FREQUENTLY ASKED QUESTIONS
When should you see a specialist?
Within the general fertile population, 90% of couples who want a pregnancy succeed after one year. Therefore, worrying after one year of trying is not justified. If pregnancy does not occur after a year, it is likely that there is a disorder that causes infertility, in which case it would be recommended to visit a specialist.
If you are more than 35 years of age and you have been trying for six months, then go see a specialist. Fertility begins to decline after 35 years of age. If there are reasons to believe that one or both spouses may have problems, such as menstrual irregularities in women, painful menstruation, a history of abdominal surgery or if the husband has had Mumps with swelling of the testicles, undescended testes at birth, injuries in the groin area, etc, it is recommended to see a specialist as soon as possible.
Today’s lifestyles, socioeconomic factors, women who have careers, marrying late in life, are responsible for a natural fertility decline.
Infertility can be caused by the male or the female or both. To find the biological cause of infertility, both men and women should undergo medical examination and laboratory testing. Even though the cause resides exclusively in one of the spouses, it is recommended both participate and be supportive in order to have a better understanding of the situation. Specialized tests are designed to answer four essential questions:
Does the female ovulate?
The female must ovulate regularly in the middle of the cycle.
Does the male produce sperm?
The male must ejaculate sufficient quantities of fertile sperm.
Does the female have permeable tubes?
When women ovulate, the egg is captured by the tube. If you had sex, sperm will fertilize the egg that is inside the fallopian tube.
Is the female’s uterus able to carry and gestate the embryo for 9 months? The uterine cavity must be normal and healthy to fulfill this role.
For how long is the couple assessed?
The couple’s assessment stage is indispensable in order to find the probable cause of infertility. It will lead to the establishment of proper treatment. This stage should not take more than female’s cycle which is a month.
There are many causes of infertility. In order to understand them it is important for us to explain the human reproduction process.
The man ejaculates in the woman’s vagina depositing sperm close to the cervix which later ascends to the same. There is mucus produced during a woman’s ovulation peak, which protects the sperm. From there, they migrate to the uterus’ cavity and then to the fallopian tubes where they will find an egg to fertilize.
Women ovulate once a month. At the beginning of the cycle (1st day of menstruation), the pituitary gland starts to release a hormone called FSH which makes the ovarian follicle to grow. In turn, this follicle begins to secrete estrogen (female hormone) which prepares the cervix for the production of cervical mucus and to the endometrium so that the egg can be nested.
When follicle growth reaches optimal development (in the middle of the cycle), the pituitary gland releases another hormone called LH, whose action is to finish the maturation of the oocyte and it makes the follicle burst so that it releases the egg that will rest in the fallopian tube.
Fertilization or initiation of the process of creating a new being occurs, when the egg is penetrated by the sperm. It then continues its path towards the cavity of the uterus, which is implanted at 6 or 7 days, to continue its development until the end of pregnancy. The bursting follicle becomes a gland called yellow body and it produces progesterone, which is hormonally responsible for maintaining the pregnancy until the placenta is formed and is itself capable of continuing the maintenance of pregnancy.
At times, reproduction can be altered by: the absence of sexual intercourse in the fertile period of women, unhealthy mucus, lack of ovulation, the absence or obstruction of the fallopian tubes or uterus or uterine cavity absence which impedes implantation and development of pregnancy.
In the male, sperm are produced in the testicles’ seminiferous tubules. The development of these is hormonally controlled. The pituitary releases two hormones FSH and LH. The LH stimulates the production and release of testosterone in the testis. FSH together with testosterone stimulates the production of sperm. Once sperm are produced, they are stored in the epididymis where they complete their maturation. Then they go through deferens into the seminal vesicles and the prostate, whose fluids contain nutrients and enzymes to protect them so they can be a part of the ejaculate. Ejaculation propels the sperm through the terminals and sends it to the urethra, to then be deposited in the vagina and then move up to meet the egg inside the tube and produce fertilization.
How is the female evaluated?
It begins with a thorough personal and family history in order to understand fertility issues. It is necessary to know the age of onset of menstruation, regularity of the same, illnesses, surgeries, sexual history and the nature of the couple’s emotional relationship.
A gynecological exam takes place in order to rule out changes that could prevent a pregnancy. This exam consist of evaluation anything from the absence of bodies to malformations in the vagina, cervix and uterus.
