Fertility Basics

For getting pregnant, the first step is to understand your menstrual cycle, which is divided into 2 phases: follicular or proliferative and luteal or secretory phases [1]. You will lose about 30 mL of blood during the menstrual period and if it exceeds > 80 mL, it is abnormal. Ovulation, the process of egg release from your ovaries should occur for pregnancy to happen, and if you have regular periods it is well known that you are ovulating normally. For regular periods to occur, certain events should happen without any issues in your ovaries and uterus.

Now we will know about ovulation.

Ovulation process: Many immature eggs are present in your ovaries at the beginning of the menstrual cycle and these will begin to develop and grow. On the 9th or 10th day of your cycle, the ovaries will select one of the eggs which is said to be dominant and this dominant egg will get mature completely and then get released [2]. Meanwhile, when the dominant egg is maturing, the ovaries release estrogen, a hormone that signals the brain that ovaries are working normally and this estrogen also causes the uterus lining to get thickened. This thickening of the uterine lining will happen to make the uterus ready for implantation of the fertilized egg. When the dominant egg that is selected by the ovary reaches maturity in its follicle or fluid-filled cavity, a hormone LH is increased and this will make the release of the egg from its follicle. Luteinizing hormone LH, is released by the brain into the blood and its increased level at egg maturation can be measured by using the ovulation predictor kit OPK. Now that the egg is released from its follicle, this empty follicle without an egg is called a corpus luteum cyst and it has the job of producing progesterone hormone. This progesterone, acting as a master, continues to help in keeping the uterine lining intact for the implantation of the embryo. Your fallopian tubes will pick up the released egg and if the egg meets sperm here, fortunately, it gets fertilized and moves towards the uterus to get implanted into the thickened uterine wall.

When fertilization of egg with sperm happens successfully and if the resultant embryo implants into the uterine wall, then the uterine tissue will release a hormone called human chorionic gonadotropin HCG. This HCG is known as pregnancy hormone and you are said to be pregnant when the HCG test is positive. In case, that pregnancy will not occur, the corpus luteum will stop producing progesterone after 14 days and the uterus lining will start to shed because of the absence of progesterone. This is the beginning of your menstrual period.

Some of you may feel ovulation pain which is one of the signs of ovulation along with changes in cervical mucus texture, breast tenderness, shifting of the cervix to a higher position, and increased basal body temperature.

Tracking ovulation: Ovulation occurs for 5 to 6 days every month. If your periods are regular, then you may ovulate anywhere between 12 to 15 days before your next period begins. You can track your ovulation using the ovulation calendar, which keeps a record of your last period. Other methods used to track ovulation are measuring basal body temperature that helps to identify the fertile period, cervical mucus checking, and testing of hormones [3].

Fertile days: You can get pregnant if you plan intercourse before and during your ovulation time. Ovulation takes place about 14 days before your menstrual period starts. If your average menstrual cycle is of 28 days, you can ovulate around day 14, and your most fertile days, when you can get pregnant easily are days 12, 13, and 14. If your menstrual cycle is of 35 days, ovulation happens around day 21 and your most fertile days are 19,20 and 21. Pregnancy is technically possible only if you have sex during the five days before ovulation or on the day of ovulation. But the most fertile days are three days which include ovulation. Having sex during this time gives you the best chance of getting pregnant. The sperm of your partner can live for only 5 days in your fallopian tubes and if ovulation occurs within these few days Then pregnancy will happen.

Before you decide to start a fertility journey or if you already are on fertility treatment, then it is very important for you to be an educated patient. We will now discuss how your body works, your common causes of infertility, when to see a fertility specialist, and how to start the fertility journey. You can doubt your fertility when you can't get pregnant even after a year of regular unprotected intercourse. If you are over 35 years old and have tried 6 months for pregnancy but not conceived then you should think about fertility treatment. There are some common causes of infertility which you should be aware of so that you can focus on them to find fertility solutions.

Causes for Female Infertility

In women, issues that cause infertility include your age, lifestyle choices, endometriosis, blockages in fallopian tubes, being over or underweight, infections, repeated miscarriages, fibroids in the uterus, premature ovarian failure, polycystic ovarian syndrome (PCOS), disorders of ovulation and unexplained infertility. According to a study, women, related infertility factors like the above contribute to 88.6% of infertility [4].

Let us now know about male infertility issues.

Causes for Male Infertility

Your infertility is linked majorly to sperm disorders like low sperm count, poor sperm movements, abnormal size and shape of sperm, and blockages in your tubes that carry sperms. Other factors include hormonal disorders, psychological issues, lifestyle issues, and single-gene defects [5]. Now that you are aware of the reasons for your infertility, we should now talk about the time to visit your fertility specialist. You should think of various factors when you decide to visit a fertility specialist. if you are under 35 years of age, then after trying for one year you may visit your doctor and if you are above 35 years, then after trying for 6 months, you may go for a doctors’ visit.

