Diagnosing the problem

The infertility investigation is a comprehensive process involving the taking of a proper medical history, physical examination, checking hormone levels (blood tests), diagnostic imaging that includes ultrasound and x-ray procedures, and possible diagnostic or corrective surgical procedures. The infertility work-up can, usually, be completed within 6-8 weeks.

Upon completion of the medical testing, an appointment is made with the couple to review test results and come up with a plan of management that is appropriate for the couple. Treatment strategies can range from simple to complex, and are, ultimately, based on the couple’s particular problem and their previous reproductive history and previous treatments.
At the Markham Fertility Centre, we believe that all couples should take part in decision making about their potential treatment options. Preference of treatment(s) should be based on cost, pregnancy rates and patient choice, and the couple should understand their chances of conceiving with each treatment alternative.

Investigating Infertility

An infertility work-up should be tailored to each couple’s needs. There are standard tests that need to be done, irregardless of a couple’s history, but various options are available to help diagnose your infertility problem.

1. Ovulation:
• Basal body temperature graphs (BBT)
• Serum progesterone levels
• Daily monitoring of estradiol and LH and ultrasound follicular monitoring
• Urine LH predictor kits
• Endocrine testing

2. Male Factor:
• Semen analysis
• Sperm chromatin structure assay testing (SCSA: DNA fragmentation)
• MAR testing (anti-sperm antibodies)

3. Tubal Factor:
• Hysterosalpingogram (HSG)
• Sono-hysterosalpingogram
• Diagnostic laparoscopy

4. Uterine Factor:
• Ultrasound
• Hysteroscopy
• 3D ultrasound
• Sono-hysterosalpingogram
• Hysterosalpingogram
• Laparoscopy

IVF may be an important “test” for a couple to undergo for diagnostic reasons. Many couples that have unexplained infertility, prior to their IVF cycle, have their questions answered following their treatment. Only IVF can answer questions about egg quality, sperm function and embryo quality.

MFC Success Rates

The Markham Fertility Centre does not post pregnancy rates in general. Pregnancy rates can be misleading and give some couples a false sense of hope. On the other hand, some couples may have a better pregnancy rate than the norm.

We prefer to individualize pregnancy rates for each couple.Major factors that influence a couple’s chances of conceiving are:

• Age of the patient
• Semen DNA fragmentation
• Uterine structure
• Past reproductive history including previous treatment attempts

For example, a 25 year old woman that has blocked fallopian tubes has an excellent chance of pregnancy (70%), if one or two good quality blastocysts are transferred.

Conversely, a 43 year old woman who’s husband has poor DNA fragmentation will have close to a 1% chance of conceiving.

Recurrent Pregnancy Loss (RPL)

Many couples have no problems conceiving, but are incapable of sustaining a pregnancy. Occasionally, couples that, originally, present with infertility, will achieve numerous pregnancies through ART procedures, but unfortunately, have recurrent miscarriages.

The traditional definition of recurrent pregnancy loss is 3 consecutive losses. At the Markham Fertility Centre, we offer testing after 2 losses. Fortunately, a cause, and treatment, for a couple’s recurrent pregnancy loss can be found in, approximately, 80% of cases. One third of couples will present with more than one problem contributing to these losses.

Testing for recurrent pregnancy loss includes:

• Male and female chromosome (karyotype) testing
• Evaluation of uterine cavity: HSG, sono-HSG, 3D ultrasound, hysteroscopy
• Mycoplasma testing
• Endometrial biopsy
• Immune screen
• Sperm chromatin structure assay (DNA fragmentation)

Treatment of recurrent pregnancy loss is dependent on the diagnosis once the testing is complete. Treatment can range from surgical removal of a uterine septum, luteal phase support with progesterone therapy or IVIg transfusion for immunological causes. Occasionally, couples resort to egg or sperm donation if a genetic abnormality is discovered in one of the parents. Rarely, a gestational surrogate is indicated for patients with unexplained recurrent pregnancy loss.

Fertility Medications

Fertility medications play a key part in the treatment of infertility. Up-to-date, evidence based medical literature states that fertility medications do not cause an increased incidence in breast or ovarian cancer.

Fertility medications are used to induce ovulation, and often, produce more than one egg per month. The risk of multiple pregnancies must always be discussed when starting fertility medications.

Fertility medications can be in pill form (Clomid, Serophene, Letrazole) or injections of gonadotropins (Puregon, Gonal-F). The gonadotropins are more powerful medications and produce multiple follicles/eggs per cycle in higher doses.