Doctor Interview: Unexplained Infertility by Dr Partha Das

Given below is the transcript of the interview conducted with Dr. Partha Das

Mrinalini: Hello everyone, my name is Doctor Mrinalini and I am the patient advisory at MediGence. Today we have Doctor Partha Das with us. He’s the deputy medical director at Orchid fertility. So hello Doctor, how are you doing

Dr. Partha: Hello Mrinalini. I’m good. Thank you so much for the invite. Thank you so much.

Mrinalini: So Doctor Das has over 15 years of experience in tertiary center care and he has handled gynecological complex gynecological. Issues related to infertility and have helped many couples achieve parenthood. So to start this, today’s topic is based on unexplained infertility. Now couples nowadays face a lot of confusion and they come across a lot of acronyms when we talk about deciding on the best fertility treatment that is to be used. However, they do not know actually what is the cause of infertility, so this brings us to today’s topic that is unexplained infertility. So to start with Doctor, can you let us know what exactly is unexplained infertility?

Dr. Partha: Alright, thank you so much for the question. I mean so before I start talking to you about unexplained infertility, let’s know what is infertility. So as we all know, infertility has been classified by the World Health Organization nowadays as a disease. Alright, so it is basically defined as somebody who has been trying to achieve a conception. And uh, after one year of unprotected intercourse, and they have still not been able to achieve a pregnancy. So then that’s when we tell them that, OK? This couple is infertile because they have tried for one-year unprotected intercourse, but this duration of one year is reduced for ladies who are 35 years and above. So if somebody is 35 years and more than 35 years above and they’ve been trying to achieve our conception and having unprotected intercourse for six months, then for those ladies we say that OK, you are infertile and you need to go in for an evaluation. So when you go to the doctor and the doctor has tested, your scans your blood test, your tube tests, and the husband sperm test, and if everything has come back normal then that’s when we say that yes, it is an unexplained infertility variant. No cause can be found for your information.

Mrinalini: All right, doctor. So moving on there can be different reasons for unexplained fertility. So can you please let us know what are the different causes like you just mentioned a few of them, so can you let us know more in detail about what are the other causes of unexplained infertility?

Dr. Partha: So as we all know, and we understand very clearly that life begins with an egg, if the egg is good, that’s how life starts propagating forward. So first and foremost, advanced maternal age is the number one cause for ladies who are not able to get pregnant at the right time. And when we say advanced middle age our the scientific community has defined an age 35 years and more than 35 years. To be the mark age mark where you know the fertility status can be compromised. So with advanced age comes the quantity of the eggs left in the ovary as well as the quality of the eggs and ovary. So all these factors can go hand in hand to prevent a pregnancy outcome. Of course, we have to understand lifestyle factors when we say lifestyle factors mean somebody who has who’s leading a sedentary lifestyle who does not do much physical activity. Who does not do much exercise? Who has got habits like smoking alcohol or having recreational drugs? And of course, we have to understand that we are surrounded by environmental pollutants and stress. So all these factors do culminate in this problem of infertility. Also, we have to understand that the tubes are to blame for now. Hearing we are not talking about blocked tubes because we have told the couple that you are infertile because of unexplained reasons and all those tests which we have done like your tubes test is normal. So we are talking about the micro ciliary function of the tubes and that can happen when somebody has got any kind of pelvic infection like from ideal infection or tuberculosis. We also have to understand the husband’s sperm parameters. You know there are some specific problems in these sperms which we call long DNA fragmentation tests, which can be done on men wearing the morphology of the sperm count seems to be a little on the lower side. Endometriosis which are. I’m not talking about endometriosis which is the big cysts I’m talking about the microscopic small deposits in and around the ovaries which can cause scarring and adhesions at. You know, adenomyosis of the uterus, which is nothing but the end of it. Blockage of the uterus. Come and also we have to understand about the unseen variety, which is the immunological factors is the mother’s body making a lot of immune cells which is detrimental to embryo implantation and of course last but not the least. Psychological issues need to be addressed because many times a lot of women have what we say or vaginas must, where they are not able to have penetrative intercourse. And, and these are the things which are that which is considered a taboo in the society. And they did not want to discuss it out. And the problem is that they are not able to have intercourse and that is why they do not determine our pregnancies. So psychological issues and all these factors need to be understood and discussed and spoken with the patients. So yes, these are the telltale causes of unexplained infertility.

Mrinalini: Alright Doctor. now, as you just mentioned, now see whenever a male and a female they come together and you know they will. This will definitely enhance their fertility. In a positive way, however, if like you just mentioned. However, when there is an infertility cause or factor that’s there. So how does it affect the psychological well-being of the patient? So can you. Can you let us know about that and how can that be overcome?

Dr Partha: You know this is a big question that you have asked me, you know, and that it sounds very simple, but it is to answer this question is quite difficult now. Psychological issues do play a very, very important role, not only for fertility POV but in general also. The second point being is that in our community of we always consider somebody who is not able to get pregnant. As soon as we try and tend to look down upon and which is which should not be up. A problem actually. The thing is that. Couples who are not able to achieve a pregnancy. They should seek out. They should reach out to their physician. To the gynecologist and or the fertility doctor to discuss their problem and plan or treatment modality forward and at the same time, our counseling sessions are psychological counseling sessions needs to be addressed not only for the woman, of course, but also for the men and our family at large. To explain to them the process of baby-making and sometimes it is time-consuming, but if it is discussed properly then all these health problems can be addressed. Yes.