Determining the basal temperature is the first step that the doctor will require for his female patient to take. This must be done correctly, as it is used to know when ovulation takes place. From the first day of menstruation until the day 13-14, the basal temperature has no major changes (no more than half a degree). Then, there is a rise in temperature that is maintained until the end of the cycle. According to temperature graphs, it is inferred that the ovulation day of is the day prior to the rise in temperature. To do this, women should take their morning rectal temperature and write it down indicating date of the cycle.
SUPPLEMENTARY EXAMS FOR WOMEN:
The exams are designed to answer the four basic questions:
Is there ovulation?
Are there enough sperm?
Can the gametes compatible?
Can the egg be fertilized?
INSEMINATION TEST:
The couple has to have sex in the middle of the cycle. Between the following 2 to 20 hours a drop of mucus from the cervix is removed with a pipette, and it is studied under a microscope with a 40x magnification where at least five motile sperm must be found per field.
LABORATORY TESTS:
Hormonal dosages: FSH, LH, Prolactin, E2 and thyroid profile to see if there are abnormal concentrations of the same.
HYSTEROSALPINGOGRAPHY:
It is an x-ray of the female’s genital tract which allows the viewing of the uterine cavity and fallopian tubes. This procedure does not require anesthesia, although some patients reported some discomfort. The speculum is inserted into the empty bladder and then the neck of the uterus is channeled with a catheter which injects a substance in order to view through x-rays the uterine cavity, the passage through the tubes and its exit. This is performed in the first half of the menstrual cycle, after menstrual bleeding has stopped.
Hysteroscopy:
Used to examine and surgically correct any abnormalities found in the uterus. It is usually performed under general or local anesthesia and it uses an optical fiber that is vaginally inserted into the uterus. An endometrial biopsy is always taken upon removal of the hysteroscope to confirm if the day of the menstrual cycle is consistent with information given by the patient. Polyps, a septum (piece of tissue that divides the uterus) and fibroids (tissue in the wall of the uterus) can be corrected during a hysteroscopy. After this procedure, patients usually experience a type of discomfort that responds quickly to medication.
FALLOSCOPY:
It is a specialized technique used to examine the light inside of the fallopian tubes. A fiber optic tube is vaginally inserted under anesthesia and.
LAPAROSCOPY:
Allows for the internal inspection of the abdomen and genital tract. It is a minor surgical procedure performed under general anesthesia, where carbon dioxide is used to separate the organs and make them more visible. An incision is required to place the fiber optics and another to place an auxiliary hand in the event of wanting to repair abnormalities. It allows the viewing of the tubes, uterus and ovaries, biopsies, removal of adhesions, electro coagulation of endometriosis, and so on. It is completed by the vaginal introduction of a dye in order to detect blockages.
ENDOMETRIAL BIOPSY:
This is done at the clinic and consists of removing a small sample of the endometrium (glandular tissue that covers the inside walls of the uterus). This diagnoses ovulation and the hormonal levels of the second half of the cycle from the yellow body to determine if there are enough to initially keep the pregnancy. It is also used to diagnose infections or inflammations of the uterus.
What are the most common causes of infertility?
The causes of infertility can be 40% male, 40% female or 20% joint. In the case of men, it may be due to lack of or low number sperm or that sperm is immotile or abnormal. The impotence or premature or retrograde ejaculation is also a cause of infertility.
A woman may not ovulate or do so irregularly, or have blocked fallopian tubes, endometriosis or problems in the uterus such as fibroids (myomas).
When the cause for infertility is joint, it could be a combination of two factors, one male and one female. For example, that the cervical mucus may not be receptive to ejaculation due to the presence of antiesperm antibodies or that there are problems with the sexual relationship itself.
What are the treatments for female causes?
Once the specialist diagnoses the cause of infertility, the next step is to try to solve it medically, surgically or by assisted fertilization.
TREATMENT FOR OVULATION:
One of the most common disorders is the failure to ovulate, which is evidenced by the curve of the basal temperature and the endometrial biopsy. Various induction methods are used to produce ovulation. The most commonly used are clomiphene and human gonad atropines. The effect of these hormones should be closely monitored with clinical, laboratory and echography systems.
CERVICAL MUCUS HOSTILITY:
Sperm improve their quality to climb and reach the fallopian tubes and fertilize the egg when they are inside the cervical mucus that women produce during the middle of their cycle. Infections, hormonal dysfunction or mucus can be altered and become hostile to sperm. In case of infection, a germ culture will be done and the most appropriate antibiotic will be chosen to eradicate them the problem. Sometimes sensitized women can produce antibodies against their husband’s sperm. Corticotherapy and sex with a condom can reduce the concentration of the same.
