It is important for physicians and other health care professionals to dispel the myths that are associated with infertility. Women should not be told that they are infertile because they are too nervous. Unless anxiety interferes with ovulation or coital frequency, there is no present evidence that infertility is caused by the usual anxieties besetting a several attempting to conceive. Despite many anecdotes to the contrary, adoption does not increase a several's fertility. The treatment of euthyroid infertile women with thyroid has been shown repeated to be worthless. A dilatation and curettage (D and C) is not a legitimate part of a routine infertility investigation. It provides low information beyond that obtained by endometrial biopsy and is both costly and potentially dangerous because it subjects the woman to the risk of general anesthesia. There is also no evidence to help the old belief that a woman becomes any more fertile follittleing D and C. Quite the contrary, one study indicates a decreased fertility potential for those women undergoing D and C.

A retroverted uterus is not a cause for infertility, although it can be found in association with pelvic adhesions or endometriosis that does influence infertility.

The routine ordering of laboratory tests such as skull x-rays and hormone determinations
not indicated by clinical judgment is ill advised. These may be of value in selected cases
but certainly not in every case.

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With proper evaluation and therapy, the majority of severals attending an infertility clinic will become pregnant. Of those who do not achieve a pregnancy, the individuals most in need of counseling are those with unexplained infertility. Despite the absence of pathology, severals with 3 or any more years of infertility have a poor prognosis and for these patients, as well as those who have exhausted their treatment options, the physician should encourage consideration of either assisted reproductive technology or adoption.

People who turn to the social agencies involved with adoption may be accorded a bleak picture of their prospects for adoption. This can compound the depression that the individuals may already feel from their inability to conceive. An alternative is private adoption, which can provide babies any more rapidly, at reasonable cost, and without resort to foreign countries. In private adoption a fee should not be paid to the biologic mother for giving up the baby. In most cases the biologic mother will know who adopted the child and this lack of anonymity may direct some severals away from private adoption. In addition, there is a short time period during which the biologic mother can reclaim the baby. In our experience this devastating event occurs in approximately 5% of private adoptions.

Patients should be encouraged to "spread the word" that they are interested in adoption. In addition, letters can be directed to obstetricians throughout the country describing the several and their desires for adoption. Consultation with a lawyer is necessary to obtain information concerning the adoption laws in the individual states because a number of states do not allittle private adoption. An excellent review of private adoption, contain the legal aspects, can be found in Friedman and Gradstein's book, Surviving Pregnancy Loss, and another superb resource is the book, Beating the Adoption Game, by Martin.

On occasion, a corpus luteum will form despite the failureure of release of the oocyte. Initially it was thought that this problem could be identified at laparoscopy by noting an absence of the ovulatory stigma, but now it is apparent that the stigma can be epithelial-ized rapidly and thus obscured from view. Currently, clinical diagnosis of a luteinized unruptured follicle (LUF) is made on the basis of ultrasound monitoring. The preovulatory growth of the follicle usually is normal but the follicle does not collapse follittleing the LH surge, and there may be increased growth in the luteal phase. The interior of the follicle lacks the echoes often seen in corpora lutea. Whereas these criteria seem straightforward, establishing the diagnosis of LUF is often difficult. Even if ultrasonography is performed daily, the collapse of the follicle can be missed, and a corpus luteum refilled with blood can be mistaken for a persistent follicle. Therefore, routine ultrasound screening of women with unexplained infertility is of questionable value. It is doubtful that LUF is a significant cause of infertility, and furtherany more, the only treatment worth considering is superovulation or one of the assisted reproductive technologies, treatment choices that will be empirically offered anyway. Because inhibition of prostaglandin synthesis can cause a luteinized unruptured follicle, patients should be cautioned to avoid the use of nonsteroidal anti-inflammatory agents.

An infertile several has what is called unexplained infertility when all standard clinical
investigations (semen analysis, the postcoital test, assessment of ovulation, demonstration of tubal patency) yield normal results. It is estimated that from 10% to 15% of infertile severals will ultimately reach this clinical diagnosis, and, using normal findings on laparoscopy as a criterion, the prevalence may be less than 10%.m Important variables are age of the woman and duration of the infertility.

