Unexplained infertility is a frustrating condition, not just for the couples but also their doctors. A couple is labelled as having unexplained infertility when the basic work up of the couple does not reveal a clear reason as to why a couple is having difficulty in becoming pregnant. Not just that it is a dilemma for the patient that why they are not getting pregnant, also it poses a big challenge for the treating infertility specialist on how to proceed. Unfortunately, there is no single treatment option that provides an edge above the others.
Infertility is defined as the inability to conceive after a year of unprotected intercourse. Infertility affects about 10 -15% of women ages 15 to 44. For those desiring a baby, the inability to get pregnant can have devastating social, psychological and physical effects. The drive to seek treatment and going to any extent to achieve the same is understandable.
Management Strategy
The first logical step is a detailed evaluation of the couple. Infertility is caused by female factors in one thirds of the patients, male factors in another one thirds and combined male and female factors in remaining one thirds. The most common causes accounting for infertility in India are sperm abnormalities (low sperm counts and motility/ speed or no sperms at all) leading to male factor infertility, and in women, a hormone condition called polycystic ovarian disease or PCOD. Other important causes are blocked fallopian tubes which may be due to past infections, tuberculosis, endometriosis, surgeries etc. In 10-15 % of all infertile couples, there is no cause found for infertility on routine investigations, such cases are called “unexplained infertility.”
Many couple with “unexplained infertility” will get pregnant with watchful expectancy which means without ivf treatment but trying naturally. It is still not advisable to wait naturally beyond 2 years of trying as the chances of conceiving without medical aid start decreasing thereafter. Once a decision to start treatment is taken, the first step in young couples could be to try using medicines for ovulation induction to push the ovaries to produce more than more one egg (multifollicular response) to increase the chances of sperms fertilising the egg. For some couple, doctor may advise intrauterine insemination or IUI. This has a proven role in couple with “unexplained infertility”. This therapy is simpler and much less expensive and cost effective than in vitro fertilization (IVF). Although a couple may have to go for repeated cycles of IUI to enhance the probability of conceiving. In IUI, sperms are centrifuged and through special semen preparation techniques, the best sperms are selected, loaded in a fine tube or catheter and gently deposited inside wife’s uterus at around 12-16th day of woman’s menstrual cycle as this is the time when the eggs mature and rupture inside a woman’s body. This cycle has to be carefully monitored with serial ultrasounds.
Sometimes your fertility doctor may also advise you to directly go for IVF (In Vitro Fertilization). Doctor has to take into account various factors like age of both the partners, ovarian reserve, tubal status, duration of infertility, previous response to treatment, semen profile etc. before making the final strategy. Another thing to remember is that the choice is only based on the chances to conceive. No treatment can ever guarantee us a pregnancy.
Although medical breakthroughs have helped improve and optimise treatment results, it is equally important to minimise multiple pregnancies and complications arising out of the treatment. Proper counselling about success rates and possible complications before starting with the treatment is very important. The desired and heartfelt goal of infertile couples and their doctors isn’t just achieving a pregnancy, but a pregnancy with a good outcome—a healthy mother and a healthy baby
The incidence of infertility is much more than most people realize. An estimated 10 percent to 15 percent of couples trying to conceive will have difficulty doing so.
What is infertility and when to see your doctor?
Infertility is the inability to conceive after:
- 1 year of unprotected intercourse when the woman is 35 years old or younger.
- For women over 35, this timeframe is 6 months
- For women close to 40, the timeframe is 3 months.
Once you have crossed this timeframe, it is better seek to advise from an infertility specialist.
The exception to this is if a woman has any of the following:
- Irregular periods (or none at all), or extremely painful periods.
- Two or more miscarriages.
- Previous ectopic pregnancy.
- A history of pelvic surgery.
- A diagnosis of endometriosis or other another complex ovarian cyst/ tumor.
- A history of systemic illness or previous history of tuberculosis (PID)
In any of these conditions, you should seek a consultation from a fertility specialist right away.
Once a couple decides to seek professional advice or help, it is prudent to see a gynecologists who specializes in fertility management and hormone disorders. Also, it is a wise idea to see a fertility specialist before actually planning a pregnancy for what is called as ‘PRECONCEPTIONAL COUNSELLING AND MANAGEMENT’ Pre-conception advice/ management
History: Pre-existing medical problems:
- Stabilize medical conditions, if any, like thyroid disorders, hypertension, diabetes or prediabetes, epilepsy, etc. and ensure that medical control is optimal.
- Check that drugs needed are safe for use in pregnancy and do not affect sperm function.
Weight
- Check BMI The formula is BMI = kg/m2 where kg is a person’s weight in kilograms and m2 is their height in meters squared.
