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Female Infertility - What Do Know About It?

Written and reviewed by
MBBS, MD - Obstetrics & Gynaecology, FICS, FICOG
Gynaecologist, Mumbai  •  42 years experience
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Hello,

This is Dr. Shubhada Khandeparkar from Mumbai. Today I will carry forward my previous discussions on the management of infertile of an infertile couple. Now, when the for the treatment of an infertile couple there are two people involved: the male and the female partner. Today I'll be concentrating more on the female partner and I will come to the male partner in the further next videos. Now, when we consider the female the first important few things are the age of the female and the weight of the female. Now, many times the female though she may be just 35 but her BMI that is a basal metabolic index or the weight is more than 25 in that case it becomes very difficult for this female to have a good ovarian reserve. Even otherwise, if the female is more than 40 and she may have a low BMI in that case also the ovarian reserve is poor. Now, how do we know the ovarian reserve? We have to again as I have already mentioned in my previous videos we look at the antral follicle count on day 2 of mensus and the AMH that is anti mullerian hormone.

If these two are relatively good I mean the AMH is more than 2.5 and the AFC is about 3-5 follicles in each ovary on day 2 yes that means the female has a very good chance of having a baby. Once we have established these two things, then we go further and then we have to see what is the next step is the tubal patency; are her tubes open or closed. I have already discussed this with you that how we test the tubes and any one of the test can be done for the patient and once we know that the tubes are open then we go further up the ladder and we say ok now let us evaluate the ovarian function. Now what do we do in this? We have to see how the oocyte or the egg is growing in the ovary.

In each cycle we see that the female develops one oocyte either on the right or the left ovary and as the oocyte matures, as it reaches a particular size, then it ruptures and around that time if one has intercourse and the sperm reaches the oocyte around that time, around the time of ovulation, one conceives. So, now our priority is to look at the ovarian oocyte folicular development. How do we do that? The gold standard for this today is to evaluate the follicles by doing the ultrasound. By doing a transvaginal scan from say day 5 or day 6 we come to know how the egg is developing. Now, every second or third or fourth day depending on how the follicle growth is coming up we call the patient and do the ovarian study, the folicular growth aspect and we also see the blood flow to the follicle and once the folicular blood flow and the growth has reached to a point of about say the growth the size has reached to between 18-22 mm or 1.8-2cm and the blood flow is increased to about 75% of what the original blood flow was, we think yes that this is the ripe and a mature follicle.

Now, in that event there are two ways we can treat this patient further. Either we give a drug or an injection not a drug an injection to rupture this follicle so that we can time the follicular rupture and then we can advise them when to have intercourse or the other thing we can do is we can tell them to have a planned intercourse. Now, if the follicle is very turgid and we feel yes patient says No, I don't want an injection we can also observe if the follicle ruptures on its own and if a follicle ruptures on its own then we tell them to have the intercourse around that time so we will tell them once follicle is reached 22 we will tell them that ok have intercourse for these three four days and plan your relation, plan your relationship.

If the patient says No, I want to take an injection then we give the injection and we time the follicular rupture exactly 36 hours after the injection, the follicle ruptures. So, in that case we can tell them to plan the intercourse accordingly. We can also confirm rupture around 40 hours, call the patient and see that it has ruptured and then again decide for the relationship or the intercourse to have. Other thing is if the sperms are compromised, if the semen sample is not being so good, the count is less than 20 million, motility is not so great 30%, 40% maybe even less 20% then we advise them that ok let us do intrauterine insemination. Now what is intrauterine insemination? Around the time of rupture, it can be a few hours before or a few hours after we tell the husband to us his semen sample, we process it, remove all the unhealthy sperms, immotile sperms, add a culture media, make them more motile you can say make them powerful and hyper motile and then make them 100% motile if possible till about at least the concentration of 10 million sperms and final count should be at least 10 million, between 8 to 10 million and we put them right inside the uterine cavity around the time of rupture. So, this also helps in the ova meeting the sperm and forming an embryo.

So, this way we can help the couple to conceive. Now, WHO says that ideally one should not do more than 6 intrauterine insemination procedures in career because more than 6 that means you have some other reason for not conceiving. So, one can try 5-6 times IUI, if IUI doesn't succeed I think one should go further and see what best can be done next after this. The other thing is that to promote egg development or what is there with us and actually if the eggs are not the ova are not coming up well then what we do for the couple the lady is there are certain drugs. Now, there are tablets; the two types of tablets: one is a clomiphene and the other is a letrose. Now both these tablets the only disadvantage, no I wouldn't say disadvantage but they help promote one single egg or one or two eggs and also at the same time when we are doing all these folicular studies, I missed out to mention that we should be also monitoring the lining of the uterine cavity that is the endometrium.

As the follicle grows, the endometrium also starts getting better and better and thicker and thicker and implantation also is achieved because of the thick proper endometrium. Now with some of these tablets which I told you the drugs like Clomiphene citrate sometimes the endometrium though we need mono follicular growth the endometrium doesn't responds so well and it doesn't improve so well, so we have to add some hormones. The other drug is letrose which also is again giving us some mono follicular growth and that is not affecting the lining or the endometrium, so it is many times considered a better tablet to give for folliculogenesis than clomiphene. Of course, it's a choice of the gynaecologist, the personal experience and the condition of the ovaries of the patient and what she/he perceives is very good for the patient and they will choose the drug.

What are the other drugs we can give? We also have injections. You must have heard about them. The injections are gonadotropins are quite expensive, they need to be given every day and they are you know they have to be monitored closely otherwise you can have multiple follicles coming up so there are certain disadvantages of injections on a routine this to give to the patient. So, we will prefer injection maybe for particular cases, in certain well established centres where proper care can be taken of the patient if multiple eggs are produced.

So, in short I will say that the treatment of infertility for a female today is advanced could extend and yes we can monitor closely the oocyte development, help the woman conceive with certain hormonal support and everything. Now after 12 days of the IUI or the inter course planned relations we can do a card test and then during the leutal phase between these 12 days from the intercourse to the twelve days we do support the lady with hormones again and the card test will tell us if it is positive. If not, we been the mensus and the whole thing starts again. I will thank lybrate for giving me this opportunity to speak to you all.

Thank you.

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