Fertility overview

Pregnancy happens after the ability of the man to produce healthy sperms and the woman healthy eggs. Then the Release of the egg from the ovary to be picked by the tubes, the Ability of the sperms to move from the vagina through the secretions of the cervix and continues its way through the uterus to the tubes till it meets the egg and fertilizes it.

What are the Causes of delay?

Male reasons for delayed fertility

Testicular varicocele, Problems in the spermatic cord, Erection problems, Problems in the testicular tissue not being able to produce sperms at all, Disturbance in the hormones concerned with making of sperms, Sexually transmitted diseases, Bad habits like nervousness and smoking.

Female reasons for delayed fertility

  • Ovary problems like Poly cystic ovarian syndrome, ovarian cysts, Low ovarian eggs reserve, tumors in the ovary or Genetic disturbance.
  • Fallopian Tubes kinking or occlusion
  • presence of endometrial tissue outside the uterus –endometriosis,
  • Disturbance of the hormones that control endometrial growth and egg growth
  • Uterus problems like congenital abnormalities or Presence of fibroids or polyps obstructing the cavity of the uterus or Weakness in the endometrial cavity that hosts the fertilized ovum.
  • Others e.g. sperm antibodies, unorganized sex, Psychological disturbance and stress, obesity, old age, unexplained infertility.

How is a diagnosis reached?

When the couple agrees on starting their quest to know their problem they visit the reproduction specialist. The specialist takes a good history of the case then performs specialized tests.

Male diagnosis

  • Semen analysis: A normal man ejaculates about 1-3 ml of semen, each ml contains more than 20 million sperm , more than 50 % of it moves normally and the abnormal forms does not go more than 20%.The test is performed after 3 days of abistence.
  • Ultrasound and Doppler study, Analysis of the hormones and a Testicular biopsy.

Female diagnosis

  • Hormonal analysis on special days for Pituitary hormones, Progesterone, Prolactin, Testosterone and thyroid hormones level.
  • Ovulation detection by ultrasound or Progesterone levels or Temperature rise on ovulation day or Examination of the cervical discharge.
  • Hysterosalpingiography: The doctor injects a solution through the cervix which is reflected by X-Ray to check patency of the tubes and abnormalities in the shape of the uterus.
  • Ultrasonography examination: It is a machine that uses ultrasound waves to draw the internal organs of the female on a display screen.
  • Endometrial biopsy: It reflects the influence of hormones on the endometrial lining of the uterus.
  • Laparoscopy: The doctor inserts a scope through a small incision in the abdomen which is connected to a monitor allowing the surgeon to see what is inside.
  • Hysteroscopy exam: It is a scope that allows the doctor to look into the uterus directly by inserting it into the uterus after inflating it with certain fluid or gas. It is attached to a TV system.

What is the treatment for delayed fertility?

The doctor directs treatment according to the results of the testing performed and they can be summarized into:

  • Treating the general condition like diabetes mellitus or anemia, Stopping bad habits, Weight control programs and exercises.
  • Male factor treatment is done by surgical treatment of varicocele or hormonal induction and tonics or by Extraction of the sperms from the testes.
  • Treating of hormonal disturbance and Ovulation induction and monitoring.
  • Surgical treatment by treating tubal occlusion, uterine fibroids or ovarian cysts by laparoscopy or open surgery.
  • Medial or surgical handling of endometriosis.

Premarital counseling

There are genetic diseases that are widespread in some societies. A person carrying the gene for a certain sickness can pass it to his children. Also With the wide spread of sexually transmitted disease there is a chance that these diseases can be spread to from one couple of the other. At the same time there is an increase in the levels of delayed fertility worldwide. All this strengthened the importance of requiring couples to  undergo pre-marital exams before marriage. Some countries have encouraged their citizens to go for such pre-medical exams while others have made doing so a legal requirement for marriage. The marriage contract is a serious commitment that is supposed to be permanent and stable.

Premarital counseling aims in checking the couple’s ability to produce children, detecting genetic problems in the couple that can be transmitted to their children, detecting any infectious disease in either of the couple which can harm either of them or their children and detecting any chronic illness that can affect the ability to produce or take care of children.

It also helps in educating couples on reproduction in terms of teaching them facts concerning the male and female reproductive parts, how menstruation, ovulation and pregnancy happens, family planning methods, the common preventable problems (e.g. Rh incompatibility and Down’s syndrome). It also helps couples to discuss their concerns freely.