- Advise on weight gain or loss where BMI is <18.9 or >24.9 respectively.
Folic Acid
- Women who are trying to conceive should take folic acid supplements (400 mcg) daily to reduce the risk of neural tube defects. Women with a history of neural tube defect or epilepsy should take 5 mg daily.
Diet
- Dietary modification is good for weight management as well as detoxification.
Recreational Drugs
- Advise both partners to stop using recreational drugs.
Caffeinated Drinks
- Caffeine intake more than two cups of coffee daily should be avoided.
Smoking
- Advise both partners to stop smoking
Virology Screening
- Screen for rubella immunity and offer immunization to those not immune. to those not immune.
Prenatal Diagnosis
- Tell older women about options for prenatal diagnosis and the need for early referral for IVF in Jaipur
Blood Tests
- Before trying to get pregnant, your fertility doctor may ask you to get few blood tests done like thyroid and diabetes screening, tests for ovarian reserve(capacity of woman’s body to produce eggs) and manage accordingly.
Timing of Intercourse
- Check couple's understanding of ovulatory cycle and relate most fertile days to the length of woman's cycle
- Advise that intercourse occurs regularly. Two to three times a week should cover the most fertile time.
Blood Tests
- Few blood tests including thyroid screening, diabetes/ prediabetes
- screening, checking ovarian reserve(the ability of the body to produce eggs) are also required in some cases.
A couple trying or planning for a pregnancy should consider seeing a doctor for a “preconception management” to review what you can do to optimize your chances of a successful pregnancy. For example, certain medications and habits like alcohol, smoking, tobacco intake are harmful to the developing fetus and should be stopped well before planning a pregnancy. Certain conditions like Thyroid problems, Diabetes, Hypertension should be well controlled before attempting to conceive. Also, few supplements like folic acid and antioxidants, if started for both the partners, can help achieve the goal of a faster conception and healthy pregnancy.
The recommendations mentioned below are aimed at preventing and reversing ovulatory infertility, which accounts for one-third of all cases of female infertility. These hold equally good for the male partner. These are meant for improving natural fertility in the form of better ovulation and correction of mild sperm abnormalities. However detailed evaluation and targeted steps are always advisable as problems like tubal factor infertility, uterine factors, severe ovulatory and sperm dysfunctions would need medical assistance. But one thing is for sure that a healthy lifestyle will never go wasted. It can not ensure a pregnancy but can definitely help improving results in most of the cases. Also, it's virtually free, available to everyone, can be done at home, has no side effects, sets the stage for a healthy pregnancy and a healthy baby, and forms the foundation of a healthy lifestyle not just for motherhood but for. That's just like a win-win situation either ways
DO’S AND DON’TS
Avoid trans fats. These fats commonly found in junk foods like chips, cookies decrease chances of conceiving as well as have a negative impact on the heart and blood vessels. Say NO to TRANS FATS.
More fiber, fewer carbohydrates: Choosing foods that are rich in fiber, like whole grains, raw salads, leafy vegetables, whole fruits, and beans, instead of rapidly digested simple sugars can improve fertility by controlling blood sugar and insulin levels.
Drink lots of water: Drink plenty of water, that is the mantra.
Start pre-conceptional vitamins/ folic acid (with doctor’s prescription). Taking extra folic acid (recommended 400 micrograms a day but available as 5 gms) before you get pregnant could actually help reduce the chances of early pregnancy losses.
Drinks to avoid: Caffeinated drinks like Coffee, tea, and alcohol are okay in moderation but excess consumption at any one point or for a long duration is not as good as these have a cumulative effect. Avoid sugared sodas, packaged juices, canned drinks with artificial flavors and concentrated sugars.
Use proteins from a vegetable source: A serving of vegetable proteins each day with beans, peas, soybeans, kidney beans, chana/ roasted chickpeas, tofu, nuts can improve fertility.
Make it whole milk: If you drink milk, choose whole milk while trying to get pregnant, or full-fat yogurt every day.
Regular exercise to stay active and fertile. Daily exercise can help improve fertility, not just for overweight and obese but also for lean thin men and women.
Iron-rich diet. Extra iron from plant sources, like whole-grain cereals, spinach, beans, tomatoes, and beetroot, help boost natural fertility.
Weigh healthy. Weighing too much or too less can cause hormonal disturbances and disrupt normal menstrual pattern by impairing ovulation. The best range for fertility is a body-mass index (BMI) of 19 to 24.9. Try to achieve the targeted BMI rather than a target weight. Reducing 5-10 % of body weight over 6 months can actually help almost 50% women regain ovulation regularly. Also, obese women have a higher risk of complications.