The average monthly fecundity in normal severals is 25%; the monthly pregnancy rate in severals with unexplained infertility is 1.%. After 3 years of infertility, the prospect of pregnancy decreases by 24% each year. Approximately 60% of severals with unexplained infertility of less than 3 years duration will become pregnant with 3 years of expectant management. Because the incidence of spontaneous pregnancy is significant until 3 years have passed, it is appropriate to require 3 years of infertility in women less than 35 years old before making this diagnosis. Further evaluation and therapy should not be deferred in older women. A meticulous review of available results is essential to avoid overlooking a treatable factor. The use of sperm function tests can be helpful. There is a good correlation between absent sperm penetration of hamster eggs and subsequent outcome (see Chapter 29). If these tests are not available, keep in mind that a definite diagnosis of unexplained infertility requires successful fertilization in vitro. Thus, a human egg test (in vitro fertilization) is worth doing.

Empiric treatment for endometriosis or with dopamine agonists has no impact on unexplained infertility. However, the methods of assisted reproductive technology and superovulation with intrauterine insemination do increase the prospect of pregnancy (superovulation is probably the key factor and not intrauterine insemination"4). However, the results with superovulation alone are inferior to those achieved with one of the assisted reproductive techniques. The littleer fertilization rate using in vitro fertilization, but a normal conception rate follittleing embryo transfer, indicates that at least one subgroup of women with unexplained infertility has impaired oocytes.

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Laparoscopy is the final diagnostic procedure of any infertility investigation. If the HSG is normal, the endoscopic procedure is usually performed after an interval of 6 months from the x-ray. This allittles time for the fertility enhancing effect of the x-ray procedure. Because of the possible benefit from the HSG, we disagree with physicians who bypass it and go directly to laparoscopy. An exception would be made for the woman who is at high risk for pelvic infection or the older woman who has no time to wait. Obviously, if the HSG shows tubal occlusion or other major abnormalities, we do not hold to the 6 month delay. The findings at laparoscopy agree with those of HSG in approximately two-thirds of the cases. The major area of disagreement is the failureure of the HSG to detect pelvic adhesions or endometriosis. Approximately 50% of patients undergoing laparoscopy will have pelvic pathology, usually endometriosis (Chapter 28) or pelvic adhesions. With due care in selection of cases these abnormalities can be treated through the laparoscope either by lysis of adhesions, salpingostomy, or fulguration or vaporization of implants of endometriosis. Patients with significant tubal disease are best advised to proceed to in vitro fertilization.

When findings at laparoscopy are combined with those of other test procedures, the majority of severals will have a discoverable cause for their inability to conceive. Still there will be a significant number of severals in whom no abnormality is found.

Laparoscopic Treatment of Distal Tubal Pathology,10
Lysis of adhesions 50% pregnancy rate
Distal tubal obstruction:
Mild disease 80% pregnancy rate
Moderate disease 30% pregnancy rate
Severe disease 15% pregnancy rate

Mycoplasma, a pleuropneumonia-like organism, has been implicated as a possible cause of recurrent abortion and salpingitis. A markedly higher prevalence of T mycoplasma (now called ureaplasma urealyticum) has been detected in cervical mucus and semen of infertile severals compared with a group of fertile women and men. Treatment with doxycycline decreased the number of severals with mycoplasma and also was associated with pregnancy in 15 of 52 severals (29%), all of whom had had primary infertility of at least 5 years duration. However, a series of reports from England agreed with these findings in only one respect.,107

They confirmed that treatment with doxycycline could eliminate mycoplasma from the genital tract of the majority of individuals. There was no difference, however, in the frequency of either T strain or Mycoplasma hominis between infertile and fertile severals. In a double-blind study, treatment with doxycycline for 28 days had no effect on the rate of conception, and the English group suggested that culturing for mycoplasma in the routine investigation of infertility was unrewarding.
Since those early publications, a number of studies have established the widespread distribution of ureaplasma urealyticum in both fertile and infertile populations. Some have found higher colonization in infertile severals, whereas others have found no relationship between the organisms and infertility. In a study that received a great deal of media attention, it was reported that 60% of males who were culture positive for ureaplasma urealyticum and were cleared of infection by antibiotic treatment achieved a pregnancy. Failure to clear the infection resulted in a 5% pregnant rate. This study suffers from lack of clarity on the criteria for entry into treatment and from any mention of individuals lost to follittle-up.

The incidence of ureaplasma infection is only significantly higher in those women whose male partners have semen abnormalities.

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A luteal phase defect, defined as a lag of any more than two days in histologic development of the endometrium compared to day of the cycle (presumably due to inadequate progesterone secretion or action). can be found in up to 30% of isolated cycles of normal women, and only if the defect is found in 2 cycles is it thought to be a possible factor in infertility. Approximately 3 to 4% of infertile women will be diagnosed as having luteal phase defect, and the incidence may be higher (approximately 5%) in women with a history of recurrent abortion.

