When 25-year-old partners have unprotected sexual intercourse, the chances of obtaining a pregnancy are 25% in the first month, 70% in the first 6 months, 85% within the year, and 95% before the end of the second year. These statistics apply to partners who do not suffer from any medical condition which may influence the process of obtaining a pregnancy.
In case of women older than 35, because the number and quality of oocytes decrease with age, it generally takes longer to become pregnant. Also, endometriosis, uterine fibroids, and spontaneous abortion are more common after this age. These are pathologies known to undermine the chances of obtaining a pregnancy. After the age of 38, approximately 50% of pregnancies end in spontaneous abortion, compared to only 10% in the case of 25-year-old women.
In order to increase the chances of obtaining a pregnancy naturally, a couple is recommended to be sexually active every 2-3 days, especially during the fertile period. Ovulation occurs approximately on day 14 of a regular 28-day menstrual cycle. If the woman has a regular menstrual cycle of 28-30 days, unprotected sexual intercourse is recommended between days 10 and 17.
IVF is the acronym for the medical term In vitro fertilization, while ICSI represents the abbreviation of the medical term of intracytoplasmic sperm injection or introcytoplasmic injection of semen, which is a more complex type of IVF. IMSI - intracytoplasmic injection of morphologically selected sperm represents a development of the ICSI method and involves the use of special equipment to select the best sperm. All these techniques require the collection of oocytes (mature eggs) by means of transvaginal ultrasound-guided ovarian drilling.
After the oocytes are collected, they are fertilised by bringing them in contact with the spermatozoa. This procedure is carried out in a laboratory. In ICSI, mobile spermatozoa are injected directly into the oocytes, one for each available mature oocyte. The resulting zygote or zygotes (fertilised egg or eggs) get transferred into the uterus via the cervix during development, after fertilisation. For the pregnancy to progress, two conditions must be met: implantation must take place and the embryo must develop continuously. Medical providers of ICSI and IVF follow the same rules and incur the same costs. In both ICSI and IVF the couple will undergo the same procedure. The difference between the two are strictly related to the laboratory infrastructure used.
A diet rich in fruit and vegetables, especially those rich in folic acid, is recommended. Both partners are advised to supplement their diet with folic acid, at least 400mg per day, 3 months before conception. The pregnant woman must continue to take folic acid for at least 12 weeks of pregnancy. Folic acid reduces the incidence of foetal malformations and especially of neural tube defects.
Sudden weight gain or weight loss may influence ovulation and the menstrual cycle. A woman’s Body Mass Index (BMI) within normal range is important when she wants to get pregnant.
Excessive consumption of alcohol affects the quality of oocytes and spermatozoa. Drinking 1 glass of wine/week for the woman and 2 glasses of wine/week for the male partner is generally accepted as not harmful. Smoking severely decreases the quality of spermatozoa, impairing their mobility, number, and morphology by at least 40%.
The consumption of light drugs and smoking have negative effects on ovulation, fertilisation, and implantation.
It is prudent to avoid contact with solvents, pesticides, and lead because these are known to reduce the possibility of obtaining a pregnancy.
Men should know that high temperatures (sauna, hot baths) and tight underwear that constricts the genital area can also affect the quality of their spermatozoa.
Always inform your doctor if you are taking any medication. It is possible for commonplace medication to influence the chances of obtaining a pregnancy or to be contraindicated during pregnancy. Food supplements, energisers, or weight loss pills may alter the results of preliminary tests or the response to therapy.
We advise couples to make a medical appointment when the partners have not obtained a pregnancy within 1 year of unprotected sexual intercourse. Sometimes, this recommendation does not apply. Make an appointment at our clinic immediately in any of the following cases:
- irregular menstruation or absence of menstruation;
- history of repeated genital infections;
- history of complex surgical interventions;
- menstrual pains;
- 2 or more abortions or arrested pregnancies;
- history of infections with Chlamydia, Ureaplasma, Mycoplasma, or Gonorrhea in one or both partners;
- trauma, accidents, surgical interventions on the man’s genital area;
- mumps in adulthood;
- premature ejaculation, erectile dysfunction;
- changes to the frequency or quality of sexual intercourse during the last 3-6 months;
- female partner older than 35;
- family history of menopause before the age of 40 (grandmother, mother, or sister).
In Romania, the evaluation of an infertile couple must be performed by a certified doctor, issued by the Ministry of Health, specializing couple infertility therapy and assisted human reproduction. This overspecialization is also called reproductive medicine. The treatment and the monitoring of the therapeutic response, as well as any specific procedures should be carried out by medical professionals who hold relevant accreditation following the completion of specialised training courses and exams.