For the couple

The doctor starts by checking the familial relation between both couples and checking if there are any hereditary diseases in their family. Then he asks for history of any medical diseases in the couple themselves or their families e.g. diabetes, tuberculosis, hypertension. After the history taking he starts his examination by a general examination and checking for symptoms of common diseases like kidney or liver or heart diseases then he look for symptoms of glands and hormone problems and he finished by a general abdominal examination. After the examination he writes out a set of laboratory investigations to be performed e.g. Complete blood picture, Blood Group and Rh factor, Blood Glucose, Rubella screening, Hepatitis Virus B and C, Urine analysis and Other investigations (if needed), such as:  syphilis, hepatitis or HIV.

Specific for men

The doctor takes history from the male partner about any previous operations done E.g. laparotomy, varicocele, hydrocele, hernia and mumps. Then he inspects the external reproductive parts and look for Genital ulcers, Urethral discharge, Varicocele, Hypospadias or undescended testicles. After finishing he writes some laboratory investigations to be done like Hormonal analysis of Testosterone, FSH, LH and Semen Analysis which is the first tests done to help determine whether a man has a problem producing children .Semen is checked for its volume, Liquefaction time which is a measure of time for the semen to liquefy from its original gel form, Sperm count, Sperm shape and Sperm motility. In addition to other tests like acidity measure, White blood cell count and Fructose level.

Specific For women

The doctor takes the menstrual history from the female partner by asking about age of first period, regularity, duration, heaviness of flow, Pain during period, vaginal discharge and date of last menstruation. After that he inspects the external reproductive parts and look for Genital ulcers, condition of the labia minora and clitoris, evidence of Female genital circumcision. Then he performs a pelvic ultrasound which uses sound waves to form a picture of the organs and structures in the lower belly (pelvis). A pelvic ultrasound looks at: The bladder, ovaries, uterus, cervix, and fallopian tubes of a woman. After finishing his examination he writes out some laboratory investigations e.g. hormonal analysis of ESTRADIOL (E2), F.S.H, L.H, PROGESTERONE, and PROLACTIN.

Assisted reproductive techniques

Assisted reproductive techniques involve the laboratory preparation of sperms, ovum or both and artificially bringing them together to raise the fertility rates. It is used in cases of tubal occlusion or severe endometriosis or adhesions in the pelvis or low sperm motility or prolonged unexplained infertility. It is also used in cases of high semen viscosity or male sub fertility like low count or motility. It is also used in cases of severe endometriosis or polycystic ovaries.

Artificial insemination

It is a technique used for problems with husbands (erection problems, low count or motility of sperms) or sperm antibodies or unexplained infertility. Intra uterine injection of sperms after preparing them with special material that increases their motility. They are injected by a special catheter at ovulation time in the uterus.

In Vitro Fertilization IVF or Intracytoplasmic Sperm Injection ICSI

  • Ovulation induction: In case of IVF or ICSI we need more than one egg. Ovulation induction is performed by giving a preparatory drug (GnRh agonist or antagonist) then giving (HMG/FSH) which helps eggs to reach the correct size and maturity for fertilization. During induction the woman should be monitored well by ultrasound measurement till the eggs reach the best size and then other drugs are given which induces ovulation within 36 hours from taking them after which eggs are collected.
  • Egg collection: Eggs are collected through the vagina with the aid of vaginal ultrasound with a special aspiration needle attached.
  • Egg fertilization : Eggs are inspected by the embryologist then the best eggs are chosen and placed into plates with nutrient and enrichment media which are kept into incubators at certain temperature with enough oxygen then fertilization occurs by either of 2 methods:
    • In Vitro Fertilization: Some sperms are placed into a special plate with media containing aspirated eggs.
    • Intra cytoplasmic sperm injection: A sperm is injected into the egg under microscopy.
  • Embryo transfer: After about 3 days 2-5 embryos of the best quality are transferred into the endometrial cavity using a special embryo transfer catheter which does not harm the embryos or endometirum. Before the transfer the doctor measures the cervical and endometrial length by ultrasonography then injects the syringe with embryos inside them through the catheter and into the uterus.
  • Follow-up: The woman is given hormonal support drugs that help the embryos to implant inside the endometirum. After 14 days the woman is tested for pregnancy by checking her HCG levels and if found pregnant she would return for checking her pregnancy by ultrasound and during that time she would be under good medical care.

