This article is aimed at medical students and doctors learning about obstetrics and gynaecology, but it could be helpful for anyone who wants to learn more about basic infertility course. Infertility is defined as being unable to become pregnant within one year of regular unprotected intercourse. We would only start investigating a couple if they fail to become pregnant after 12 months, unless the woman's over 35 in which case it's worth starting early, as the longer she waits the less likely she is to become pregnant. It can be defined as primary infertility, this is when a patient has been unable to conceive their first child, or secondary, when they previously had a child and they're struggling with their second or third. Overall, around 15% of couples struggle to conceive.

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The key to investigating and managing infertility is to establish the cause. The best way to understand the causes is to think of all the steps that are involved in becoming pregnant and where there can be a problem. I recommend checking out my video on the menstrual cycle as it's really important to understand how the eggs develop and ovulation occurs each month.

First of all, the couple need to be having regular, normal sexual intercourse without contraception. They should aim to have sex around every 2-3 days, and although pregnancy is more likely when they have intercourse around ovulation, we don't generally advise to time the intercourse as it can lead to a bit of anxiety and pressure. It's better to just have regular intercourse throughout the cycle.

So next let's look at the basic anatomy and physiology of getting pregnant. Some landmarks here are the vagina, the cervix or the neck of the womb, the uterus where the baby grows, the fallopian tubes which lead to the ovaries. Given that they are having regular intercourse, let's look at the process of getting pregnant.

Firstly, an egg needs to develop in the ovary, and it needs to be released in a process called ovulation. This happens around day 14 of a 28-day cycle. It happens 14 days prior to the onset of the next period.

So, if the cycle is 34 days long, subtract 14, ovulation happens on day 20, and if the cycle is 24 days long, subtract 14, ovulation happens on day 10. This egg then needs to be fertilised by sperm. So, during sex, the sperm are released into the vagina, they then travel through the cervix, the uterus, and into the fallopian tubes, and it's in the fallopian tubes that the egg and the sperm meet.

Once they get to the egg, they need to be able to fertilise it, and then once it's fertilised, that cell then moves back down the tubes into the uterus and implants into the endometrium, or the lining of the uterus. So where can this process go wrong? Well firstly, in male infertility, there can be insufficient or abnormal sperm. We ask the male partner to provide a sample of their semen to assess the number and the quality of the sperm.

The next thing to look at is whether the woman has sufficient eggs in her ovaries. And women are born with a set number of eggs, about 200,000 immature follicles in each ovary, and as the woman ages, she uses up the number of immature follicles, and so the number goes down, and so does her fertility. We call the number of immature follicles in her ovaries ovarian reserve.

We can measure ovarian reserve by checking follicle-stimulating hormone at any time between day 2 and 5 of the menstrual cycle. Now remember, day 1 is the first day of bleeding. If there's lots of follicles waiting to be stimulated, then the pituitary gland only has to release a small amount of FSH to get those immature follicles to start to develop.

But if there's only a few immature follicles, basically a low ovarian reserve, then the pituitary has to try really hard to get those follicles to develop by releasing loads of FSH. Therefore, if the woman has very little eggs left in her ovaries, the day 2 to 5 FSH will be high. Another way to assess this is to use a hormone called antimularian hormone, and that can be measured at any time of the cycle, and a higher level indicates a better ovarian reserve.

We can also use another technique to check ovarian reserve, and this is to use an ultrasound scan to measure the number of antral follicles between day 2 and 5 of the cycle. Antral follicles are the secondary follicles that develop when the immature or primordial follicles become activated. More antral follicles mean a greater ovarian reserve and a better response to FSH, however a very high number of antral follicles could suggest polycystic ovarian syndrome.

Next, we have to check whether she's ovulating and actually releasing the eggs each month. We can check this using something called a day 21 progesterone, and it's commonly called a day 21 progesterone, however checking progesterone on day 21 is appropriate for somebody with a 28-day cycle. We want to check the progesterone level 7 days after ovulation.

The best way to do this is to take her normal cycle length and count back 7 days from the expected onset of the period. So, if she has a 27-day cycle, subtract 7 days and you get a day 21 progesterone. If she has a 32-day cycle, you subtract 7 days and check the day 25 progesterone and so on.

