Infertility and sterility issue are closely linked. The first is considered a difficulty in having
a reproductive success while the other is a condition of impossibility and it can also happen that one of the two diagnoses may migrae during the investigations towards each other. It is also true that very often now Infertility and Sterility are used as synonyms of a generic concept of difficulty to procreate instead has very specific origins: in fact, the cause may be female, but also male and of couple.
For convenience, I will use in this article the term infertility (most common) to refer to these issues. A first point to be clarified, however, is to start from the fact that the problem is always a couple problem. Which couple can be defined infertile? According to the World Health Organization (WHO), we can talk about infertility when a couple has a conception targeted sex for a continuous period of at least 12-24 months without having a baby.
This boundary is necessary because even a perfectly healthy young couple expresses a maximum potential of conception equal to 20% per cycle and 90% in a whole year of attempts. Because the woman’s age plays a much more important role than the man when female is 36 or older, 12 months without reproductive success is considered sufficient to deal with investigations; but you could get the same consideration in the presence of very aged male.
It is estimated that approximately 8-10% of couples have this problem and that most of them must have a consultation with a specialist to solve it.
Before making a discussion of the diagnostic tests I would like to mention to what are the main causes of infertility in women. Basically, female infertility is due to one or more of the following causes:
- Age (especially when is more than 36-38);
- Anatomic factors (such as some congenital malformations or been acquired as the uterine fibromatosis or tubal occlusion);
- Endocrine diseases (such as diabetes, thyroid disorders, Hyperprolactinemyas)
- Ovarian pathology (such deficiencies, the Polycystic Ovary Syndrome, genetic disorders)
- Infectivological (pelvic inflammation but also little or no symptomatic infections by Chlamydia and Mycoplasma);
- Immunological (autoimmune diseases);
- Coagulopathies (thrombophilic states,
- Malabsorption diseases.
Sometimes even medical or surgical treatments may cause infertility as it unfortunately is the case of some chemo-radiotherapy cures. But sometimes even more innocuous treatments can actually disrupt ovulation can do treatments such as prolonged corticosteroids or certain medications that increase Prolactin secretion (i.e. antidepressants, intestinal prokinetic). But ovulation can also be affected by significant changes in weight that is at fault or in excess.
All this to make you realize that the diagnostic approach to infertility and female couple (who also considers the male component) is not easy and requires absolute respect specific and standardized paths.
When a pregnancy is desired, those tests (once called premarital) should be made:
- Blood type, RH factor, Indirect Coombs test, complete blood count, blood sugar, urinalysis;
- HBsAg, HCV, HIV (the partner);
- Rubella, Toxoplasmosis, Cytomegalovirus, Chickenpox;
- Pap Smear.
They are useful to ensure safe conditions for both those who must conceive (mother) and for those who will be the result of a conception (fetus).
Now I will explain diagnosis of infertility. These tests are commonly performed on an infertile couple. The pelvic examination it is definitely the key moment and unfortunately now it is thought that it may instead be completely outdated, driven by a more general retreat of the medical profession and by a technicality that seems to overcome the clinical observation and reasoning.
For the woman then exams that follow the visit and that constitute a common clinical attitude are then:
- Transvaginal pelvic ultrasound;
- Cervico-vaginal swab;
- Hormonal assays (i.e. FSH, LH, PRL, TSH and 17 beta estradiol at the third day of the cycle;
- Sonohysterography or Histerosalpingography.
The pelvic examination is of the utmost importance: it can immediately put into evidence congenital and acquired anatomical flaws but also highlight inflammation and pelvic floor disorders; medical history conducted during the visit is generally conducted also on the male partner and the family not neglecting even in utero life and possibly medications taken. It is generally conducted outside of the menstrual cycle and when it is conducted in the vicinity of ovulation also allows an assessment of the cervical mucus.
The Transvaginal Pelvic ultrasonography has become an irreplaceable tool in the diagnostic investigation of infertility and quite often is conducted directly (office) during the gynecological examination by integrating it with important morphological information regarding the Uterus, ovaries and pelvis. The accuracy of this method can often identify malformations, uterine fibroids (leiomyomas), endometrial polyps, ovarian alterations of functional or anatomic (polycystic ovarian hypofunction, cysts), endometrial, pelvic payments at the first approach. Even in this case, in my opinion, the better timing is during the follicular phase because it allows a better evaluation of the endometrium.
Cervicovaginal swab is conducted to find common germs but also intra-cellular organisms such as Chlamydia and Mycoplasma. Also important is a fresh examination for Gardnerella Vaginalis.
The hormonal assays generally concern the axis Hypothalamus-Pituitary Gland-Ovary but also the Thyroid and Prolactin secretion. Generally are conducted under conditions of rest and fasting on the 3rd day of the cycle, allowing in this way also have valuable information on “ovarian reserve”. In our study, are generally required FSH, LH, PRL, TSH, 17-beta-estradiol.
The sonohysterography (SHG) has long since replaced the Hysterosalpingogram (X-ray method) in addition to providing information on tubal patency, it also gives a good representation of the uterine cavity with more chances of detecting polyps, submucosal fibroids and malformations. It is a transvaginal ultrasonography associated with the introduction of an echoreflecting means into the uterus and fallopian tubes using a very thin probe. This procedure is not painful and takes only a few minutes.
Second-level tests are:
- Genetic investigations
- Immunohaematological investigations
Regarding the male component, it always starts from at least two spermiograms spaced approximately by 1-2 months. Any alteration must be evaluated by Andrologists or Urologists.
An examination that evaluates the couple and that I consider interesting (particularly in a first-level approach) is the Post-Coital Test: it is a microscopic examination of vaginal and cervical secretions conducted after sexual intercourses. It allows an evaluation of the number and motility of sperms as well as the characteristics of the cervical mucus (as Ph. Its information do not only concern seminal fluid “in situ” quality but also its interaction with the cervical mucus.
Just two more recommendations:
- always consider the psychological and sexological conditions;
- a good diagnosis is important for a good reproductive outcome.