Generalized Plan for Most Couples Fertility is achieved if the biochemical and biological values are optimum at the various phases of the ovarian cycle. Evaluation and clarification of each phase is important to find the factors that need support to achieve conception. It requires experience and highly specialized in-depth knowledge in fertility management. One complete ovarian (Menstrual) Cycle is evaluated for ovarian function and other factors. The ovarian cycle has three phases
- Preovulatory, Follicular Phase;
- Ovulation phase and;
- Post ovulatory luteal phases.
Follicular and Luteal phases are further subdivided into early and late phase. 3-5 observations in one reproductive cycle of the woman are done. This schedule determines the ovarian, cervical, uterine and to some extent male factor. In irregular and prolonged cycles more observations are necessary, as the various phases of the cycle can not be accurately fixed. Pelvic and tubal factors evaluation requires invasive techniques and is deferred to be done selectively.
On each visit Transvaginal Sonography (TVS) is done, characteristics of Cervical mucus observed and appropriate Hormones assayed. At ovulation time Postcoital test is performed
Ovarian, cervical, male and to some extent uterine factors are thus assessed. All the observations of one cycle are compiled after the last visit to draw the inference. It is important to relate follicle diameter, cervical mucus feature, endometrial thickness and hormone levels with each other & with the time of cycle.
Was the cycle observed Ovulatory? It was not Luteinization of unruptured follicle (LUF).
Were there FSH, estrogen peaks and LH surge?
Were there sufficient motile sperms in PCT to exclude cervical hostility or male deficiency?
Womenrequire appropriate levels of LH, Estradiol & progesterone in the luteal phase to strengthen pregnancy. High FSH, LH levels in early days require down regulation. Low Estradiol in mid follicular phase requires additional LH. First estrogen peak and LH surge levels determine the requirement of midcycle hCG.
Low levels of progesterone & Estradiol in luteal phase indicate luteal phase deficiency needing luteal support. Many women do not lack fertility, fertilization occurs, but the pregnancy does not progress beyond early development. Luteal phase support helps in such circumstances. This shows the importance of the in-depth study of an ovarian cycle.
One time hormone assays at mid-luteal phase (day-22 of cycle) or Mid-Luteal Progesterone only is advocated. These are useful but detailed studies are required in marriages of long duration.
Following one cycle of woman may not be conclusive. It evaluates the situation in that particular cycle alone, which may not be the same in the other cycles. Observations of another cycle are useful in case of abnormal findings. In irregular and prolonged cycles more observations are necessary, as the various phases of the cycle can not be accurately fixed.
Evaluation of female passages is invasive requiring a procedure to enter the reproductive passages. There can be infection and other risks that can create fertility problems. As a matter of policy we treat if ovulation failure or male factor is found out without evaluating the reproductive passages, if clinical judgment expects those to be healthy. If clinical judgment suspects involvement of Reproductive passages, those are then evaluated prior to the treatment.
In this way more than 50 % successful pregnancies can be achieved without Patency tests.
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