ENDOMETRIOSIS:
Consists of the presence of endometrial islets in the fallopian tubes, ovaries, ligaments, vagina, etc, which are places where they normally should not exist. These endometrial pockets just like the normal endometrium, undergo cyclical changes that would imposed by hormones, causing regular inflammation and bleeding with the subsequent fibrosis of the affected area, thus disrupting the mobility and shape and texture of the tubes, ovaries, etc. This prevents ovulation, fertilization and nesting. Medical treatment can be administered through hormones or surgery that eradicates endometrial pockets. This is done through FULGUR or removal of the same.
SURGICAL TREATMENT OF PERITONEAL TUBE FACTOR:
In cases where it obstructions of the tubes due to previous infection or previous operations are found, surgical techniques are used to release these adhesions (adhesiolysis) Microsurgery is used for treating blockages in the fallopian tubes so that they become permeable again.
How are males evaluated?
It begins with a thorough personal and family history. It is important for the practitioner to know about previous issues, conditions or illnesses, such as a history of Mumps with swelling of the testicles, hernias, undescended testes at birth, testicular trauma, diabetes, urogenital infections, work environment, smoking and drinking habits, sexual history, etc. Physical exams are important because it allows the verification of minimal alterations previously undiagnosed, such as the size of the testicles, consistency, the presence of varicocele, etc.
SUPPLEMENTARY EXAMS FOR MEN:
SPERMIOGRAM:
It is the basic exam where studies and treatment for the male is initiated. This test allows you to know the quantity of sperm, their motility and morphology. It also provides information about the seminal vesicles and prostate.
Semen is considered to be normal when you have:
• More than 20 million sperm cells in a cubic centimeter.
• More than 50% of sperm and at least 30% of fast translative motility.
• Over 30% of the sperm with normal shape and size.
Semen is considered abnormal when it has:
• Absence of sperm: Azoospermia.
• Decrease in number of sperm: Oligozoospermia.
• Decreased motility: Asthenozoospermia.
• Alteration of morphology: Teratozoospermia.
• Alteration of the three parameters:
• Oligoastenoteratozoospermia.
In case of Azoospermia it should be consigned if the ejaculate was spinning at 2,000 g.
BIOCHEMICAL SEMINAL PLASMA: Provides the functionality of the accessory sex glands. Determines citric acid for prostate evaluation, fructose for seminal vesicles evaluation and L-carnitine for the epididymis.
PRESENCE OF WBC:
The peroxidase test is used to differentiate round sperm cells. Leukocytes are peroxidase positive, while the immature germ cells and male genital tract are peroxidase negative. Leukocyte spermia is when there are more than a million white cells per milliliter which indicates a probable infection.
MICROBIOLOGICAL STUDIES:
Studies the presence of common bacteria, gonococcus, mycobacterium, mycoplasma and chlamydia. Antibiotic therapy is used on the couple if infection is found.
TESTICULAR BIOPSY:
It is an intervention consisting of a small incision to remove a piece of testicular parenchyma to be histologically or genetically studied. Histological studies show the formation of the seminiferous tubules, their diameter, the thickness of the tubular wall, the germinal epithelium and whether the spermatogenesis is complete. The genetic study will verify the chromosomal constitution of the spermatogonia, primary and secondary spermatocytes.
SEXUAL CHROMATIN TEST:
It is a simple test that is usually done though scraping of the oral mucosa. It is used to detect the number of X chromosomes that a male has. The normal male has a negative sex chromatin. Approximately 15% of men with azoospermia have a positive sex chromatin.
KARYOTYPE STUDY:
Is generally done on peripheral blood lymphocytes. Results provide the chromosomal constitution of the individual. Since there is an inverse relationship between the severity of spermiogram and the chromosomal aberrations, it is important to determine them in men with abnormal semen due to an oidiopathic cause.
STUDY OF AZOOSPERMIA AZF GENES: It is the molecular study of a family of genes, located on the long arm of Y, which are associated with spermatogenic process. Up to 30% of men with normal karyotype who have azoospermia or severe Oligozoospermia, have microdeletions that are associated with abnormal spermatogenesis.
FISH IN SPERMATOZOA:
It's the best study available to estimate the production of normal sperm produced by a male. It is especially useful in assessing the risk factor on males who have abnormal semen reproduction and have to be submitted to ICSI.