Below, we provide you the criteria to consider before visiting a fertility specialist. These criteria include:

• When you are aged above 37 years.
• When having blockages in fallopian tubes at reproductive age.
• History of ectopic pregnancy
• Endometriosis of severe or moderate level
• Presence of male factor infertility in your partner
• Ovulatory problems are seen in PCOS condition
• Abnormal ovarian test results like increased day 3 FSH levels

On your visit to a fertility specialist

Once you reach the clinic the doctor will do the evaluation of your past and present medical history. You can ask your doctor all your questions and both you and your doctor can plan your further testing and treatment. Both partners should be involved in infertility testing. After a thorough study of your personal and medical history, the doctor will order certain diagnostic tests and explain to you the possible fertility treatment options that suit your situation.

An accurate diagnosis of your infertility can help to overcome it and as there is more than one issue causing your infertility, a complete and thorough evaluation helps a lot. By identifying the correct cause of your problem, the doctor can help you in recommending the best-suited treatment. After a complete physical examination, your doctor will order other essential diagnostic tests. Here, we will proceed to talk about the first female infertility diagnostic tests.

Female Fertility Tests

There are general screening tests that help your doctor in the early detection of your reproductive problems. These test results can help to reduce the risk of infertility and know the cause of infertility so as to treat it earlier with effective treatment. 40% of couples with infertility present with a female related cause. If you are a woman, then the factors that contribute to your infertility can be your age, body weight, ovulatory problems, tubal problems, polycystic ovarian syndrome, endometriosis, unhealthy habits like smoking and alcohol, disorders of the uterus, and pelvic infections.

1. Female screening tests include

• Screening for infectious disease: If your infection with viruses like HIV, syphilis, Hepatitis B, Hepatitis C, and with organisms like chlamydia, gonorrhea goes untreated due to ineffective diagnosis then your pregnancy, your fertility treatment outcomes, and your overall health will be seriously affected.
• Screening for pregnancy: Tests like complete blood count, Rh factor testing, and blood test to know your blood group help to avoid complications to the baby during pregnancy and also help to detect anemic conditions and other genetic health problems.
• Screening of thyroid and pituitary: Hormonal tests like TSH test, Free thyroxine test, and Prolactin tests are done to detect the problems that can impact your fertility treatment or pregnancy.
• Genetic screening: if you have the risk of genetically transmitted diseases like cystic fibrosis or Sickle cell then other tests may be ordered before commencing your fertility treatment.
• Pap smear: This testing is done when you are above 30 years of age to screen for the risk of cervical cancer.

2. Ovarian functioning tests: You may also have fertility problems due to ovary disorders and it may roughly 30 to 35% of your infertility. Testing helps the doctor to know whether your ovaries are able to ovulate or not. In case, if you are ovulating regularly, ovarian functioning and ovarian reserve testing will let the doctor know about your ovulation status and tell you about the quality of your eggs. Sometimes, even if you have regular ovulation, your egg quality may be reduced, and this is considered natural. These ovary tests include [6]:

• Baseline ultrasound: The information on the total size and volume of ovaries, and Antral follicle count are obtained through a baseline ultrasound method. It is specifically performed by your doctor on 2, 3, or 4 days of your cycle.
• Hormonal testing of FSH, LH, and E2: Your ovarian reserve can be determined by doing testing of hormones like Follicle-stimulating hormone (FSH), Luteinizing hormone (LH), and Estradiol (E2). These hormones are tested at 2, 3, and 4 days of your menstrual cycle.

3. Fallopian tube testing: Common fertility problems that arise due to fallopian tube problems are scarring or damage caused due to past pelvic infection, appendicitis rupture that may cause infections within the abdomen, past ectopic pregnancy, and surgeries of the abdomen, previous history of tubal ligation and endometriosis. A special X-ray test known as HSG is performed by your doctor which helps to detect patency of fallopian tubes and any abnormalities of the uterus.

4. Uterus testing: The inner lining of your uterus is lined with endometrial cells and to these cells, the embryo gets attached itself and develops into a baby. If there are any defects in this endometrial lining, proper embryo implantation does not occur and these defects can be scarring of uterus tissue resulting due to past surgeries or procedures, fibroids of the uterus, and other structural deformities of the uterus. The further uterus can be tested by:

5. Physical examination: A complete and thorough uterus examination including palpation is done to identify any masses or swollen areas over the uterus. Breast and cervical testing is also done.

