Many couples, (about 15-20 percent according to the latest estimates in Italy) have difficulty becoming natural parents and, according to the World Health Organization (WHO), after 12-24 months of targeted relationships without any success the couple is called infertile. A problem that is difficult to tackle, especially from a psychological point of view. Often sadness, discouragement, loss of self-esteem and the relative crisis of the couple occur. Yet today the innovative techniques of medically assisted procreation (PMA) allow to obtain excellent results, even where the woman tends to “throw in the towel”. Here are the main steps that the couple can take to solve infertility with the help of medicine.

Talk to your doctor

The first step is to tell the doctor your clinical history, that is to say every detail about your own health and that of your family, specifying also how long you have been looking for a child, the obstacles faced, the problems and diseases present or past and any clinical investigations already carried out. The gynaecologist, once all the data (anamnesis) of the couple have been collected, will be able to understand and advise on the best way to achieve a pregnancy.

Although it may seem of little use, anamnesis is actually the best way to arrive as soon as possible at a correct diagnosis of infertility. If the woman is more than 35 years old, in fact, the time factor is fundamental and can affect the chances of success in Pma.

Analyses to do before

Depending on the couple’s difficulties in seeking pregnancy (menstrual cycles that are too short or too long, miscarriages, recurrent infections, etc.), the gynaecologist will recommend a series of medical investigations. In general, some blood tests are required to dose certain hormones in both women and men, tests for toxoplasmosis and rubella (diseases that, if contracted during pregnancy, can be very dangerous) in women, a gynecological ultrasound to assess the uterus and ovaries, examinations to exclude the presence of infections and inflammations (i.e., the vaginal swab and the Pap-test for the woman) and for the man a spermiogram (to analyze the quantity and health status of the spermatozoa) and a spermiocultura (to detect any infections in the male genitalia). Depending on the results, the couple may then be subjected to further more invasive investigations (such as hysteroscopy and laparoscopy) to verify the cause of the difficulty of conception. Each centre, however, has its own list of tests that it recommends to the couple before performing a Pma treatment, which varies according to the problem found at the basis of infertility.

The choice of Pma

Once the problem of the couple has been identified in the search for a pregnancy, the gynaecologist will advise with which method of assisted reproduction it is best to start. In the most minor cases, for example if the woman has simply irregular cycles but ovulation is still present, it will be possible to start with a simple stimulation of ovulation to increase the chances of pregnancy with each cycle. If this is not the case, more targeted techniques will be recommended, generally divided into two large groups: the basic ones carried out in vivo, i.e. with fertilization inside the woman’s body (such as artificial insemination), and those where in vitro fertilization and external manipulation of oocytes and spermatozoa is almost always foreseen (such as IVF and ICSI). In the most serious cases or if the techniques mentioned above have not led to any success, it is possible to undergo even more complex techniques, such as the transfer of oocytes and sperm into the tubes (GIFT, ZIFT and TET) and, in the most serious cases of male infertility, the surgical removal of the sperm (ie, MESA, TESA and TESE). Finally, in the cases provided for by law, it is possible to cryopreserve the spermatozoa, oocytes and embryos.

Stimulating ovulation

When the couple does not seem to have specific infertility problems or when there are simply irregular cycles or long periods of amenorrhoea (lack of menstruation) with poor ovulatory capacity, there is a tendency to start with stimulation of ovulation with drugs. The gynecologist, in practice, prescribes to the woman a therapy usually based on clomiphene citrate or gonadotropins (drugs also used in vitro fertilizations, but at lower doses) to increase the ovulatory capacity of the woman. The drugs act, in fact, stimulating the ovaries to produce more mature follicles and, usually, the goal is to obtain no more than 2-3 per cycle to avoid complications of multifemale pregnancy. With transvaginal ultrasound, then, the gynecologist is able to understand the day of ovulation and so advise the couple when to have targeted relationships.

Intrauterine insemination

The most common Pma technique in Italy is intrauterine insemination, which usually involves stimulation of ovulation in the woman and the subsequent introduction of sperm into the uterus to facilitate the encounter with the mature oocyte is released by the ovary. Often, in order to better identify the exact moment in which to perform insemination, ovulation is induced by administering an injection drug. About 24-36 hours after this injection, in fact, ovulation usually occurs and insemination can be performed, which involves the introduction of a sperm sample after careful selection. Before being inserted into the uterus with a small catheter, in fact, the seminal fluid is subjected to the “capacitance test”, that is, to the selection of only the most mobile and morphologically best spermatozoa.

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