How is infertility diagnosed and treated in women?

Fertility relies on the ovaries releasing eggs that are healthy. The reproductive tract needs to allow an egg to pass through into the fallopian tube and join the sperm in order to be fertilised. This egg, having been fertilised, then travels to the uterus to be implanted in the lining. Tests for fertility in women determine if there are any issues in the fertilisation process.

A physical exam is first conducted as well as a gynaecological evaluation followed by specific fertility tests that can include:

• Hysterosalpingography – this evaluation looks at the state of the fallopian tubes and uterus for problems such as blockages. An injection of an X-ray contrast agent is administered into the uterus in order to take a specialised X-ray (known as a fluoroscopy) to see if the area is normal as well as to make sure that the injected fluid does pass out of the fallopian tubes (i.e. they are not blocked).
• Ovulation testing – this is a blood test that measures hormone levels in order to see if the woman is ovulating.
• Ovarian reserve testing – doctors may use a combination of blood tests and findings from the ultrasound of the ovary to determine the ovarian reserve.  These tests determine the egg quantity and quality of those that are available for ovulation: 
  
  
  • Ultrasound: The size of the ovary (ovarian volume) and the antral follicle count are determined using an ultrasound.  
  • Blood tests: FSH (Follicle Stimulating Hormone) and oestrogen levels on day 2 or 3 of the menstrual cycle, as well as AMH (Anti-Mullerian Hormone level), will also be done. AMH is a hormone that is secreted by the cells in the developing follicles (egg sacs).  
• Imaging tests – these are typically pelvic ultrasounds to check for fallopian tube or uterine disease and provide access to the ovary to determine the size and follicle count at a particular time in the menstrual cycle. These can also include a hysterosonography, which is used if something cannot be viewed on a normal ultrasound scan. As mentioned, the ovarian volume (the size of the ovary), as well as the antral follicle count are both determined using the ultrasound.
• Other hormonal testing – these tests determine the levels of the ovulatory hormones, including the hormones that control the reproductive processes, known as the pituitary hormones.

All of the above give an indication of the ovarian reserve and efficiency.

If indicated, testing can also include:

• Laparoscopy – this is minimally invasive surgery which involves creating a small cut below the navel and then inserting a small and thin device to view and examine the ovaries, fallopian tubes and uterus. This test is able to pick up on scarring, endometriosis, blockages and more.
• Genetic testing – this helps to find out if a genetic issue is the cause of infertility.
• Hysteroscopy – this test is done based on the symptoms that may suggest infertility is the result of uterine or fallopian tube disease. In this test, the doctor will insert a small and lighted device through the cervix to view any abnormalities.

What are the treatment options for infertility in women?

It may only be that one or two treatments are needed in order to restore fertility. However, in some cases, several treatments may be required. It is purely dependent on the symptoms and causes.

Bear in mind, that this does not necessarily mean that you will require assisted reproductive techniques, you may only require minor investigations and treatments for various hormone level imbalances. Examples of this include hormone treatments to assist in the regulation of thyroid or insulin levels to aid in achieving natural conception.

Some of these can include:

• Using fertility drugs to stimulate ovulation – these are seen as the main treatment for infertility as the drugs can regulate or induce ovulation.
• Intrauterine insemination (IUI) – in this treatment healthy sperm is placed directly into the uterus, at the same time that the ovary releases an egg needing to be fertilised.
• Surgery that restores fertility –this can include a uterine septum or intrauterine scar tissue which can be removed through hysteroscopic surgery. Treatment for endometriosis is also done laparoscopically (minimally invasive surgery - MIS) to improve fertility outcomes.

To further elaborate on treatment options, it is best to focus on assisted reproductive technology, known as ART.

This refers to the treatment where an egg and a sperm are handled by doctors and lab technicians to achieve pregnancy. IVF (in vitro fertilisation) is the most common kind of this technique.

IVF is conducted within one-month cycles. Your doctor is basically attempting to simulate the natural process of conception with a degree of medical enhancement. Normally, your brain will stimulate the ovary to produce an egg, in IVF, your doctor will administer ovarian stimulation drugs in order for mature eggs to be harvested for fertilisation. Therefore, instead of ovulation occurring inside of the body, your eggs are removed and the process of fertilisation is induced in a lab. Once the embryos (fertilised eggs) are five days old, at the same time that the uterus would normally be prepared to accept an embryo (or multiple embryos, usually up to three, if you so choose), your doctor will transfer the five-day old embryo/s back into the uterus.

If this works, it can result in a viable pregnancy, and sometimes more than one foetus being formed. Multiple births are often a reality with IVF.

There are also other techniques that are used in the IVF cycle involving both men and women, known as:

• ICSI (intracytoplasmic sperm injection) – this involves injecting a healthy sperm directly into an egg that is mature. This technique is normally used when IVF cycles have not worked or semen quantity is poor.
• ZIFT (zygote intrafallopian transfer) or GIFT (gamete intrafallopian transfer) - this involves collecting the sperm and the egg in a lab and quickly placing them into the fallopian tube.
• Assisted hatching –this sounds like something that is done using hens and their eggs, however, this technique involves implanting the embryo (egg fertilised with sperm) into the endometrium (lining of the uterus/womb) by opening the outer cover of the embryo, known as hatching.
• Donor sperm or eggs – most cases of ART are conducted using a woman’s own eggs and a man’s own sperm. There can sometimes be issues with the eggs or the sperm, in which case eggs, sperm or embryos can be used from an anonymous donor.
• Surrogacy – for a woman whose uterus does not function correctly or needs to be removed for some medical reason (this is known as a hysterectomy ), the embryo can be placed in the uterus of a gestational carrier (also known as a ‘surrogate’) in order for a foetus to form. The gestational carrier carries the foetus to full term and the baby is given to the biological parents at birth.