ENDOCRINE HORMONAL PROFILE: The thyroid profile and FSH, LH, testosterone and E2 hormones, allow us to identify the hypothalamus-pituitary-gonadal axis.
IMMUNOLOGICAL STUDIES:
The presence of A, G and M immunoglobulin on the sperm’s surface can cause infertility. IgA antibodies are produced locally in the male and female’s genital tract, while the IgG and IgM are circulatory. When these antibodies are present, they bind to the surface of sperm and hamper their motility, sperm-egg interaction and fertilization and its penetration into the cumulus and the pellucid zone of the oocyte. Sperm can also be destroyed by the immune system.
DOPPLER STUDY:
Determines venous flow direction. It is useful in diagnosis of varicocele.
VESICULOGRAPHY:
Used to evaluate the permeability of the deferens ducts and the state of the seminal vesicles. It is also prescribed when there is suspicion of sperm flow obstruction.
TRANSRECTAL ULTRASOUND:
Useful in the study of prostate cancer and in patients with low ejaculation volume.
SPERM PROCESSING FOR THE RECOVERY OF MOTILE SPERM:
There are basically two methods: swim up or Percoll gradient technique migration. Both procedures show the functionality of sperm and are therapeutically used in live or In Vitro inseminations.
What are the treatments for male causes?
The quantity and / or quality of sperm may be insufficient for various reasons. This can be treated with hormones, drugs or surgical correction or assisted fertilization. As in women, hormonal treatments should be monitored by the specialist.
SURGICAL CORRECTION OF THE VARICOCELE:
The varicocele is a varicose dilation of the venous plexus which surrounds the deferens that receives the blood that comes from the testicle and scrotal bags. Such dilations cause a local increase in temperature that can interfere with the quality and quantity of sperm. This condition is surgically corrected in order to abolish the varicose vein, and it can be done under general anesthesia on an outpatient basis, or with laparoscopic surgical technique or traditional microsurgery. After a year of completion of a varicocele ligation there is an improvement in the quality and quantity of sperm in nearly 60% of patients.
VASOVASTOMY AND EPIDIDYMOVASOSTOMY:
The sperm produced in the testes may be unable to reach the urethra for ejaculation. This may be due to an obstruction of the deferens or at the deferens union with the epididymis. Obstructions along the deferens can be microsurgically corrected with a technique called Vasovasostomy. On the other hand, if the obstruction is close to the epididymis, it can be corrected with a technique called epididymovasostomy. During surgery, a dye is injected into the deferens and the position of the blockage is viewed through X-rays. These two procedures allow for sperm to be collected and later frozen. If after surgery the ejaculate is not powerful enough to achieve pregnancy, thawed semen can be used to fertilize the egg using special techniques.
SPERM SUCTION:
It is a technique to collect sperm from the vas deferens, epididymis or the testis or in cases of obstructions, vas deferens agenesis or secretory azoospermia, respectively. Once sperm are collected, fertilization is achieved through ICSI (intracytoplasmic injection of sperm). The aspiration is performed under anesthesia on an outpatient basis or during a surgical or a Vasovasostomy or epididymovasostomy. The aspiration is done with a soft suction needle. Each sample collection is microscopically examined to verify the presence of sperm. These samples can be frozen and processed later. If the sperm are not obtained through aspiration, a sample of testicular tissue could be taken. The scattering of the tubules will allow for immature sperm collection, which can mature a few hours later In Vitro to be used with ICSI.
How important is the psychological evaluation of the couple?
Pregnancy is not always consistent with the desire to have a child. Therefore, psychological counseling, whether it is of couples, individual or group, allows for emotional stability in order to make conception easier.
Psychological aspects relate to the emotions, feelings, thoughts, attitudes and any remorse about the difficulties of having a child, which could consequently be a cause for infertility.
In human beings, mind and body is a unit. The best possible scenario in is to achieve psychophysical stability. Sometimes the mind can block the normal functioning of certain organs, including those involved with reproduction. Generally, these mental blocks are of a traumatic nature due to past or present situations, which in turn may affect the disposition to have a child. That is why psychological evaluation, which aims to enhance awareness and understanding of the causes that impede conception, is advisable for any couple with fertility disorders. On the other hand, when the cause is physical, this could produce feelings of guilt, doubt, as well as low self esteem. In all cases, psycho-therapy addresses these issues in regard to the possibility of having a child, whether it is genetically, biologically or through adoption; it also allows for the recommended medical process to take place.