The initial diagnosis of infertility may be established by the general practitioner, the gynaecologist or the endocrinologist. They may also recommend a series of preliminary diagnostic tests. Afterwards, however, it is necessary that a specialist interpret the results and prescribe appropriate therapy in reproductive medicine..
The Fertility Institute in New Orleans established a classification based on their success rate in treating couple infertility and obtaining pregnancies in 12 000 cases.
|CAUSES OF INFERTILITY||INCIDENCE||SPECIFIC TESTS|
|Male||40%||Semen analysis test/postcoital test|
|Ovulation||35%||ultrasound / progesterone / endometrial biopsy|
|Uterus/Fallopian tubes||25%||HyCoSy / Laparoscopy with Dye Test|
|Endometrium||10%||Ultrasound / endometrial biopsy|
The postcoital test is important in assessing the interactions between spermatozoa and the cervical mucus produced by the woman in the middle of the menstrual cycle, during the days 12-17 in case of a regular cycle. The test is carried out 7-12 hours after sexual intercourse. With a special instrument called Aspiglaire a small quantity of cervical mucus is collected on two slides which are studied under the microscope at a 30-minute interval one from the other. The first slide is inspected, and the mobile spermatozoa swimming forward are counted.
The test is considered positive is at least 5 spermatozoa are found swimming in the examined medium. The second slide is analysed 30 minutes later for the fern-like crystallisation pattern of the cervical mucus. A negative test is that in which fewer than 5 mobile spermatozoa are found progressing through the medium, indicating an unfavourable interaction between the cervical mucus and the spermatozoa as a potential cause of infertility. In this case, intrauterine insemination is the recommended solution for the spermatozoa to bypass the cervical barrier by being released directly in the uterus and fallopian tubes with the help of a catheter.
The sex of the baby is decided when the oocyte is fertilised by a spermatozoon. The spermatozoon may carry a chromosome X or a chromosome Y. In assisted human reproduction procedures, there are several ways in which the sex of the future embryo can be decided in advance. One of the indications for such a decision is to prevent the future child from inheriting a genetic disease that is transmitted specifically to male or to female offspring. The details about the possibility of choosing the sex of the future child can be discussed in a specialised consultation at the Origyn Fertility Center.
Ovulation is associated to regular menstrual cycles of 28±5 days. In most cases, when a woman has irregular menstrual cycles, her ovulation is also known to be inconsistent and to not occur naturally. The causes of ovulatory dysfunctions are related to the ovary or to the signal that the central nervous system sends to the ovary. Several specific tests are available in order to determine the cause of the ovulatory dysfunction. They are a compulsory part of the protocol for investigating infertility.
The polycystic ovary syndrome occurs in 10-15% of women of reproductive age. According to the Rotterdam Consensus from 2003, the diagnosis is established based on at least 2 of 3 clinical criteria.
These criteria are:
1. Irregular menstrual cycles;
2. Excess of androgynous hormones (excessive pilosity/testosterone levels above normal);
3. Indicative ultrasound presentation (more than 12 follicles ≤ 9mm on each ovary).
A ratio of 2 to 1 or greater between LH and FSH levels.
Typically, increased resistance to insulin or metabolic syndrome is also noted. In this case, however, the LH/FSH ratio is 1:1. The metabolic syndrome is also called syndrome X, and its diagnosis is established based on:
blood pressure ≥130/85mmHg
triglycerides ≥ 150mg / dL
HDL cholesterol ≤ 50mg / dL
- obesity, predominantly abdominal fatty tissue, abdominal circumference ≥89cm
glycemia à jeun ≥ 110mg/dL
Resistance to insulin is identified based on the glucose tolerance test. Insulinemia and glycemia are assessed à jeun then 1 hour and 2 hours after ingesting 75g of glucose. Insulinemia ≥150μU/mL is indicative of syndrome X. The outcome of ovarian stimulation is influenced by this condition.
Several methods can be used to assess if the fallopian tubes are obstructed or blocked (tubal occlusion). One of them is hysterosalpingography (HGS), but it has been abandoned lately because it is painful, and it does not always produce conclusive results. Hysterosaplingoultrasonography or HyCoSy has replaced HSG as a less painful procedure that is also easier to perform. By comparison, the patients who undergo HyCoSy report pain levels similar to menstrual pains and rate it as 4-5 on a 1-10 scale, which the pain experienced during HSG has been rated as high as 9-10.
The best method available to assess tubal permeability is the laparoscopy and dye test, currently the golden standard in the field. laparoscopy with Dye test, being considered at this time the gold standard.
HyCoSy or hysterosalpingocontrastsonography is a method for assessing the permeability of the fallopian tubes. The procedure is done in the first part of the menstrual cycle in the absence of haemorrhage. An ultrasound machine, a special catheter, and contrast substance are used. A 2-3mm thick catheter is introduced through the cervix and fixed in position by inflating a small balloon. A previously stirred saline solution is injected through the catheter and its spread inside the uterus and into the fallopian tubes can be seen on the ultrasound. The same procedure can be used to diagnose endometrial polyps, submucosal fibroids or various uterine anomalies.
