A Primer on Infertility

December 14, 2007

Before 1978, infertility diagnosis and treatment involved mostly surgery, repairing fallopian tubes, and inserting sperm into the uterus. Mainly mechanical blockage that prevented egg from meeting sperm was addressed. Then came Louise Brown and Dr. Patrick Steptoe, a couple a couple who were destined to be associated forever in the infertility history books before Louise had ever been conceived. This is because in 1978, Dr. Steptoe made it possible for Louise to be conceived in a laboratory in England.

From this turning point in the science of infertility came techniques that broke the merely mechanical barriers and addressed the biochemical and hormonal aspects of infertility. This sparked the beginning of a whole new subspecialty called Reproductive Endocrinology. With Dr. Steptoe's technique, called IVF (In Vitro Fertilization), couples who otherwise had no problems that could be fixed surgically now had another option. But this was just the starting point.

With everything riding the coat tails of the Information Age, the explosion of Assisted Reproduction Technology ART) has resulted in the sophistication of additional techniques that is now responsible for the existence of over 20,000 human beings a year that would never have existed. Currently, the most popular methods of ART involve a lot of other initials--IVF, GIFT, ZIFT, AI, and ICSI.

Before delving into these clusters of initials, there are preliminary protocols that are simpler and should be used first.

The Male Factor

The absolute first test that should be done is a male sperm analysis, since a lot of infertility is male-related. A urologist should join the team if this occurs.

Ovulation Inducers

Next, it's important to understand that jumping to the fancy-schmancy ART may be jumping the gun, since a lot of infertility is because of faulty ovulation, not problems of actually conceiving.

There are basically two halves of the menstrual cycle. In the first half the ovary makes estrogen, ovulation marks a mid-point, and in the second half progesterone is secreted and added to the mix. If ovulation is faulty or fails to occur at all, the second half of the cycle may be prolonged or non-existent. When irregular periods result, this is called dysfunctional uterine bleeding (DUB), because the normal period doesn't come as a result of defective functioning of the whole process. Three methods of evaluating this function are:

  • Serum progesterone levels. After ovulation, progesterone rises and should be at least 15-20 by day 21-22 of the cycle.
  • Basal Body Temperature graphs. This is a technique done by the woman herself, taking advantage of progesterone's "thermogenic" ability to raise her body temperature by ½ to 1 degree. When graphed out, the temperature remains constant for half the cycle, then jumps to a new baseline level for the second half until menstruation occurs. On paper, when it looks like this, it's called "biphasic."
  • Endometrial biopsy (EMB). An office scraping of the endometrium with a thin, plastic straw can sample the lining of the uterus (the endometrium) to see if it's the right consistency for that particular time of the cycle.

If the tubes are open, as determined by other tests (see below), and the problem seems only to be ovulation, ovulation inducers can be used.

Clomiphene is a substance that acts like an estrogen. Ovulation is stimulated by the filling of estrogen receptor sites in the brain-like a pail of water that finally tips over when enough water is added. Clomiphene fills those receptor sites, so it takes less estrogen to cause an ovulation-a shallower pail of water.

Blockage of the Fallopian Tubes

This condition will move an infertility patient closer to ART. Everything works right, but it's getting sperm to meet egg that is the problem. Scarring in the tubes is most likely from these causes:

  • Salpingitis. Salpingitis is infection in the tubes. Chlamydia and gonorrhea are the most frequent offenders, gonorrhea being very noticeable with it's pain and pus, but chlamydia sometimes having no symptoms at all-silently dooming a woman to infertility.
  • Pelvic adhesions. Scarring around the tubes and ovaries can occur from previous surgery and previous infections. Appendectomy, surgery for ovarian cysts, and other abdominal surgeries can cause scarring at the opening of the tubes, blocking the egg from the ovary, or causing unreasonable kinking such that an egg cannot negotiate the pathway. The most frequent cause of adhesions, however is endometriosis.
  • Endometriosis. A disease of normal tissue in abnormal locations, this bloody menstrual-like tissue causes pockets of inflammation which draws other organs to it in an attempt to wall it off. The result of this policing is adhesions. Also, there seems to be a chemical reaction of the fluid in the abdomen of endometriosis patients that also hinders conception.
  • Uterine fibroids. Called "leimyomata," these can sit in the wall of the uterus close to the openings of the tubes, blocking the way.
  • Previous tubal ligation. Self-explanatory.