6. Baseline ultrasound of pelvis: The length of your uterine cavity is measured by using this Transvaginal ultrasound technique. It is done on 2, 3, and 4th day of the menstrual cycle.

7. Hysterosalpingogram (HSG): Tubal defects and any structural defects can be provided by using HSG

8. Sonohysterography: The health status of the wall of the uterus and its inner cavity is evaluated using sonohysterography or saline sonography. Any issues related to the uterus wall and the endometrial cavity is known by this test.

9. Hysteroscopy: If your doctor finds anything suspicious while doing sonohysterography, or when there is a need for you to undergo IVF treatment, then this test is usually recommended. High-resolution cameras are used to see the inner uterus cavity and passages of fallopian tubes.

10. Endometrial biopsy: Developmental and infections of the endometrial lining can be diagnosed with this test.

The following are tests done to check male fertility issues.

Male Fertility Tests

There are a number of tests that your doctor can perform to know the cause of your infertility.

Routine diagnostic tests of your infertility involve:

• Physical examination and medical history: The doctor will check your private parts, know about any of your genetic diseases, injuries, chronic health issues, your sexual habits, sexual growth at puberty or any surgeries that may be related to infertility.
• Semen analysis: You are asked to provide a semen sample and it is checked in the lab for sperm count, determine defective shapes of sperm, and measure the volume, pH, viscosity, color, liquefaction and ro evaluate sperm movement.

Additional tests that are done by the doctor to identify the cause of infertility include [7]:

• Ultrasound of testes: This helps to see Varicocele or any other structural problems in the testes and surrounding tissues.
• Hormonal testing: A blood test to measure testosterone and other hormones is done.
• Post-ejaculation urinalysis: If sperms are present in urine, it means that you have retrograde ejaculatory problems. Testing of this can help to treat your infertility.
• Genetic tests: Testing of changes in the Y chromosome or to know of the inherited or congenital syndrome is done.
• Testicular biopsy: This is the testing of sample tissue that is removed from your testes. If it shows normal results, then your fertility problem may be due to blockages in ducts or problems with sperm transport.
• Transrectal ultrasound: By using this device, your doctor can check prostate health and can see for any blockages of the ejaculatory and seminal vesicle tubes that carry sperms.

Once you come to know about your fertility issue, it is time to think about it. Certainly, when self-changes are made it brings a lot of benefits in achieving a successful pregnancy. Let us discuss simple steps that you can implement and follow at home as a primary measure before visiting a fertility specialist. here are a few things that you can do:

Healthy Diet and Lifestyle

Having plenty of green leafy vegetables helps to improve ovulation and make your sperm healthy. Including beans and walnuts into the diet can boost fertility. Trans-fats are bad for your fertility and should avoid them. Regular exercise, aerobics, and swimming activities burn those extra calories and help to maintain ideal body weight. Practicing yoga and meditation helps to manage a stressful lifestyle.

Track Menstrual Cycle

If you know the length of your menstrual cycle, you can have an idea of your ovulation period and plan intercourse to maximize pregnancy chances. To know the length of the cycle, start to count from day one of your bleeding until the first day of your next period. On average, the length of the cycle is 28 days and can differ from woman to woman.

Know Ovulation Symptoms

Start to identify the signs that your body makes at the time of your ovulation. They include an increase in basal body temperature that can be measured by basal body thermometers, changes in cervical mucus that are visible as egg whites while you ovulate, changes in cervix position, one-sided pain in your lower tummy. You can also experience a hike in your smelling sense when you ovulate. Light spotting, breast tenderness, and increased sexual desire are common while ovulating.

Following Fertile Days to Plan Intercourse

Fertile days are the days of your menstrual cycle that can double the chances of getting pregnant if you have planned sexual intercourse. If your menstrual cycle is 28 days long, then you ovulate on the 14th day and fertile days are three days prior to ovulation i.e. 12, 13, and 14th days. If your cycle length is 35 days, then ovulation happens on 21 days and fertile days fall between 19, 20, and 21.

Testing fertility using Home Test Kits: There are home fertility testing kits available in the market for your convenience. Ovulation predictor kits OPKs that are available at drug stores help to know your LH surge in urine that happens 12 to 36 hours before you ovulate and this is known as LH home test. By knowing this, you can have good chances of getting pregnant by having intercourse. Sperm count checking kit is available for men and they help to give a measurement of sperm count (the number of sperm in the semen that is ejaculated). You will get results in a few minutes and this test works by detecting a protein found in sperm. If there is a negative home sperm test which means that your sperm concentration is lower than normal, you should consult a doctor for fertility evaluation.