New technologies

Pre implantation genetic diagnosis

It is a method to check for genetic problems in the embryos before transferring them to the uterus. It is done by extracting a cell from the embryo with special instruments and then studying these cells. Sometimes it is used to choose the gender of the baby by studying the gender chromosomes of the embryos.

Assisted hatching

The embryo is surrounded by a thin shell which breaks and the cells come out to be implanted in the uterus. Assisted hatching assists the breaking of this shell and improves implantation rates.

Blastocyst transfer

A Blastocyst is an embryo that is left in special culturing media till the fifth or sixth day. After that it is transferred to the uterine cavity. The concept is that the embryo which reaches the 5th day safely has a 50% chance of implantation in the uterus. It is advised for people who have repeated failure of Invitro fertilization process with transfer done on the 3rd day, pregnancy without fear of twins because only the best one will be transferred. The only problem is that about 40% of embryos could not survive to the 5th day leaving no embryos at the end for transfer.

Cryopreservation of embryos

In cases of too many embryos being fertilized, some of them can be cryo persevered in any stage of division if they are good quality. The embryo is mixed with a cryo preservant that protects the embryo when frozen. The mixture is put into straws that are stored in nitroglycerin incubators at 196 degrees below zero centigrade. Thawing the embryos consist of removing the cryo preservant material after removing the straw from the nitroglycerin incubator then it is left in another special incubator ready for transfer inside the uterus. This technique is used for a woman who might be of risk of ovarian hyper stimulation, weak endometrium or a woman who will get cancer radio therapy. It can also be used for a couple who have failed cycle or successful one and want to more kids.

Annual Gynecological Checkup

Women should begin annual gynecological exams when they become sexually active even if they are feeling well and have not noticed any problems.

Despite the warnings from all leading medical organizations, almost half of all women fail to have an annual gynecological check up. Failure to receive this examination costs thousands of women their lives each year.

According to research, reasons cited by women for not having an annual gynecological exam include embarrassment, lack of money. However, the most common reason cited is the idea that an exam is not necessary unless one is experiencing some type of problem.

According to Alhayah Fertility & Women Care Dr. Ashraf Sabry, “It is sad to see that women think they don’t need to see their doctor except if they are having a problem, while it is often during a routine examination that a problem is first detected. Early stages of breast, cervical and ovarian cancer have some obvious symptoms which can show up in an annual exam. Early detection is every woman’s best defense against all types of cancer; by finding abnormalities at the onset you increase your chances of a full recovery. Don’t take a chance; see your doctor for a checkup every year– whether you feel sick or not.

To begin, your doctor will review your medical history, sexual history, menstrual history and contraceptive history then discuss any health concerns you might have before the test. Your doctor will discuss exercise and nutrition plans with you then he will proceed by explaining how the test is performed and its benefits.

The doctor will start the test by doing a brief general physical exam where he will feel your neck (thyroid), listen to your heart and chest; take your blood pressure, pulse, temperature, height and weight. After that your doctor will ask you to leave a urine sample and then proceed with blood testing to check for anemia and cholesterol levels.

A breast exam will follow where your doctor will inspect your breasts for lumps or unusual soreness and then he will teach you how to do a monthly self breast exam yourself.

After the breast exam, the pelvic exam follows. Your doctor will examine your outer genitals for any changes or abnormalities, and he will insert a speculum into your vagina to see your cervix. Next your doctor will use a small brush to take a sample of cells from both inside and outside the cervix. The sample is called a Pap smear and it will be sent to a laboratory to be examined for any abnormal cell growth which can be caused by precancerous or cancerous cells on the cervix.

After the speculum is removed, your doctor will insert gloved fingers into your vagina and place his other hand on your abdomen, applying slight pressure. This examination is done to determine the size, shape, and position of your uterus and ovaries.


  • A Breast mammogram can be added to the annual test if seen beneficial by the doctor, It is an x-ray test that produces an image of the inner breast tissue on film. It shows normal and abnormal structures in the breasts.
  • A Bone densometry can be added to the annual test of seen beneficial by the doctor, it is done using DEXA machines or sometimes using ultrasound measuring of the bones of the heel as a screening method.