It is noteworthy that anything that can partially block the tube may allow sperm to meet egg, but not make a smooth passage for the fertilized egg to roll down to the inside of the uterus. (An egg is much bigger than a sperm and much more likely to get hung up.) This is how ectopic pregnancies develop.

Weird Stuff

There are women who have "hostile mucus," toxic to the passage of sperm. Antibodies to sperm are also possible, with the resultant infertility. Lupus-like antibodies can result in infertility as well as recurrent miscarriage. And then there are of course the unknown reasons.

Assisted Reproductive Techniques: Artificial Insemination.

This is a technique established long before Louise Brown or Patrick Steptoe. Sperm is injected into the uterus from a vaginal approach. Fertilization still takes place in the fallopian tube, like normal.

IVF-In Vitro Fertilization

This is the legacy of Dr. Steptoe. The infamous "test-tube" baby is actually first conceived by the mixture of sperm and eggs in a laboratory dish. Within this technique are:

  • Ovulation induction, so that more eggs can be retrieved, more pregnancies begun, more fertilized eggs can be transferred, and more success expected.
  • Ultrasound, to follow the follicles so stimulated during ovulation induction.
  • Egg retrieval, via ultrasound-guided needles to suction the eggs out of the follicles.
  • Insemination in a dish, with resulting conception of one or more embryos.
  • Embryo transfer.

GIFT-Gamete Intrafallopian Transfer

In this technique, eggs and sperm are injected into a woman's fallopian tube(s), where fertilization takes place.

ZIFT-Zygote Intrafallopian Transfer.

In this technique, a fertilized egg via the IVF technique is injected into the fallopian tube, as in GIFT. Conception takes place in the lab. The fertilized egg, called a zygote, rolls down toward the intrauterine cavity, like in normal fertilization.

ICSI-Intracytoplasmic Sperm Injection.

This process, wherein a single sperm is injected into the egg, is used when there is a low sperm count or only a small percentage of sperm is healthy.

Religious Note:

The Catholic position on ART is mostly negative, except for AI and GIFT, where fertilization takes place in the tube, as is the norm. In all of the other techniques, fertilization outside the human body is seen as unnatural and is viewed as not acceptable. IVF, in particular, is denounced because of the practice of inseminating a woman with only the best of the conceptions, discarding the rest.

Multiple pregnancies and ART

It used to be that the rate of twins was 1 in 90 pregnancies. That rate has dropped to 1 in 45 since the popularity of ART. The chances of triplets has gone up five-fold. Quadruplets and quintuplets have similarly increased. Since these multiple gestations are all fraternal (coming from different eggs), the complication rate is limited to that of pre-term labor, and pregnancy-intensive illnesses like Pregnancy-Induced Hypertension (formerly, toxemia and pre-eclampsia). Identical twins--two babies from the same split egg, has a horrible complication likelihood, including cord entanglement and discordancy, where one twins takes more than the rightful share of nutrition and oxygen.

Fetal reduction-the great paradox

Be careful what you wish for...the saying goes.

The insertion of several embryos into the uterus or tube has created a new problem-too many babies for the woman who wants a baby at all. Crowds of four, five, and six babies will undoubtedly create a problem with size, and with it, maternal compromise and pre-term labor. So the answer is fetal reduction, a term that reeks of pro-choice double talk.* Aborting enough babies to bring the population down to a manageable number--twins or triplets--creates a paradox for a woman: An unwanted pregnancy is the acknowledged distinction that justifies a woman's right to have an abortion. But this isn't an unwanted pregnancy. This couple has spent $10,000 to $15,000 to get pregnant. Yet, not aborting some will more than likely result in the death or detriment of all of them. This is a personal struggle that couples should resolve before being put into such a position.

*The term reduction has even had its definition changed. Scholarly journals, in reviewing fetal reduction, will discuss which fetus should actually be reduced. English teachers should be very, very afraid.

Assisted reproductive techniques have been a blessing to those who would make great parents but can't have babies on their own.

And God knows, we need some good parenting in these troubled times.

And ART has resulted in people who are pretty much glad they exist.

When we think of the advances we missed out on because of a second or third generation descendant that didn't exist because of the holocaust, we have to celebrate the advances that will come because of people who wouldn't have otherwise been. ART is a good thing, but there are moral considerations that must be identified honestly, without double talk, so that couples can follow their own principled paths.

 

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