If you have been trying to conceive for six months without success, it may be appropriate to visit your doctor for help in finding out what’s preventing conception. The factors that decrease fertility fall into three main groups: First, problems associated with ovulation\ you must produce eggs (ova) in order to conceive. Second, what is referred to as male factor infertility or subfertility the man’s sperm count and the normalcy of the sperm produced and their ability to get from where they are produced (in the testes) to where they will fertilize the egg (in one of the woman’s Fallopian tubes). In an older man erectile dysfunction may also be a consideration. Third, there may be mechanical problems in the womanЎЄsuch as blocked Fallopian tubes, endometriosis, or fibroids that are interfering with the normal process of conception.
What Happens Next?
If you have decided to investigate a lack of success in conceiving, what can you expect? Initially, a full history of your health should be taken if it is not already known to the doctor. Family physicians and internists are best at history taking. If not already in your record, a full sexual history will be needed. Don’t be embarrassed these questions are not prurient; they relate directly to your wish to conceive. You will be asked questions like the following: Do you and your partner have full vaginal intercourse? How often? Is your cycle regular? Do you keep a menstrual calendar (we recommend that you do so in advance of the appointment and bring it along)? Do you plan intercourse to happen during your fertile time? Does your partner have any difficulty with erection or ejaculation? Has your partner fathered any children (or pregnancies that did not go to full term)? Has either of you had any sexually transmitted infections? Have you ever been pregnant? In asking these questions your doctor is looking for any possible barriers to your becoming pregnant, especially those that are readily treatable.
You should also have a general physical, which will include a check of your abdomen and likely an internal exam, unless you have recently had one. Your doctor may also suggest testing your thyroid gland and screening for diabetes; both of these require blood tests at a lab.
Some hormone levels may be tested at this stage. The progesterone level on day 21 of your cycle is commonly measured (counting the first day of your period as day 1; the test day may be adjusted slightly by your doctor to reflect your cycles). Progesterone is a hormone produced by the ovaries; the level of progesterone should be elevated if you have ovulated in that cycle. Your prolactin level may also be measured. Prolactin, a pituitary hormone, is responsible for milk production when a woman is lactating, and it inhibits ovulation. Sometimes even without lactation there can be excessive production of prolactin, and this abnormal level prevents ovulation. Certain prescription medications can elevate your prolactin level. Very occasionally, the prolactin level may be elevated because a tumor of the pituitary gland is producing prolactin. Whatever the cause, raised prolactin levels are usually managed by drug treatment under the direction of an endocrinologist, rather than by surgery.
Also usual at this point is a pelvic ultrasound, to look at the outline of the uterus and ovaries and see whether there are any fibroids or polyps inside the uterus or cysts on an ovary and to check the size of the ovaries generally. An ultrasound will give some idea of how many potential eggs are still present in the ovaries and can pick up on some mechanical problems that might need to be dealt with.
The next step may be a check of your Fallopian tubes, and for this you will be referred to a gynecologist, if you haven’t seen one already. There are a number of ways of checking the Fallopian tubes. One is laparoscopy, which we will describe. This procedure is less common now in the United States for older women who are not conceiving naturally, because they are now more readily recommended for assisted reproductive technology. What happens in a laparoscopy? Under a general anestheric a fiber-optic tube, the laparoscope, is inserted into your abdomen through a small incision. There is a tiny camera on the end of the laparoscope, and with it the doctor can look at the uterus, tubes, ovaries, and other organs within the pelvis, and test whether the Fallopian tubes are open. Some blue dye may be passed through your cervix, and a video screen will show whether or not the dye appears in the Fallopian tubes.
A laparoscopy is surgery, and there are risks, however, it will definitely give good information about your pelvic anatomy and function. Your surgeon will be able to check that your ovaries and the external surfaces of the tubes and uterus appear normal, to discover any adhesions (scarring) from previous surgeries or infections, and to see whether any endometriosis is present.
Marie, the healthy 36-year-old, had a laparoscopy after all other exams and tests had failed to explain why she had been unable to get pregnant. The laparoscopy showed some adhesions around her right Fallopian tube from her appendectomy, but otherwise her uterus, tubes, and ovaries all appeared normal. During the laparoscopy, the surgeon went in and divided the adhesions. That procedure may have done the trick, because two months after the surgery she was happily pregnant.
In fact, statistically, there is a small increase in pregnancy rates 2 to 4 months following laparoscopy, even when no specific treatment is performed.