Finding it difficult
to conceive

Tubal blockage is the least understood and most commonly made out reason for infertility. The fallopian tubes are mobile organs cylindrical in shape, attached to the uterus at one end and free at the other end. The free end has finger like projections which can catch the egg when it is released from the ovary. These eggs are then placed somewhere in the middle of the tube waiting for the sperms to reach. Now, if there are enough sperms which can make their way to the egg, then these sperms secrete two acids which dissolve the capsule around the egg allowing one sperm to go through into the egg to fertilize it. Thereafter, when the egg has become an embryo about 4-5 days old, there are hairs like projections (cilia) inside the lumen of the fallopian tube that push the embryo towards the other end into the uterine cavity for implantation. So, to reiterate, the tubes have three roles to play, pick up the egg, allow to sperms to come through and finally transfer the embryo to the uterine cavity. Two of these are dynamic activities which really cannot be assessed in any sure way. Only the fact that the sperms may not reach up to the egg can be commented upon by checking whether the tubes are open or not.

Tubes are open or not are again a little tricky to test. We do an hsg/ssg/laparoscopy to find out tubal status. But as mentioned before none of them is accurate. In quite a few cases, we are no wiser after the procedure. In all of the above procedures we rely on pushing water/dye into the uterus hoping that if tubes are open some of it would trickle out through their free end. So while tubes are not open for innocent sperms as they have no pressure to put, they open up miraculously in HSG/SSG when we do apply pressure to push the water/dye in. This is a dichotomy to be remembered always.

Also while we keep emphasizing tubal patency, we forget that tubo-ovarian relationship is just as crucial. If the tube and the ovaries are far apart, or as I have been stating again and again, somehow the tube and the ovaries are sticking to the back of the uterus and none is mobile then it is more at fault for the egg not finding its way into the tube rather than tubal block.

The straight and simple answer for all tubal factor infertility is IVF. But we could attempt other things provided duration of marriage is less than 5 years and the female is young. Tubal cannulation is a technique where a fine malleable catheter (pipe) is introduced into the fallopian tube from inside the uterine cavity. As it passes, it may take care of occasional blocks in the tube and create a sort of inner passage within the fallopian tube which if it maintains can allow sperms eventually to get to the egg. But as mentioned earlier, the success rate in terms of a pregnancy is not very encouraging because if the tubes are really damaged then opening them does not solve the problem as the hair like structures are not ok and would not transfer the baby back to the uterus when needed. We should attempt this in young women who have no known reason for picking up tubal damage such as past abdominal infection, appendicitis, chronic pelvic infections, history of TB etc.

In all of rest, IVF currently offers the best possible chances at the least cost in terms of money and time.

Sometimes cases taken as unexplained infertility also eventually turn out to be tubal factor infertility. Because when we do IVF, we see that most of the eggs taken out have fertilized well and pregnancy happens quite easily with this technique whereas they had been toiling for last so many years with apparently everything ok.

A reliable test for diagnosing egg production problems are Blood test like AMH (anti mullerian hormone) Ultrasound.

It is easy to identify fibroids. A simple ultrasound may detect these tumours. We could also do a HSG/SSG to see the location of the tumour and whether they are impinging on to the endometrium. Based on that we do we may also recommend removal of these fibroids. Only the risks need to be evaluated against the possible benefits. Lot of western societies have set guidelines for their member doctors to follow. So it is very easy for both the patients and their treating doctors. But medicine cannot be cut paste application of formulae. So we need to go on a person to person basis. See the tumour location, number and size and then decide. I would try naturally for sometime with a woman who is 25, just married and no obvious cause of infertility but indeed ask for myomectomy who has failed two IVF before even with excellent embryos.

A blood test measures hormone levels to determine whether you're ovulating.

Hysterosalpingography (his-tur-o-sal-ping-GOG-ruh-fee) evaluates the condition of your uterus and fallopian tubes and looks for blockages or other problems. X-ray contrast is injected into your uterus, and an X-ray is taken to determine if the cavity is normal and ensure the fluid spills out of your fallopian tubes.

This testing helps determine the quality and quantity of the eggs available for ovulation. This approach often begins with hormone testing early in the menstrual cycle.

Pelvic ultrasound looks for uterine or fallopian tube disease. Sometimes a hysterosonography (his-tur-o-suh-NOG-ruh-fee) is used to see details inside the uterus that are not seen on a regular ultrasound.

Based on your symptoms, your doctor may request a hysteroscopy to look for uterine or fallopian tube disease. During hysteroscopy, your doctor inserts a thin, lighted device through your cervix into your uterus to view any potential abnormalities.

This minimally invasive surgery involves making a small incision beneath your navel and inserting a thin viewing device to examine your fallopian tubes, ovaries and uterus. A laparoscopy may identify endometriosis, scarring, blockages or irregularities of the fallopian tubes, and problems with the ovaries and uterus.

Genetic testing. Genetic testing helps determine whether there's a genetic defect causing infertility.

Semen analysis is the mainstay of male evaluation. Please maintain a gap of 3 days before giving the semen for test. It should be checked in an infertility clinic because they are using standard counting chambers. Otherwise the counts tend to be falsely high. Also number of sperms capable of moving are of value not the dead nonmotile ones. So pay attention to the motile count. If it’s more than 10 million, rest assured. Any lesser, repeat the test and if still short check with an andrologist (male reproductive specialist). Unfortunately there is very little known about the man’s low count and motility. So other than trying useless supplements one by one and praying they succeed, it’s better to accept the fact fast and go about getting pregnant with medical help. Your doctor may ask for one or more semen specimens. Semen is generally obtained by masturbating or by interrupting intercourse and ejaculating your semen into a clean container. A lab analyzes your semen specimen. In some cases, sperm may be tested for in the urine.

You may have a blood test to determine the level of testosterone and other male hormones.

Genetic testing may be done to determine whether there's a genetic defect causing infertility.

In select cases, a testicular biopsy may be performed to identify abnormalities contributing to infertility and to retrieve sperm to use with assisted reproductive techniques, such as IVF.

In certain situations, imaging studies such as a brain MRI, bone mineral density scan, transrectal or scrotal ultrasound, or a test of the vas deferens (vasography) may be performed.