The aggressiveness by which a patient pursues pregnancy will differ from person to person based on individual desires and age. I believe it is also of utmost importance to consider the many medical factors which can impact the patient’s ability to conceive in order to properly help direct her.
Important things to keep in mind:
- The mean conception time for patients in their twenties is six months. After the age of 30, it begins to increase and will significantly increases after the age of 37.
- Having coitus three times per week increases the chance of pregnancy one and one-half times over having coitus one time per week.
- A man is twice as fertile in his twenties as he is in his forties.
The causes of infertility are as follows:
- Male factor – 40%
- This includes either low sperm counts, poor morphology (physical appearance), and poor mobility (movement of sperm)
- Ovulation factors ( inadequate or no egg production) – 20%
- This includes hormonal imbalances, poor egg quality, and inadequate corpus luteum (inadequate progesterone production)
- Tubal and pelvic factors – 20%
- Includes congenital anatomic abnormalities, scarring, and endometriosis
- Cervical and uterine factors – 10%
- Poor mucus , scarring of the cervix , uterine lining scarring, and myomas (fibroid tumors)
- Immunologic factors – less than 5%
- Sperm immobilizing antibodies (patient produces antibodies which can inactivate husband’s sperm)
- Nutritional and metabolic disorders – 5%
- Thyroid, elevated prolactin, diabetes, obesity, and too thin.
- Evaluation of egg quality and proper egg production can be accomplished with a few simple blood tests and sonography.
- Blood testing on day three of the menstrual cycle consisting of an FSH (follicle stimulating hormone) level, and AMH (anti-mullerian hormone) and estradiol level will help determine the quality of eggs. A progesterone level will be determined by a blood test in the middle of the second part of the menstrual cycle to predict proper egg production.
Evaluation of sperm quantity and quality are easily evaluated through an ejaculated specimen.
Hormonal imbalances such as thyroid, elevated prolactin, and insulin resistance are also evaluated through blood testing.
Evaluation of anatomy and fallopian tube patency (opening) can be evaluated by a X-ray dye test or laparoscopy (day surgery procedure).
The method and speed by which we evaluate a patient will depend on her age, her history, and her physical exam. As an example, if a patient is in her mid-thirties, has a history of pelvic pain, and has evidence of marked scarring on a pelvic exam, she would be best evaluated by laparoscopy.
I feel it is very important to individualize the approach to assisting patients with their efforts to conceive. A patient who is in their mid-twenties and has not been successful in conceiving may become very anxious. I believe that a few inexpensive steps like using an over-the-counter ovulation kit, timing coitus, and drawing a properly timed progesterone level through a blood test will potentially improve her chances of conceiving while giving her reassurance that she is producing normal eggs. On the other hand, a patient who is 36-years-old or more should take a much more aggressive approach to conceiving because she will statistically have more difficulty conceiving.