Counsel patients about fertility
as soon as you can

By Jennifer Laliberté

"Approximately 30% of women over 30 have some delay in conceiving," says Dr Edward Hughes, an infertility expert at Hamilton Health Sciences. And the greater the delay, the greater the impact. "Pregnancy rates start dropping by 9% a year once a woman gets to 45," adds Dr Albert Yuzpe, co-director of the Genesis Fertility Center in BC.

One in six couples will have trouble conceiving — and odds are you're the first person they'll come to with their concerns. To help you ease their fears, here's a rundown of baby-making basics.

FERTILITY FACTS
It takes the average couple about six months to get pregnant. Women under 35 with regular menstrual cycles don't need to worry unless they've been trying without success for over a year. Older women, however, should be encouraged to seek help after six unfruitful months. But even if those time frames have come and gone, reassure patients it doesn't necessarily mean something's wrong. Some patients just need a step in the right direction and a little reassurance.

Let's talk about sex "There's a lot of misinformation out there about how to make love, and when," says Dr Hughes. Tell patients they should be having sex about every other day throughout the woman's cycle. Not everyone works like clockwork, so limiting sexual activity to a woman's "fertile period" — between day 11 and day 17 of a 28-day cycle — isn't always going to get the job done. If they had previously been taking oral contraceptives, reassure them that a history of taking the Pill shouldn't delay pregnancy. "There's no evidence that the Pill has a 'hang-over effect' of longer than one menstrual cycle," says Dr Hughes.

Hot and bothered Experts agree basal temperature testing and ovulator predictor kits are rarely useful. "By the time the woman sees a rise in temperature, it's too late," says Dr Yuzpe. "People get addicted to things like that, and it becomes very stressful," adds Dr Hughes. So unless it's recommended along with ovulation induction medication, you can tell patients they can do without the thermometer.

COMMON CONCERNS
There are many reasons a couple could be having trouble conceiving — in fact, 15% of cases are unexplained. Before referring to a specialist, there's a lot you can do to try and figure out what's wrong. Your patients will appreciate the effort, and the head start will speed up their access to the right treatment.

Ovulatory disorders are one of the leading causes of female infertility. "Very irregular periods suggest lack of ovulation may be the problem," says Dr Yuzpe. Hormonal imbalances are the most probable cause, but overexercising and eating disorders can also interfere with the ovulatory cycle. In polycystic ovarian syndrome (PCOS), cysts on the ovaries prevent them from functioning normally. "Women with PCOS will show signs of increased androgen production, like hirsutism," says Dr Yuzpe.

If you suspect a problem with ovulation, a few simple blood tests should help confirm the diagnosis. Thyroid stimulating hormone (TSH) and prolactin levels should be checked, as well as serum follicle stimulating hormone (FSH) and estradiol on day three of the menstrual cycle. Elevated levels of either are indicative of a problem with ovulation, as is elevated serum progesterone in a sample taken about a week before an expected period.

Endometriosis is a very common and underdiagnosed condition where the uterine lining is found outside of the uterus. Infertility occurs in about 30-40% of women with endometriosis. Pain in the abdomen or lower back during menstruation or sexual activity is the most common symptom. The diagnosis is confirmed by laparoscopy.

Tubal factor infertility, where the fallopian tubes are blocked either by infection or some sort of mechanical interference, account for about 20% of infertility cases. "As many as 50% of women with tubal disease have no history of problems," says Dr Hughes. Risk factors include STDs, early sexual activity and pelvic surgery for ruptured appendix at a young age. A hysterosalpingogram (HSG) — an x-ray exam of the fallopian tubes — and a laparoscopy are needed to examine the inside and outside of the tubes respectively and confirm the diagnosis.

Low sperm count Standard sperm analysis is a quick and easy way to test the man's fertility. "Semen analysis should be done with two to five days of continence before they do the semen collection," says Dr Yuzpe. Dr Hughes says it's a little tricky to interpret abnormal sperm quality, but you can at least find out if there's a severe problem, like no sperm at all in the sample.

BABY STEPS
Armed with these test results, your patients are in the best position to seek advice and assistance from a fertility expert. Reassure them that whether the problem lies with the man (40% of the time), the woman (45%) or both (15%), they shouldn't give up hope. "In younger patients, 75-80% will get pregnant on their own or with treatment," says Dr Yuzpe. Couples wanting a child might be surprised at their excellent odds of conceiving with a little help from advanced reproduction technology.