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Evaluation of the Infertile Couple Part Two: By Dr. Barry Jacobs

Posted Sep 18 2009 10:07pm

This is a continuation of Dr. Barry Jacobs article on how he evaluates infertile couples who come to him for help. Your comments are welcomed!

Sharon LaMothe

Evaluation of the Infertile Couple Part Two

By Dr. Barry Jacobs

Now we can talk about spending a little money. Ovulation predictor kits test for the presence of LH in urine. LH is a hormone from the pituitary gland which is supposed to trigger ovulation. If ovulation actually does occur, it takes place about 36 hours after the surge in the level of LH, and about 24 hours after it is detected in the urine. At least now you have some predictive value to a test – if you actually ovulate. Again, among the infertile population of women, we see evidence of an LH surge, without rupture of the follicle to release the egg. There is still progesterone production, so the level of progesterone may be appropriately elevated, but you have still not ovulated. For that reason, testing your blood for progesterone level is not entirely reliable, either.

There are only 2 reliable ways to know if you ovulate. One of them is ridiculously obvious. You become pregnant. OK, if you do, you don’t need this article. The other reliable way to know if you ovulate is to perform ultrasound evaluations of the pelvis starting on the 12th day after the start of the menstrual cycle. If you are going to ovulate, you should see a follicle about 17 mm in average diameter on one of your ovaries. Two days later it should be gone. You ruptured the follicle to release the egg – ovulated. Some times we see that the pre-ovulatory follicle has become significantly larger, and there is progesterone in the blood. The follicle has gone through the hormonal changes of ovulation without releasing the egg. The resulting un-ruptured follicle is called a luteal cyst. If this happens, do not be alarmed. In young women, 98% of all ovarian cysts go away without any treatment, at all. You do not need any treatment, especially surgery if it is gone within 2 menstrual cycles.

Women who do ovulate regularly have clock-work regular menstrual flows, every 28 days. Ovulation should occur on cycle day 13 to 14 and, if no pregnancy occurs, there is menstrual flow 2 weeks later. There are a number of subtle ovulation dysfunctions which impair fertility. A variance from a 28 day cycle may signal a problem. Late ovulation and a short interval from ovulation to subsequent menstrual flow will probably prevent a pregnancy form becoming established.

We need an adequate number of good quality sperm. Performance of a thorough semen analysis is an essential part of the evaluation. Too often, semen analysis is delayed until after treatment efforts have been initiated, only to discover that there is a male factor problem contributing to the couple’s impaired fertility. We have now wasted both time and money. In the interest of cost effectiveness, semen analysis should be part of the initial evaluation. Often I have heard, as an excuse not to provide a specimen that he has a child from a previous relationship, or simply, “I know it is not him.” Things can, and often do change in the male, and until appropriate evaluation is performed, you do not know. Remember, also, that a male factor problem does not always prevent pregnancy, but merely decreases the chance one can be achieved. A previous mild male factor problem may not have prevented pregnancy in the past, but may contribute to the current problem. The mild problem may have become worse. Do your part, guys. Your wife has a lot more to deal with, even if the primary problem is a male factor issue.
~Part three will be posted next week

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 75010
www.texasfertility.comPhone: 972-394-9590 Fax: 972-394-9597
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