diagnosed by ultrasound scan, showing enlarged ovaries containing several small cysts. In rare cases, women do not ovulate because of premature menopause.

Blocked or Damaged Fallopian Tubes: Fallopian tubes can be damaged following pelvic infections, endometriosis or after pelvic surgery. Laparoscopy will confirm the extent of the damage.

Hostile Cervical Mucus: Clear and abundant mucus is normally produced at the time of ovulation by the cervix, allowing sperm to penetrate the endometrial cavity. Hostile Cervical Mucus will prevent sperm movement and pregnancy.

Endometriosis: is the presence of parts of endometrium (the inner lining of uterus) outside of its normal location. It is commonly noted on the ovaries, fallopian tubes or anywhere in the abdominal cavity. Endometriosis will bleed at the time of the period and cysts filled with blood will be produced causing painful periods and infertility. Adhesions can occur as a consequence of

endometriosis, which is a major factor in infertility.

Fibroids: are fibrous growths of the uterine wall. They cause infertility when they are very large and therefore distort the uterine cavity or when they develop inside the uterine cavity. In these cases they should be removed either by open surgery, Laparoscopy or Hysteroscopy.

problems such as blockage and dilation (hydrosalphinx)

Day 2 LH/FSH: This is a blood test that checks whether there is good reserve of eggs in the ovary and the hormonal system leading to their release is intact.

Progesterone levels: This will check if ovulation has taken place. It should be taken 7 days before a period,

Semen analysis: A sample of semen is needed to check the total count, whether the sperms look normal, and if they are motile. It is important to abstain from sex for a few days before the test and to ensure that the sample is transported to the lab without delay when produced.

Other investigations — for special circumstances
Pelvic ultrasound scans: to check that the uterus appears normal and whether the ovaries are ovulating or have a polycystic appearance. An internal or transvaginal scan is most accurate.

Diagnostic Laparoscopy and dye test: if there is a significant degree of pain with intercourse or painful periods then a laparoscopy might be suggested instead of a HSG. This involves general anesthesia and small telescope to look through the umbilicus into the pelvis to see if there is anything causing infertility (e.g. endometriosis, fibroids, PCO and adhesions). At the same time some dye is injected to check the patency of the tubes. This is also done if a HSG suggests that there might be a problem with the tubes. In many cases Laparoscopic surgery can correct the problem leading to

infertility in the same sitting e.g. drilling of PCO, removal of adhesions fibroids and endometriosis

Hysteroscopy - if the HSG suggests that there is an abnormality of the inside of the womb, a hysteroscopy can be done for a closer look. A fine telescope is passed through the mouth of the uterus (cervix) and the uterine cavity is visualized. Hysteroscopy can

detect fibroids, polyps or congenital variations such as a double-womb, bicornuate (heart-shaped) uterus or a uterine septum.

Thyroid function tests and prolactin - in woman with irregular or infrequent menstrual cycles or other signs of thyroid disease it is important to exclude this. Prolactin is normally involved in production of breast milk and abnormally high levels of prolactin (hyperprolactinaemia) prevent ovulation. Prolactin levels should be checked if cycles are infrequent or there is an unusual discharge from the breast.

Treatment Options
Ovulation Induction Medications: Ovulation induction medications like clomiphene citrate or inject able FSH/LH hormones, commonly called fertility drugs, may be used to stimulate the follicles in ovaries to produce multiple eggs in one cycle. Sexual intercourse and/or intrauterine insemination (IUI) may then be scheduled around the time of ovulation to achieve a pregnancy.

Intrauterine Insemination (IUI): with washed and prepared sperm. This is advised for low sperm counts, hostile cervical mucus and some female factors. The female partner must produce eggs and have healthy/ patent Fallopian tubes. The sperm is placed in the woman's womb or uterus (Uterine insemination) after ovulation induction. One or more inseminations may be carried out around the time at which the egg is released. A pregnancy rate of 15-20% per treatment cycle is expected, depending on factors such as the woman's age and treatment cycle number, cause of infertility etc.

Donor Insemination: If a couple cannot conceive because of azoospermia (absence of sperm) it may be suggested that they consider DI using donated sperm.

In Vitro Fertilization (IVF): IVF (test tube pregnancy) treatment may be appropriate if infertility is caused by blocked fallopian tubes, severe endometriosis, severe polycystic ovaries or low sperm counts.
IVF involves retrieval of one or more eggs from the ovaries prior to release. Most IVF clinics usually recommend that the woman takes drugs, which cause the ovaries to mature several eggs in one cycle. This procedure is called controlled ovarian hyperstimulation. It increases the chances of producing several embryos. The eggs are collected or retrieved under anesthesia with the help of ultrasound. After collection, the eggs are mixed with the man's sperm in a dish and placed in an incubator to be fertilized and so produce one or more embryos. These embryos are then replaced in the woman's womb 48 hours after retrieval. If one or more embryo implants, a pregnancy begins. A pregnancy rate of 30- 35% per treatment cycle is expected.

If the egg fertilizes, it can be transferred to the womb in the way described for IVF. The live birth rate for ICSI treatment is broadly similar to standard IVF.

IVF using donated eggs, sperm or embryos: IVF treatment may be available using donated sperm if the male partner is infertile or using donated eggs if, for example, the woman has no eggs or responds poorly to ovarian stimulation. Donation might also be used if one of the couple is at risk of passing on a serious inherited disease.