 million sperm in an ejaculate. At least 50 per cent of the sperm cells should be able to move forward, 75 per cent should be live, and more than 15 per cent of the sperm cells should have a normal form. If the analysis suggests
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Further tests
If you have an irregular cycle or infrequent periods, you will be offered additional tests on the hormones controlling egg production and release to look for an underlying disturbance in the key hormones. If you have symptoms that might be indicative of a thyroid problem, then your thyroid gland function will also be checked.
a sperm problem, the test should be repeated. As it takes around 70 days for sperm to mature, it is usual to allow two to three months between samples so that any temporary upset in sperm production will be rectified. If there is a more extreme problem, such as no sperm in the ejaculate, then the test is repeated as soon as possible.
Assessing the function of the fallopian tubes
Several investigative methods are available for assessing tubal function. X-ray assessment of the tubes is commonly used. Special dye that appears white on an X-ray is injected through the cervix. An X-ray is then taken and the outline of the womb and tubes will be seen. If the dye is seen spilling into the abdomen, then the tubes are open. This test will also check if the womb is normally shaped. Ultrasound can also be used in a similar way to determine if your tubes are open. However, you should know that even if the tubes are open they may not necessarily function normally. For example, the lining of the tube may have been damaged by infection in the past, so preventing normal transport of the egg down the tube to the womb.
If there is the possibility that you have endometriosis as well as a fertility problem, then diagnostic laparoscopy is considered by many gynaecologists as the method of choice. During the procedure, which usually requires general anaesthesia, a laparoscope (a telescope-like instrument) is inserted into the abdomen through a small cut, usually below the navel, so that the surgeon can view and assess the womb, fallopian tubes and ovaries. Blue dye is injected through the cervix using an instrument placed in the cervix through the vagina. The dye flows through the womb and fallopian tubes and, if the tubes are open, spills into the abdomen. Through the laparoscope, patches of endometriosis appear like blue or black spots and sometimes scar tissue and adhesions are seen.
As infection is the most common cause of tubal damage. Your doctor may suggest a test to look for evidence of past or current infection that might be affecting the tubes.
Fertility treatments
As you have seen, many couples have fertility problems, but this does not mean that they cannot have a baby. There is now the potential for the vast majority of fertility problems to be treated and success rates are good. So if you have a problem, the outlook is usually optimistic. Some fertility problems can be treated without recourse to assisted conception techniques and it is these treatments that this section is concerned with.
Treating a disturbance in ovulation
The treatment of disturbance of ovulation depends on the reason causing the disturbance. Irregular or infrequent periods are most commonly due to a hormonal disturbance affecting the ability of the ovaries to produce eggs. Sometimes the cause is not directly linked to the hormones controlling the ovaries, but to other hormones that have a knock-on effect. For example, upsets in your thyroid or adrenal glands can also disturb ovarian function. Obviously, if you have a specific problem, such as thyroid disease, or you don’t produce the hormones that regulate the ovary this should be treated directly. Your specialist will be able to advise you on the best treatment for your particular problem.
Correcting an excess of prolactin
One such problem is an excess of the hormone prolactin. This hormone, produced from the pituitary gland at the base of the brain, stimulates milk production after pregnancy, but sometimes women can produce high levels of this when they are not pregnant. This hormone not only stimulates milk production but inhibits egg production.
This means that women who are exclusively breastfeeding don’t ovulate regularly until their baby is weaned. However, if you develop high levels of this hormone when you are not pregnant, your periods will become infrequent, ovulation will be disturbed and you may notice some milk leaking from your nipples. This can be treated with a medication, such as bromocriptine, which suppresses the prolactin production and allows ovulation to occur.
Ovulation induction through medication
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Clomifene and IVF
This tablet form of ovulation induction is not suitable for linking in with procedures like IVF.
Most commonly it is a disturbance in the balance of hormones controlling the ovaries that causes irregular ovulation and this can be treated with medication, usually clomifene. Clomifene is given in tablet form and the medication enhances the body’s normal hormonal changes that lead to egg production – known as ovulation induction. Some side effects of clomifene are hot flushes, nausea and breast tenderness. Its success is checked by measuring progesterone levels in the blood.
One drawback of this therapy, however, is that sometimes the ovaries produce more than one egg in response to stimulation so that there is an increased risk of conceiving twins or even triplets. Where this is considered a significant risk, the response of the ovaries to the drugs is monitored through regular blood hormone measurement or ultrasound to visualize the eggs developing on the ovaries. These checks may only be needed during the first cycle of treatment so that your response to this medication can be assessed.
If you are overweight with a BMI of more than 25 and don’t respond to medication like clomifene, then metformin may be added to the clomifene treatment to improve the response. This medication can sometimes cause some nausea and gastric upset.
It is often useful to combine these ovulation induction treatments with intrauterine insemination, where your partner’s sperm is injected directly into the womb.
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