Mrinalini: And, uh, and you know before starting any treatment, you know the patient would definitely undergo certain fertility tests. So what is the evaluation that is involved and what is the series of tests that can be done to diagnose unexplained infertility?

Dr. Partha: So if a couple comes to us and, uh. Saying that you know they have been trying unprotected intercourse for a year or so and they are not able to achieve a pregnancy, so that’s when we want to do some baseline tests. So starting from the woman we would like to do an ultrasound of her ovaries to check how many follicles and eggs she has. We can count those follicles we need to check the endometrium of the uterus to make sure that there are no anatomical lesions like fibroids and polyps. We need to look for endometrial cysts. We also have to do tubal patency and see tests to check if the tubes are open or not open. We also have to do conduct some blood tests which a specific one being AM age which is for anti malarian hormone and that is a marker of ovarian reserve and for the men, we have to do a semen test to check for his firm sperm count, motility and morphology and other endocrine blood parameters like the thyroids and the prolactin. Also needs to be validated.

Mrinalini: Alright, so moving on to my next question. Now, how is a patient supposed to know that OK, he or she has unexplained infertility?

Dr. Partha: So as I said in my initial, uh. Question the initial question that was asked to me that if somebody has had one year of trying and they have not achieved pregnancy, so that’s when they reach out to their gynecologist or the local physician. And when the doctor does the initial checks and they found that your tubes are open, the uterus looks brilliant. The eggs are absolutely good. Husbands sperms are good and all other hormonal or endocrine biological factors in the blood are good and there is no cause. That needs to be found, so that’s when they say that. OK, with all these factors being normal and you’re still not able to get pregnant, so probably we are dealing with something called unexplained means we cannot explain the reason for you being infertile. So what needs to be done? So we as infertility specialists, step in and we have to analyze this whole issue, and then we have to offer a treatment plan so the treatment plan would be to maximize the time to pregnancy means reducing their time duration of you know, achieving a conception and a positive outcome. So then we try to. Do scan serial scans and advise them to have now planned natural intercourse. If that’s not successful, then we can do few cycles of artificial insemination, and if that is unsuccessful then we have to resort to in vitro fertilization. What we say is test tube baby treatment.

Mrinalini: Yeah. And, uh, assuming that none of these treatments work, then what is the approach that is being used then? What is supposed to be done?

Dr. Partha: That is where the enigma of the whole infertility issue comes in. Because of infertility practice, we cannot guarantee a 100% success rate. We just. Of 18 nature’s way of doing things scientifically. So if somebody has not had an outcome, a positive outcome. After a few cycles of artificial insemination, then we have to discuss these options and we have to resort to in vitro fertilization program now in vitro fertilization program can be done umpteen number of Times Now with the recent advancements of scientific advancements of technology and medications that we use us usually. Uh, do IVF like once where we harvest a good number of eggs and the freezer. A good number of embryos, and if the embryos are genetically tested, if they come out normal, then if she has got more than 3-4 embryos frozen then she has got 3-4 attempts to achieve a conception. So most of the ladies in this group almost like 65 to 75% of the women in this group. They fall pregnant, the remaining of 20-25% who are not able to achieve. Then we have to conduct. Further, causes of further treatments of IVF program, but also understanding to give do a little more evaluation from the uterus POV by making sure to do a hysteroscopy to make sure there is no end endometriosis of the uterine lining. Adenomyosis is taken care of. We do some immunological treatment and most of this add-on treatment. Sometimes we achieve our good conception and we try to. Try to achieve success as soon as possible. The rest depends upon the patient’s wish. If they want to continue further courses of you know IVF around and take it forward yes.

Mrinalini: Alright doctor now. We’ve also seen in the past that you know there are certain medications that might be used. For example, the use of Clomid is very common and you know also there are treatments or stimulation drugs that are given. So would you like to tell us more about that?

Dr. Partha: So, uh, the Clomifene citrate  or Femera or letrozole tablets. These are the basic, uh, you know, population induction medications that we have and that we usually would like to start with. The younger you are in your age group and the good ovarian response or the central follicular count you have. We would like to start with this oral medication, which is the global concentrate or the tablets in case We find that the evolution process is not good and follicular maturation is not good, and then we have to resort to injectable gonna drop Inns to boost the overhead follicular development. So yes, we do understand that when we do give these medications either in the oral tablet form or injectable tablet form. We try to achieve a multi follicular development. Happens more than one or two follicles can grow so the chances of more than one pregnancy can happen like twin pregnancies also can happen and that is the risks involved when we want to do something like artificial insemination. So we discuss these issues with our couple and a proper counseling session is done to ensure one baby at a time in case we find that there are a lot of follicles than we either cancel that.

Mrinalini: Our audience does understand unexplained fertility better now and they understand it much better and they came to know more about this. So we do look forward to much more sessions with you. So thank you so much, doctor, thank you for taking our time and being here with us today. Thank you so much.

Dr. Partha: Thank you so much for this question and thank you for the time.

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