Evaluation of the Infertile Couple Part Three: By Dr. Barry Jacobs
Posted Sep 24 2009 10:06pm
This is the last of the 3 part series entitled Evaluation of the Infertile Couple. To read more articles by Dr. Jacobs please visit Infertility Answers, Inc. where he writes about pregnancy loss and endometriosis.
Evaluation of the Infertile Couple Part Three: By Dr. Barry Jacobs
We need for sperm to meet eggs. In nature, that takes place in the female reproductive tract. At intercourse, sperm are deposited in cervical mucus. Remember, estrogens stimulate cervical mucus production and secretion. Cervical mucus has a rather characteristic molecular structure, in that the molecules are long chains that line up to create “highways” for sperm to travel through the cervix into the uterine cavity. Although cervical mucus may look like egg white, it is quite different. I have seen recommendations from non-professionals that women with poor cervical mucus should put egg white in their vaginas as a substitute. Don’t do that!
The uterine cavity, in the non-pregnant state, is not really a cavity. It is a potential space, leading to the fallopian tubes where fertilization takes place. Assuming everything is normal. Sperm are in the fallopian tubes to greet an egg shortly after intercourse. Since we are evaluating an infertile couple, we cannot assume all is normal.
Obviously we need for this entire passageway to be intact. There are a number of ways to evaluate the uterine cavity and fallopian tubes. The least invasive way is to perform a hysterosalpingogram or HSG. An HSG is an X-ray study performed by injecting an X-ray contrast solution into the uterine cavity while watching on a fluoroscope. The contrast material outlines the uterine cavity and should pass through the fallopian tubes and spill freely into the pelvic cavity. Radiologists pass a small catheter with a balloon on the end into the uterus and inflate the balloon. I do not like that technique. Inflating a balloon in the uterus hurts, and the balloon can hide things I may need to see. Instead, I use an older technique of applying a canula, sort of a glorified soda straw, to the opening of the cervix. Through the canula I slowly inject the X-ray contrast and take pictures of the uterine cavity and fallopian tubes. If the cavity is not formed normally, it may increase the risk of miscarriage. Polyps, benign fleshy growths, in the cavity may impair the ability of an embryo to implant. Fibroids, benign fibrous tumors of the uterine wall can interfere with pregnancy if they are right under the endometrium (uterine lining). If tubes are blocked, well, I think it is fairly obvious that will prevent a pregnancy. There are some other more subtle findings that the radiologists commonly do not identify. Sometimes we see kinking of the fallopian tubes. That implies there is some scarring around the tubes, frequently related to endometriosis. After injecting the X-ray contrast and taking pictures, I remove all the instruments, and take 1 more picture of my patient’s pelvis while she is standing. I want to see the distribution of X-ray contrast material in the pelvis. If my patient has scarring in the pelvic cavity, the contrast material will not all form a layer over the pelvic floor. It will become trapped in pockets which can be identified while she is upright.
I have now covered the basic testing of the infertile couple. There is one other test I discuss with my patients. I recommend this test for my IVF patients because I think it is cheap insurance. If my patient does not need IVF, I think this test provides useful information, but I am less certain as to the economic value. I offer it to those who do not need IVF, but do not feel justified in pushing them to do it.
Let me provide some background about this final test. There are 4 families of adhesion molecules which allow our cells to stick together, so we do not end up as puddles on the floor. One of these families of adhesion molecules is called integrins. There are 3 integrins in the endometrium regulated by progesterone, the hormone made after ovulation. These 3 integrins come and go at different points in time during the 2 week interval between ovulation and subsequent menstrual period. All 3 are present at the time an embryo should implant in the endometrium – about a week after ovulation. One of them is present only at that time, so we use it as a marker for the receptivity of the endometrium – how likely is an embryo to stick there and grow.
There are 3 things we know of that can impair production of our marker integrin. One of them is low progesterone levels. Well, that’s s no-brainer. If you need progesterone to make the integrin, and progesterone is low, you will probably not have the integrin. The second thing that impairs production of the integrin is fluid collection in fallopian tubes which have been severely damaged by an infection like Chlamydia or gonorrhea. The fluid in those tubes contains inflammatory proteins which do impair production of the integrin. The third thing that can interfere with production of this integrin is endometriosis. So far, all of my patients who have not made this integrin when they should have had endometriosis. Since I started treating endometriosis in this sub set of patients who did not make our integrin, my IVF pregnancy rates went up 10 percentage points. That is significant increase.
Once an evaluation of the infertile couple is complete, we can start developing a treatment plan. Sometimes, it may be necessary to deal with one or more intermediate issues, such as trying to improve semen parameters, or treating endometriosis. The only times I treat endometriosis, today, is if my patient does not make the integrin we discussed, or in an effort to relieve menstrual main, which may be associated with endometriosis. Again, I do not think it appropriate to start treating a patient without knowing what I am treating. The entire evaluation can be performed in the span of a single menstrual cycle, and, if performed diligently, can actually save time and money.
Dr. Jacobs is a Reproductive Endocrinologist, practicing in Carrollton, Texas, a northern suburb of Dallas. He completed his residency training in obstetrics and gynecology at Baylor College of Medicine in Houston, and remained at that institution to become its first fellow once Baylor achieved accreditation for an advanced training program in Reproductive Endocrinology and Infertility. Dr. Jacobs has served on the faculty of several medical schools and was director of Reproductive Endocrinology at Texas Tech Health Science Center in Amarillo. Currently, in addition to his clinical activities caring for infertile patients and those with recurrent pregnancy loss, he is Chairman of the IVF committee at Baylor Medical Center in Carrollton. Barry Jacobs, M.D., 4323 M. Josey Lane, Suite #201, Carrollton, TX 75010www.texasfertility.comPhone: 972-394-9590 Fax: 972-394-9597