Dr. Rebecca B. Singson, M.D.

TUBAL FACTOR IN INFERTILITY

In 30% of patients who cannot get pregnant, there may be problems with the fallopian tube. If a patient has had a ruptured appendix or a septic abortion, an ectopic pregnancy, a previous pelvic or tubal surgery, a history of pelvic inflammatory disease or has use an IUD, the chances of a tubal problem increases in an infertile patient. If the patient has had multiple sexual partners, the chances of having chlamydial infection increases as well. Chlamydia is a sexually transmitted disease which may produce silent damage on the tubes, meaning the patient is unaware that she is infected yet the disease is damaging her fallopian tubes. After one episode of chlamydial salpingitis (infection of the fallopian tubes with Chlamydia), the incidence of infertility is 11-12%. After 2 episodes, the incidence increases to 23% and after 3 episodes, 54%. The relative risk of tubal infertility is 2.6 fold greater for women who ever used an IUD compared with those who never used one. Women who had only one sexual partner had no increased risk of primary tubal infertility associated with IUD use. Tubal problems can be evaluated by doing a hysterogram (using a fluoroscope) or a sonohysterogram (using an ultrasound) or by laparoscopy under direct visualization. In a hysterogram, a dye is injected through the cervix using a cannula under fluoroscopic guidance to determine if the tubes are open and if there are any distortions in the uterine cavity. A sonohysterogram involves the same procedure using an ultrasound instead of x-ray guidance.

UTERINE AND PERITONEAL FACTORS

The chances that a woman might be infertile due to uterine factors is only 2%. Myomas, which are benign tumors in the muscle of the uterus, are the most notorious for causing distortions in the uterine cavity. Not all myomas need to be removed in case of infertility. The obstetrician needs to evaluate if the myoma is large enough to cause infertililty either by competing for blood supply with the embryo or causing distortion of the uterine cavity or blocking the entrance to the fallopian tube. In patients who have had a history of a previous D & C for a miscarriage, the uterus might be overcuretted causing adhesions on the uterine lining, preventing the sperm from reaching the tubes. This is a rare occurrence but in such instances, the adhesions may be lysed and an IUD placed to prevent the adhesions from recurring.

UNEXPLAINED INFERTILITY

Unexplained infertility is diagnosed when a woman has had at least 2 years of infertility despite a normal history and physical examination, having adequate sexual contact with a partner with a normal sperm count, regular monthly menstrual cycles with evidence of ovulation, adequate luteal phase of the menstrual cycle of at least 12 days, normal bacteriologic cultures, immunologic tests, hormonal profile, and ultrasound studies.

IMMUNOLOGIC FACTORSs

Immunologic factors have been found in upto 40% of couples with unexplained infertility. It remains controversial even among infertility experts but it may result from depletion or destruction of sperms or inhibition of transport of sperm in the female genital tract. In males, vasectomy, testicular torsion, or trauma, or an infection, can result in an immunologic reaction that can cause formation of antisperm antibodies. Women who undergo artificial insemination, on the other hand, can develop antisperm antibodies. Infection or inflammation may also increase the probability that sperm will interact with the body’s immune system components.

APAS Syndrome is another controversial disease entity which not all infertility experts are in agreement with. Essentially, it is caused by the mother producing antibodies against phospholipid antigens resulting in clotting of veins and arteries supplying the embryo, causing failure of implantation of the embryo. A blood test to check for a panel of antibodies can clinch the diagnosis. A reproductive immunologist is very helpful in managing these problems when diagnosed.

INFECTION

Subclinical infections have been known to cause infertility over the past 30 years. Mycoplasma are microorganisms as small as a large virus but have no cell walls. Research has shown a greater prevalence of genital mycoplasma in cervical mucus and semen of infertile couples compared to fertile couples. The two kinds of mycoplasma commonly recovered are Mycoplasma hominis and Ureaplasma urealyticum. There is evidence that the sperm counts of men positive for ureaplasma tend to have more abnormal sperms with poor motility. The quality of the sperm has been found to improve after antibiotics therapy to eradicate ureaplasma. This is not universally documented though and upto 50% of men with normal sperms have been found to be positive for mycoplasma cultures. Controversial as it may seem, it is still considered prudent to treat patients with positive cultures with either doxicycline or tetracycline before any invasive procedures are planned on an infertile couple.

LUTEINIZED UNRUPTURED FOLLICLE (LUF)

This phenomenon means that the woman’s ovary goes through the selection of an egg to be released, makes it grow in size with the proper release of hormones, but in the end, the egg never leaves the ovary so there is no chance to meet the sperm in the fallopian tube. The ovum remains in the ovary and regresses there. It is unkown why this happens and it is difficult to predict to whom it will happen, and in many cases is even difficult to prove the diagnosis. Research shows that LUF Syndrome is more common in women with endometriosis or pelvic adhesions and after clomiphene citrate therapy.

It is important for the patient to recognize when it is time to seek professional medical care in cases of infertility while the chances are good for the woman to get pregnant. As the woman ages, fertility becomes a race against time. The infertility specialist can help not only to evaluate but to treat and to counsel as well. You can be informed when it is time to go for assisted reproductive techniques, or to go for adoption and other alternatives or to be directed to various social support systems available to the community. Don’t wait to look back to an infertility work-up and say, “ I should have done it when I was younger”.