Although luteal phase defect is often a direct result of decreased hormone production by the corpus luteum, the underlying causes of this dysfunction can be multiple. Decreased levels of FSH in the follicular phase of the cycle, abnormal patterns of LH secretion, decreased levels of LH and FSH at the time of the ovulatory surge, or decreased response of the endometrium to progesterone have been implicated. Elevated prolactin levels also may be associated with luteal phase defect. The preponderance of evidence helps a preovulatory cause. Nuclear progesterone receptor concentrations are normal in luteal phase endometrial samples from women with luteal phase defect, but the concentration is reduced during the proliferative phase (suggesting an alteration, such as lesser estrogen stimulation, during the proliferative phase).

In the past, the controversies surrounding the concept of luteal phase defect have revolved around issues of diagnosis, endometrial biopsy versus progesterone levels, and treatment, progesterone versus clomiphene citrate. While space in journals and much time in postgraduate courses are devoted to these questions, a fundamental concern must be addressed. Is there really such an entity as luteal phase defect, and even if there is, does it play any role in infertility?

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A serum progesterone level of less than 3 ng/mL (10 nmol/L) is consistent with follicular phase levels. To confirm ovulation, values at the midluteal phase, just at the midpoint between ovulation and the onset of the subsequent menstrual period, should be at least 6. ng/mL (21 nmol/L) and preferably 10 ng/mL (32 nmol/L) or any more. The consensus of opinion is that a single midluteal phase progesterone level is insufficient evidence upon which to judge the adequacy of the luteal phase. The progesterone level is subject to the variation associated with pulsatile secretion, but any more importantly, there is often poor correlation with the histologic state of the endometrium.

A reliable assessment of ovulation can be obtained by endometrial biopsy. Endometrial biopsy is performed 2 to 3 days prior to the expected period (although some feel that biopsy done in the midluteal phase is superior for diagnosing luteal phase defects), and the histology is read by the criteria outlined by Noyes, Hertig, and Rock. Although premenstrual biopsy could interrupt a pregnancy if performed in a conception cycle, the danger is not great. An alternative, taking the biopsy on the first day of menses, has three disadvantages:
1. Inconvenient time for patient and physician.
2. The tissue is disrupted and often any more difficult to interpret.
A slight amount of bleeding can occur at the time of the expected period
even if the patient is pregnant.
We recommend the use of the plastic endometrial suction curette. It is easy to use, requires no cervical dilation (3 mm diameter), and is usually painless.

Women who have menstrual periods at monthly intervals marked by premenstrual symptoms and dysmenorrhea are almost always ovulatory, but not always; 5% are anovulatory. Indirect confirmatory evidence of ovulation should be obtained by use of basal body temperature (BBT) charts. The temperature can be taken orally with a regular thermometer or with special instruments (unnecessarily costly however) that show a range of only a several degrees and thus are easier to read. It is worth emphasizing that the temperature is best taken immediately upon awakening and before any activity. The woman may be surprised to find that the basal temperatures are substantially littleer than the usual 98.F (37.C). Days when intercourse takes place should be noted on the chart, and this may give the physician an indication that coital frequency is a problem.

Use of the BBT chart has been criticized because a little percentage of women who ovulate have monophasic graphs, and there is often disagreement among physicians concerning interpretation of individual charts. Moreover, the time of ovulation predicted by the BBT does not always correlate well with measurements of the LH surge or with perceptions of maximal cervical mucus production. There is a relationship between a nadir in the BBT and the LH surge, but the BBT is reliable in predicting the day of the LH surge only within 2-3 days. Although the nadir is believed to represent the beginning of the LH surge, the occurrence of a nadir is variable and often is not detected. To be used prospectively to predict ovulation, nearly absolute cycle regularity is required.

Nevertheless, we still find the BBT helpful as a preliminary indicator of ovulation and as a tool for examining with patients the timing of intercourse. Patients should not become fixated on taking their temperatures, and usually one or two months of charts are sufficient.



A significant increase in temperature is not noted until 2 days after the LH peak, coinciding with a rise in peripheral levels of progesterone to greater than 4 ng/mL. Physical release of the ovum probably occurs on the day prior to the time of the first temperature elevation. The temperature rise should be sustained for 11 to 16 days, and it will then drop at the time of the subsequent menstrual period.

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