Remember progesterone is secreted by the corpus luteum after ovulation has occurred and the developing follicle has collapsed. Therefore, if you have a rise in progesterone at this time you know the person has ovulated because the corpus luteum can't develop without a fully developed follicle releasing an egg. So, if we find somebody who's not ovulating, we need to find out why they're not ovulating.

And the most common cause is polycystic ovarian syndrome. Remember that polycystic ovarian syndrome is a triad of anovulation, polycystic ovaries and hirsutism due to high levels of androgens or male sex hormones. A history of facial hair, acne, irregular periods and typically raised BMI are suggestive and we can confirm the diagnosis of polycystic ovarian syndrome with a history and also with an ultrasound of the pelvis to see the cysts in the ovaries.

We can also check luteinising hormone along with the FSH on day 2-5 and luteinising hormone will be raised in polycystic ovarian syndrome. We can also test for androgen hormones which will be raised in polycystic ovarian syndrome as well. Another cause of anovulation is hypothalamic amenorrhoea.

This is basically where physiological stress causes the hypothalamus gland to stop producing GNRH and the result of that is that you don't get the gonadotrophins that stimulate the ovary to develop eggs and release them. This can happen if the body is under a lot of stress such as with extreme diets and exercise, low BMI, chronic disease or significant psychological or lifestyle stresses. Another cause of anovulation is endocrine disorders such as hyperthyroidism or hyperprolactinemia.

If you get a high prolactin level, this is usually caused by a prolactinoma which is a benign tumour of the pituitary gland and it secretes the prolactin hormone. The person may have symptoms of galactorrhea which is where they produce breast milk, they have amenorrhoea and reduced libido and they may have symptoms of the tumour if it grows large enough such as headaches or cranial nerve palsies. You can investigate this by checking the prolactin levels in the blood and doing an MRI of the brain to see whether you can find the tumour.

So if you find that the woman is ovulating and the man has adequate numbers and quality of sperm, then we have to ensure that the eggs and sperms are going to meet. This can be a problem if there are structural abnormalities in the uterus such as large fibroids or vaginal septum’s, adhesions that are changing the shape of the uterus or polyps that are getting in the way. So, we can check all of these using a pelvic ultrasound scan and it should pick up any big structural abnormalities that are affecting the meeting of the eggs and the sperm.

Another barrier to the sperm and the eggs meeting are in the tubes. These can get scarred or blocked, distorted or they can be absent altogether. The most common cause of tubal problems is when they become damaged after sexually transmitted infections or pelvic inflammatory disease as a result of chlamydia or gonorrhoea infections.

They can become distorted by adhesions due to previous surgery or by endometriosis. The way we can assess the tubes is by something called a hysterosalpingogram and this involves squirting a contrast of dye through the cervix so that it fills the uterus and spills into the tubes. Then we take an x-ray and that dye will show up on the x-ray to show an outline of where the uterus and the tubes are.

If they're patent then the x-ray will show the tubes but if there's a blockage it'll show up as a gap on the x-ray. You can do a similar thing during laparoscopy or keyhole surgery where you have a camera inside the abdomen, you put dye into the uterus and then up into the tubes and the surgeon can actually see whether the tubes are filling with dye or whether there's some blockage somewhere. If you do a hysterosalpingogram or a laparoscopy with a dye test then it's really important to check for chlamydia beforehand because putting some dye into the uterus and spreading it into the tubes is a great way to spread infection.

So just to summarise the baseline tests that you'd do to check for infertility. In the man you would check a semen analysis to see the quantity and the quality of the sperm. In the woman between day 2 and 5 you would check FSH to check the ovarian reserve and LH to look for polycystic ovary syndrome.

You would check a day 21 progesterone to look for ovulation. You'd do an androgen hormonal profile, ultrasound of the pelvis and then chlamydia screening followed by a hysterosalpingogram to check the tubes. There are a couple of additional tests that we do routinely as a baseline.

The first is to check rubella immunity and if they're not immune they can be given a vaccine that protects them during pregnancy. And the second thing is that if the woman is attempting to get pregnant, they should use this opportunity to make sure their smear tests are up to date for cervical cancer.

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