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Question 1: Waiting period before seeking help

Question:
I know the recommended waiting period before seeing a specialist is 1 year if I am under 35. Yet a year feels so wasted if I do then get to a specialist only to learn I have needed ART all along. Have you ever wished patients would have gotten to you sooner than that? Are there any other criteria/ warning signs which would send a patient to you sooner?
If the year gets too long, is there a “basic” set of tests which can be done just to see if the year is worth waiting out?

Answer:

Infertility is defined as the inability to conceive after one year of regular unprotected intercourse, with an estimated prevalence of around 15% in the general population. The chance of conceiving after one month of regular unprotected sex for a 20-year old woman is 25%, whereas it is 21% for a 30-year old and 8% for a 40 year old. There are 3 broad reasons why a couple may struggle to conceive:

  1. Anovulation – if a woman is not ovulating (releasing an egg) every month;
  2. Pelvic/tubal factor – if the fallopian tubes are damaged & the sperm is unable to reach the egg to fertilise it;
  3. Male factor – if the sperm are unable to fertilise the egg.

The basic tests to assess these factors are:

  1. D21 progesterone – a blood test to confirm whether you ovulate or not
  2. Hysterosalpingogram (HSG) or laparoscopy – to assess whether your fallopian tubes are patent
  3. Semen  analysis – to assess the quality of your partner’s sperm

Factors that may suggest an underlying condition and thus necessitate earlier work-up include:

Irregular periods – which is indicative of anovulation and is a key feature of polycystic ovary syndrome (PCOS). Some of the other symptoms of PCOS include acne and male-pattern hair growth. Painful periods or pain with intercourse – which may be due to a gynaecological condition, such as endometriosis, adenomyosis, fibroids or pelvic inflammatory disease (PID). A malodorous vaginal discharge, with pelvic pain and fever can be due to a sexually transmitted infection that may lead to tubal damage.  Prior pelvic surgery or a history of prior ectopic pregnancy suggests possible tubal damage. Being overweight – impacts on your reproductive system and hormonal imbalances can lead to a failure to ovulate.  For each unit of BMI (body mass index) – your weight divided by your height squared – above 30, women have a 4% reduction in fertility.

For men, illnesses like mumps can cause swelling of the testicles and lead to abnormal sperm. Injuries – even a minor sporting injury – that is associated with painful swelling of the testes, can be associated with testicular damage and warrant assessment. Painful urethral discharge is suggestive of a sexually transmitted infection.

The basic tests that can be arranged by your gynaecologist include a pelvic ultrasound, day 21 progesterone and semen analysis.

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