Consult Doctor

Even after doing all the above lifestyle changes, having a healthy diet, tracking of the menstrual cycle by predicting ovulation and fertile days, and by doing home sperm testing, if there is trouble in getting pregnant, then you should consult a fertility specialist without fail. He will make necessary diagnostic tests as mentioned in the article and plan the required treatment for you. Fertility treatment of both partners is essential to achieve a successful pregnancy. There are various fertility treatments available separately for both men and for women.

Once the diagnosis of your problem is provided, the doctor will structure the treatment plan that suits your personal situation. Your fertility treatment is based on your age, diagnosis, your infertility duration, history of previous treatments, and your personal choice of treatment.

Medicines for Male Infertility

These fertility medicines can bring back normal changes in your endocrine system by making naturally available testosterone, increased sperm production, or motility, and by reducing the amount of estradiol [8]. The drugs used are:

• Clomiphene or Clomid
• Anastrozole or Arimidex
• hCG (Human Chorionic Gonadotropin) or hMG (Human Menopausal Gonadotropin)

The above medicines are taken by mouth, but hCG and hMG are injections. There are few side effects with these medicines like changes in mood, sex drive, energy levels, blurred vision headaches, nausea, insomnia, increased weight, and enlarged prostate.

Surgical Treatment for Male Infertility

Problems of sperm production are treated in men. They include:

• Varicocelectomy: Your doctor will recommend this surgery for you if you are diagnosed with Varicocele, a condition in which blood gets obstructed in the veins of the spermatic cord. About 40% of men with infertility have varicocele as a diagnosis [9].
• Varicocele Embolization: This is another type of surgery for your Varicocele condition.
• Transurethral Ejaculatory Duct Resection: If you have blockage of the ejaculatory duct ( a tube that carries semen from your testes to the urethra) this surgery is done to open the duct.
• Vasectomy reversal: Vasectomy is a birth control surgery that prevents the release of sperm when ejaculating. Reversing this surgery can help to restore your fertility by allowing the flow of sperms. According to a study, the reversal of vasectomy restores patency of the male excurrent ductal system in 80 to 99.5% of cases and promotes unassisted conceiving in 40 to 80% of couples [10].

Assisted Reproductive Technology ART

Sperm is obtained either from a normal semen sample that is ejaculated normally or can be extracted through surgical procedures or can be taken from a donor. The sperms that are collected by these methods are then placed into your partners’ uterus or can be used in invitro-fertilization (IVF) or Intracytoplasmic sperm injections (ICSI).

Though the treatment for your infertility depends on your age, duration of infertility, cause, and your personal choices, it also needs financial, physical, psychological commitments. Some may need only one or two methods to restore their fertility while some may need a combination of more than two methods. Treatments available are:

Medicines

These are used to stimulate ovulation and are best for you if you have a diagnosed ovulatory disorder. These drugs are Clomiphene citrate, Gonadotropins, Metformin, Letrozole, and Bromocriptine. As with any other drugs they too have side effects like multiple pregnancies, ovarian hyperstimulation syndrome OHSS, and risk of increased ovarian tumors later in the future.

Surgical Methods

Surgical procedures can help to correct your problem and can improve your fertility. They include:

• Laparoscopic or Hysteroscopic surgeries: Your chances of getting pregnant can be improved by making a surgical correction or surgical removal of abnormalities. Your doctor can recommend surgery for correcting the abnormal shape of the uterus, or by removing endometrial polyps, fibroids, pelvic, and uterus adhesions that can alter the normal anatomical structure of reproductive organs. In a study done on 53 patients to assess the effectiveness of laparoscopy in treating infertility due to endometriosis showed 32% success for a clinical pregnancy, 20.75% success for spontaneous pregnancy, and 11.32% success for pregnancy with the help of assisted reproductive technology [11].
• Tubal surgery: If your infertility is due to blockages of fallopian tubes or due to hydrosalpinx, then you may have to undergo Laparoscopic surgical removal of the blocks, adhesions to open the tubes or a new opening in the tube may be done.

Reproductive Assistance

When other fertility treatment methods do not work for you, then the following Reproductive assistance methods can be useful. Commonly used methods are:

• (IUI) Intrauterine Insemination: In this method, the doctor will allow your egg to get fertilized with millions of healthy sperms, at the time of your ovulation. In this way, your chances of getting conceived are improved.
• Assisted Reproductive Technology: In this procedure, your doctor will attempt to extract mature eggs from your ovaries, allow them to get fertilized with the sperm of your partner or another donor, in a special lab. The resulting embryo is then transferred into your uterus for further embryo implantation. IVF is a commonly used effective ART procedure and has a high success rate. You may need to take frequent and required blood tests and hormonal injections for several weeks in IVF treatment.

It is important to know about your reproductive health and it all starts with having some knowledge of fertility basics.