In the past, tubal cannulation was the only method available for treating the occlusion of fallopian tubes. At present, the infectious process caused by sexually transmitted diseases is known to also irreversibly damage tubal cilia. Cannulation procedures can help restore the permeability of the fallopian tubes, but soon after the occlusion tends to reoccur. Such interventions can also be harmful in the presence of undiagnosed infections of the vagina or cervix because the injected fluid can facilitate the spread of the infection to the uterus, fallopian tubes, or peritoneum, further aggravating the woman’s condition and greatly diminishing her changes of getting pregnant.
Sometimes, the fallopian tubes may be permeable on the inside, but prior surgical interventions, even an appendectomy, may have caused the fallopian tubes to adhere to neighbouring structures and bend sharply as a result. For this reason, laparoscopy remains the gold standard, as it allows the correction of such adherences.
The hydrosalpinx is the accumulation of fluid inside the fallopian tubes following an infectious process most commonly caused by sexually transmitted diseases. The only accepted method for obtaining a pregnancy in such a situation is in vitro fertilisation. Prior to the procedure, tubal ligation or even salpingectomy (the removal of the fallopian tubes) are recommended because the composition of the injected fluid has a detrimental effect on the progression of a pregnancy that could otherwise be obtained by IVF. A puncture for the drainage of the fluid is not a viable therapeutic solution because the hydrosalpinx will reoccur within a few days, according to the evidence.
Normozoospermiathe total number/concentration/percentage of spermatozoa with progressive motility and normal morphology equal to or higher than reference values
Oligozoospermia: the total number of spermatozoa below what is considered normal
Astenozoospermia: the percentage of progressive motile spermatozoa below normal
Teratozoospermia: the percentage of morphologically normal spermatozoa below what is considered normal
Oligoasthenozoospermia: small total number of spermatozoa and a percentage of progressive motile spermatozoa below normal reference values
Oligoteratozoospermia: small total number of spermatozoa and a percentage of morphologically normal spermatozoa below normal reference values
Asthenoteratozoospermia: both the percentage of motile spermatozoa and the percentage of morphologically normal spermatozoa below normal reference values
Oligoasthenoteratozoospermia: the total number of spermatozoa, the number of motile spermatozoa and the number of morphologically normal spermatozoa below normal reference values
Cryptozoospermia: no sign of spermatozoa in the fresh sample, but their presence noted after centrifugation. (3.000 g for 15 min)
Necrozoospermia: small number of alive spermatozoa, high percentage of immotile spermatozoa in the ejaculated semen
Azoospermia: no spermatozoa found in the semen sample
Leukospermia: presence of leukocytes in the ejaculated semen (leukocytospermia, pyospermia)
Hemospermia: presence of erythrocytes in the ejaculated semen (also known as haematospermia)
Aspermia: no semen or retrograde ejaculation
In case you have already had an ectopic (extrauterine) pregnancy, you stand a 10-15% chance of having another one. The good news is that most women with a history of ectopic pregnancy do not experience another such type of pregnancy. The bad news is that the risk cannot be fully eliminated. Any woman who wishes to get pregnant is at a certain risk of having an ectopic pregnancy. The level of risk is lower in pregnancies obtained by means of assisted human reproduction than in natural pregnancies.
Endometriosis is the existence of endometrial tissue (the tissue inside the uterus) outside the uterine cavity. It is a special form of this condition adenomyosis, the presence of the endometrium inside the uterine wall (muscle tissue). The causes of endometriosis remain insufficiently substantiated in order to find an explanation for the circumstances of occurrence. The diagnosis of endometriosis will take into account clinical signs of very painful menstruation (dysmenorrhea), pain on sexual intercourse (dyspareunia), persistent abdominal pain, severe menstruation and infertility. The diagnosis can be confirmed laparoscopic by direct observation of the lesion, ultrasound by highlighting the lesion and can sometimes be useful and computer tomograph (TC) or Nuclear magnetic resonance (RMN).
Apart from diagnosing endometriosis, laparoscopy can also be used to surgically remove the lesion. This increases with 50% the chances of obtaining a pregnancy beginning with the first cycle after the procedure. By comparison, an IVF cycle has a success rate of approximately 30%. In addition to improving the chances of obtaining a pregnancy, the female patient will no longer suffer from painful menstruation or persistent abdominal pains. Sometimes, however, the endometriotic lesions may be located in areas that are hard to reach laparoscopically or may be too large to be resolved by means of minimally invasive surgery. Medication treatment can be the best option in such cases.
