Q: I am 28 years old. We are married for 2.7 years now. A year back we started to plan a family. But I haven't conceived. We saw an obstetrician, who advised some blood test and semen analysis. Everything was fine. Meanwhile I was advised to take Fertomid, which I took for 5 days from the second day of the cycle. Later an ultrasound scan was done on the 12th day of my cycle. The scan reports were perfect too, with around 4 eggs found. We do have a timely intercourse. My doctor has advised me to see her after 3 months. What can be done further? How is the damage in fallopian tube detected?

A:The causes for infertility may be due to either male or female factors. The problems in females could be due to Ovulatory problems, Cervical factors, Pelvic and tubal factors, and Uterine factors. Often, a combination of these problems exists. Ovulation is a complex event in which hormonal signals and physical events are linked in a delicate balance. Women ovulate most effectively in their late teens and early twenties. By age 35-38, most women may experience a decline in the ability to ovulate effectively. Ovulation can be seriously affected by - abnormalities of the thyroid gland, overproduction of prolactin (a hormone leading to breast milk production), excessive male hormone (androgens) or physical stress, psychological stress and extreme lifestyle changes. Cervical infertility involves inability of the sperm to pass through the mouth of the uterus due to damage of the cervix. Causes include the following - Inadequate or inhospitable cervical mucous, cervical narrowing or stenosis , infections of the cervix with common sexually transmitted agents (chlamydia, gonorrhoea, or trichomonas, as well as Mycoplasma hominis and Ureaplasma urealyticum), immune attack of sperm or sperm allergy Pelvic causes include any disruption of the normal pelvic anatomy - scar tissue or adhesions , endometriosis, blocked, scarred, or distorted fallopian tubes, benign tumours (fibroids) of the uterus. Uterine causes include - thin or abnormal uterine lining, anatomic problems (polyps, uterine fibroids, abnormal shape of the uterus, septum or dividing wall within the uterus) Then there may be Unexplained Infertility, which is seen in about 10% of infertile women. In them the commonly performed tests to diagnose the cause of infertility are all normal and do not define the reason for infertility. However, subtle abnormalities like difficulty in picking up the egg by fallopian tube or failure of implantation of the embryo into the uterus or failure of the sperm to fertilise the egg may exist. Diagnosis requires a thorough history taking and physical examination which can then indicate appropriate investigations. Some defects like absence of the vagina and uterus, vaginal septum, and the presence of fibroids can be detected during the pelvic examination. Pelvic ultrasound is an important tool in the evaluation and monitoring of infertile patients, especially during ovulation induction. It allows evaluation of the position of the uterus within the pelvis, its size and irregularities. It also helps in the early detection of uterine fibroids, endometrial polyps, presence of ovarian cysts, adnexal masses, and endometriomas. The endometrial lining constantly responds to the different hormonal secretions that occur during the menstrual cycle or to the exogenous administration of estrogen and progesterone. Histopathologic examination following a D & C is an important step. Hysterosalpingography (HSG) is the most frequently used diagnostic tool to evaluate the endometrial cavity and patency of the fallopian tubes. It provides accurate information about the endocervical canal; endometrial cavity; and fallopian tubes. It can also detect adhesions and uterine, ovarian, or adnexal masses. Estimation of hormones like LH, FSH, thyroid hormones, prolactin, testosterone etc. Operative techniques like laparoscopy and hysteroscopy, are often necessary for confirmation of the final diagnosis. In hysteroscopy, direct visualization of the endometrial cavity is done and this permits both the diagnosis and treatment of endometrial problems. You should discuss with your doctor as the treating physician would know best what is the underlying cause and would be evaluating you accordingly.