Examining the background for infertility

This examination primarily addresses the couples who have not become pregnant spontaneously and who wish to know why. This can be couples who do not have a child/children already and couples who have become pregnant spontaneously and then have not been able to become pregnant since. One reason can be the male having reduced sperm quality, the other can be the woman having blocked fallopian tubes, missing ovulation, endometriosis, uterine fibroids or polyps. However, often we see a combination of the male and the female factors. Finally, we also see unexplained infertility with all tests showing no abnormalities in neither the male nor the female.

Semen analysis

We perform analysis of the sperm quality at the clinic after you have made an appointment with the secretary and the laboratory.
We will send a semen sample tube to the male or he can deliver the sample at the clinic in our dedicated ”men’s room”. If the semen sample is made at home, it has to be delivered at the clinic one hour after ejaculation and approximately two days after the most recent ejaculation.
The semen is examined under a microscope, where we assess volume, concentration, motility, morphology (appearance) and the total sperm count. You will receive the result after 1 hour. The volume of a semen sample must be a minimum of 2 ml, concentration must be more than 20 million sperm cells/mL and more than 50% of them must have high motility. The total number of motile sperm cells must be more than 20 million. Following purification, only the live sperm cells remain. In a normal semen sample, this would mean more than 10 million purified sperm cells. Men’s sperm quality may fluctuate a great deal. If the male has been ill and/or had a fever within the past three months, this will have an impact on sperm quality. However, it is possible to repeat sampling after one to two months. 

Normal semen quality:

There is no male infertility factor involved and treatment must then depend on findings in the female.
Treatment is insemination (IUI-H (intrauterine insemination - homologous)) if the female’s test results are normal, in particular if passage through the fallopian tubes is unobstructed. If there are more than 5 million motile sperm cells after washing, treatment with IUI-H is attempted three times.
Improvement of sperm quality is rarely possible except from the samples, in which white blood cells are detected, which may be a sign of an infection. If the male takes anabolic steroids, he should discontinue this as they are the cause of reduced sperm quality. Lifestyle factors such as heavy smoking, drinking and obesity have been proven to reduce sperm quality significantly. Heavy coffee drinking and stress may also be contributory factors.

Moderate to severely reduced sperm quality:

If there are less than 5 million motile sperm cells in the purified sample, we recommend in vitro fertilization (IVF).

If there are less than 1-2 million sperm cells, we recommend microinsemination, also known as Intra Cytoplasmic Sperm Injection (ICSI).

If there are no sperm cells in the semen sample, and the testicles appear normal in size, we recommend that a sample be taken from the testicle (testis biopsy) for the analysis of sperm cells. The problem could be an infection blocking the passage inside the male reproductive tract, whereby sperm cells cannot flow into the ejaculated semen. A testis biopsy can be performed here at the clinic.

If during the biopsy, sperm cells are found, we recommend IVF using Testicular Sperm Aspiration TESA. In the case of very reduced count, we always recommend  an ultrasound scan of the testicles to exclude any presence of tumours which could be the cause of the negative semen sample. We also carry out this ultrasound scan of the testicles. The examination is made on an ordinary examination bed, where an external ultrasound scan of the scrotal sac is performed whereby it is easy to scan the testicles. Please note that the male patient will not be placed in a gynaecological bed nor scanned through the rectum which is what some men believe is the case.

If there are no sperm in the semen sample and the testicle volume is small (less than 12 mL, we recommend further examination by your GP who should subject you to a chromosome and hormone analysis (FSH, LH, and testosterone). The treatment will either be IUI-D or IVF-D depending on the passage conditions of the female’s fallopian tube. In many cases, there is no reason for the reduced number of sperm cells or the lack of sperm cells in the semen. Unfortunately, there are no succesful treatmens of the condition

Examination of the female.

An ultrasound scan of the ovaries includes an examination of the appearance and the size of the ovaries for the purpose of excluding any hormone disturbances such as PCO, which could be the cause of infertility. The uterus will be examined for the presence of fibroids in the muscular tissue or polyps in the uterine mucus or partition, which may all reduce fertility. If the fibroids  or polyps are small, we recommend that you try infertility treatment once and if pregnancy is not achieved, we recommend surgery before embarking on new treatment. Partitions in the uterine cavity must always be removed prior to treatment.

Lack of passage through the fallopian tube.

Lack of passage through the fallopian tubes or malfunctioning of them are often caused by a pelvic inflammatory disease. This infection is very often caused by a previous infection known as Chlamydia, which does not necessarily give any symptoms in the female and which untreated will disappear after a while in most cases. Before this happens, the bacteria and thus the infection may have spread from the vagina into the uterus and further into the fallopian tubes, where there is a risk of scarring whereby passage blocks.

Other reasons for lack of passage in the fallopian tubes include cystitis complicated by infections of the urethra and appendicitis with an infection of the abdominal cavity, with these conditions leading to the formation of scars which render the tissues around the fallopian tube hard and inflexible.

Females who have previously had a Caesarian section or other type of surgery performed also risk scarring around the fallopian tubes , although there has been no infection.

Tubal patency test (Hy-Co-Sy)

Tubal patency is tested by using a so-called hystero-salpingo contrast ultrasonography. This examination can be made from the time when the female stops bleeding and until a few days prior to ovulation, e.g. from approximately Day 5 to approximately Day 11-12 of the cycle. Females with irregular menstrual cycles or no menstrual cycle at all due to lack of ovulation, will have a pregnancy test performed prior to examination for the purpose of ruling out pregnancy.

The examination involves the insertion of a very fine plastic catheter into the cervix and further into the uterus, following which sterile saline and air is injected into the uterine cavity and further into the fallopian tubes on both sides. At the same time, a transvaginal ultrasound scan is performed. If there is passage, the fluid and the air bubbles in particular will pass through the fallopian tubes and gather around the ovaries in the abdominal cavity. The test, which lasts approximately 15 minutes, is generally well tolerated with very little pain, and you can follow the procedure on a monitor as we go along.

The following findings can be made:

Normal passage:

The female can have insemination performed (IUI-H) if the sperm quality is acceptable.

No passage in neither of the sides:

In this case, the sperm cannot move through the fallopian tube and up to the egg where fertilization takes place. The female should be subjected to IVF.

Partial passage:
If passage is reduced in one or both fallopian tubes, the chance of becoming pregnant is reduced and the risk of ectopic pregnancy increased. In this case, we often recommend IVF. If the fallopian tubes are found to be expanded and filled with fluid after the test, we prescribe antibiotics to avoid pelvic infection. At this finding, we recommend surgery involving the removal of the fallopian tubes prior to IVF treatment. If you wish, we can refer you to surgery to spare you of the visit to your GP.

 

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