Intrauterine insemination is a valuable option in the treatment of infertility. It may be the first step in treating cases of inexplicable infertility or it may provide a solution to sexual dysfunctions, slightly modified semen analysis test results, and cervical infertility. Sometimes, it can be an option for a couple who wish to obtain a pregnancy but who have sexual intercourse infrequently or the male partner is not available when the female partner ovulates.
Depending on the type of infertility and treatment, it may be necessary to present 4-6 times in order to assess hormone levels, monitor follicle growth and endometrial thickness, conduct the procedure, and confirming the pregnancy.
The intrauterine insemination procedure is done at a specific time during the menstrual cycle. The answer is YES, except when the male partner needs to replenish his semen reserves for the purposes of insemination (the 3 days before the procedure). Sexual intercourse is actually recommended, especially on the day after the procedure.
When treating couple infertility and observing the specific therapeutic indications, once each procedure is explained, patients prefer intrauterine insemination (IUI) to in vitro fertilisation (IVF). First, 3-6 IUI procedures are recommended before trying IVF. Recently published studies suggest that up to 3 IUI attempts with controlled ovarian stimulation should be carried out and, if unsuccessful, the next option can be IVF. The cumulated success rate of the 3 IUI cycles with controlled ovarian stimulation is approximately the same as the success rate of one IVF procedure. (References: van Weert JM, van den Broek J, van der Steeg JW, van der Veen F, Flierman PA, Mol BW, Steures P– Patients’ preferences for intrauterine insemination or in-vitro fertilization. Reprod Biomed Online. 2007 Oct;15(4):422-7)
The complications of IUI are very rare. After the catheter is inserted, it is possible for patients to experience moderate pain. The pain disappears naturally in 10-15 minutes. Exceptionally, the uterus or peritoneum may get infected. At Origyn, prior to IUI, we prepare the semen by density gradient, a method which helps remove microorganisms (bacteria and viruses) that may cause infections. The media used to process the semen contain antibiotics. Because semen is not always sterile, insemination with previously unprepared semen may be dangerous. Moreover, the prostatic fluid can be extremely allergenic for the woman and cause anaphylactic shock. Sometimes, after the procedure, there may be a small amount of bleeding; this does not generally justify concern or indicate unfavourable evolution. Multiple pregnancy is more common in case of IUI following ovarian stimulation. For this reason, to avoid the risk of a multiple pregnancy, we prefer to induce a moderate level of ovarian stimulation in case of IUI procedures.
The ovarian hyperstimulation syndrome is a complication which may occur in assisted human reproduction procedures. If, on the day of the injection with hCG aimed to trigger ovulation, the level of oestradiol exceeds 2000pg/ml, the risk of OHSS is very high.
Patients older than 35 are less exposed to the risk of hyperstimulation. Patients under 35 and with polycystic ovary are predisposed to OHSS, especially if they have more than 12 developing follicles. The optimal solution to OHSS is to prevent it. If controlled ovarian stimulation creates favourable conditions for UHSS, it is preferable to delay ovulationcoasting) or to cancel the stimulation procedure. As an alternative to using hCG, ovulation may be triggered with a GnRH agonist such as Diphereline, which will facilitate the release of the oocytes. OHSS is a very unpleasant condition for patients undergoing stimulation treatment but, fortunately, only 1-2% of cases are severe.
These situations are considered medical emergencies and require hospitalisation in an intensive care unit for the swift, specialised intervention necessary to drain the fluid accumulating in the abdomen. There may be up to several litres of fluid which can be drained by means of paracentesis (a transabdominal aspiration procedure). In OHSS, fluid may also accumulate in the pleura and cause difficulty breathing. In case some fluid passes from tissues to the peritoneum, blood becomes more viscous and coagulates more easily, which may cause deep venous thrombi; these can then migrate to the lungs and cause potentially lethal acute pulmonary oedema. This is why it is very important to prevent OHSS and, if it does occur, to provide urgent specialised treatment and avoid endangering the patient’s health.
Ejaculate volume (ml) 1,5 (1,4-1,7)
Total motility (progressive + non-progressive) 40 (38-42)
Progressive motility (a+b, PR, %) 32 (31-34)
Vitality (%) 58 (55–63)
Total sperm count (106/ejaculate) 39 (33-46)
Sperm concentration (106/ml) 15 (12–16) 1066/ml) 15 (12–16) 106
Sperm morphology (normal, %) 4 (3-4)
pH ≥ 7.2
Zinc (μmol / ejaculate) ≥ 2.4
Fructose (μmol / ejaculate) ≥ 13
Neutral alpha-glucosidase (mU/ejaculate) ≥ 20
Leukocytes (106 / ml) <1
MAR test (%) <50
Immunobead test (%) <50