Female Fertility Unraveling Your Fertility Mystery

Fertility Factor #2: Sperm-Mucus Interaction
Normally your cervical mucus forms an impervious plug that keeps foreign materials, including sperm, from entering the uterus. Once each month, responding to estrogen, the cervical mucus becomes clear, thin, and stringy so sperm can swim through the cervix into the uterus.

I'll examine your cervix to make sure that the mucus has not been degraded by infection, by a cone biopsy to remove abnormal precancerous tissue, by cryosurgery, or by cervical deformities from congenital defects or DES exposure (as in Debbie W.'s cervix). In part IV, "When Sperm Meets Egg," I'll explain how I diagnose and treat sperm-mucus problems.

Since bacteria, viruses, white blood cells, and antibodies may attack and impair the sperm, a number of different vaginal and cervical infections can cause fertility problems. Some wave red flags in the form of pus (purulent discharge), inflammation, itching, burning, and foul odors, but many of the more insidious varieties can be detected only by special laboratory tests.

Minor infections include candidiasis or yeast, which may be uncomfortable and itchy; trichomonas, which may produce a bad-smelling greenish discharge; gardnerella infection, which causes a burning sensation and a gray, pasty discharge; and ureaplasma infection, which is symptomless. A microscopic examination of the discharge will disclose the identity of the invading organism. Once antibiotics eradicate these infections, fertility may improve.

Infections such as chlamydia, ureaplasma, and gonorrhea occasionally cause severe illness leading to tubal blockage and the formation of adhesions, often without the victim knowing it. Diagnosis is difficult, since the only evidence may be a reddened vagina or a burning sensation and urgency to urinate. In the presence of an abnormal cervical discharge, I will test for all of these organisms.

Janice D.'s laparoscopy, for example, revealed that she had extensive pelvic adhesions. When I questioned her, the only incident she could recall was a flulike illness she'd had during her junior year at college. She and her physician had never realized she was suffering from a chlamydia infection. It was six years later, when she couldn't get pregnant, that she received the diagnosis.

By causing an inflammation of the uterine lining, ureaplasma (often called mycoplasma) may lead to early miscarriage. When this sexually transmitted infection is found in the woman, it will probably be in her partner, too. When ureaplasma occurs in the man, he may form antibodies which attack his own sperm. Since the symptoms for this disease are as elusive as those for chlamydia, only a culture can help me diagnose it.

Gonorrhea is usually symptomless in the woman, although in some cases it causes a bad-smelling yellowish discharge and red and swollen vaginal walls, and if it invades your tubes, you'll suffer severe pain and develop a high fever.

In the presence of infertility I always culture for this organism because, once detected, I can often restore fertility with the antibiotic doxycycline.

During the vaginal examination I will also note if you appear to be having an abnormally high level of discomfort. This sometimes indicates psychological problems which could interfere with having intercourse. Since you are fertile for only forty-eight hours each month and sperm survive for only forty-eight hours in your reproductive tract, infrequent intercourse may play a role in your fertility problem.

Fertility Factor #3: Fertilization
Fertilization depends on the sperm's ability to penetrate the outer layers of the egg and transfer its genetic information. Since I cannot determine if fertilization is working properly from the physical examination, I must use the sperm penetration assay or the acrosin test, which are explained in chapter 18.

Fertility Factor #4: Tubal Factor
Other clues uncovered during the physical examination may point to transport problems. Abdominal scars, for example, could indicate that surgery might have caused adhesions to form. Margaret B. had an appendectomy scar from a ruptured appendix. Since the massive infection and surgery could have caused tubal blockage, I did a tubal X ray right away.

Abdominal adhesions can prevent the egg from entering the fallopian tube as well as impede its passage through the tube. I have seen many women whose tubes were frozen in place by this nonstretchable tissue preventing the tubal movement necessary to coax the egg toward the uterus. During the pelvic examination I manipulate your reproductive organs to detect if they move freely or if they feel like rigid, plaster models. I can often restore fertility to women with adhesions by surgically removing this scar tissue. I'll discuss these procedures in chapters 16 and 17.

Wincing, tenderness, and pain during the pelvic examination may indicate an active infection. Endometriosis can cause adhesions and impair ovulation. Sometimes I can detect endometriosis during the vaginal and rectal examination; however, just as Sherlock Holmes pulled out his magnifying glass to get a closer view of the evidence, I often must confirm the diagnosis with a laparoscopy. When I examined Shelley T., I could feel the telltale beading or bumps on the surface of her reproductive organs and supporting uterine ligaments, but I followed up with a laparoscopy to confirm my diagnosis. Endometriosis may respond to medication or, failing that, surgery. I'll discuss more about endometriosis in chapter 17. Depending on their size and location, fibroids and ovarian cysts can also interfere with egg transport. These conditions will usually respond to surgery.

Remember that having open tubes isn't the whole answer. If infection has stripped the hairlike cilia from the tubal lining, the egg may not be able to complete its journey toward the uterus. Detecting tubal problems during the physical examination is very unlikely; only an X ray can confirm that diagnosis. By combining the clues from your history and from the physical examination, I can decide if sperm/egg transportation might be contributing to your problem. A complete discussion of testing and procedures for tubal transport problems appears in chapters 16 and 17.

Fertility Factor #5: Embryo Implantation
Sometimes during the physical examination I detect obvious causes for miscarriage such as congenitally malformed reproductive organs, an abnormally shaped cervix evident of DES exposure, or a cervix distorted by previous surgical procedures. Most of the time, however, the physical examination will not reveal the exact causes for recurrent miscarriage. The tests specific to this and other disorders causing pregnancy loss are covered in complete detail in chapters 18 and 19.

Standard Laboratory Tests
As part of the physical examination, I order a number of laboratory tests.

The postevaluation conference I have with my patients reminds me of the meeting between the chief of detectives and his team to plan the final strategy for solving the mystery. Step by step the chief outlines the plan, so each person knows exactly how to play out his or her role. He also outlines contingency plans to deal with obstacles and unexpected events. And even with all this forethought and effort, sometimes the suspect isn't where they expect him to be; sometimes the suspect escapes; and sometimes the suspect turns out to be innocent.

As "chief of detectives," once I have collected all the clues from my investigation—your history, your physical examination, and your laboratory tests—I begin to outline a strategy for treating your fertility problem. I may not know the exact cause of your infertility, but I can customize the investigation to uncover the most likely problem. If I suspect ovulatory problems, as I did with Kathy S., I will want to evaluate the menstrual cycle. If I suspect tubal blockage, as I did with Margaret B., I will order an X ray. If I suspect an infection, I'll recommend antibiotic therapy. Or if I find poor semen quality, I'll want to evaluate your husband more thoroughly. As I get closer and closer to the answer, I begin to put together my strategy for eliminating your fertility problem.

Cultures/DNA Probe: Cultures for sexually transmitted infections reveal the presence of active infections which must be treated prior to initiating other fertility treatment. It's mandatory that the woman's partner be treated for the same infection, since bacteria are easily passed back and forth between sexual partners. Recently tests called DNA probes can detect chlamydia and gonorrhea from a simple smear taken from the cervix.

Day 3 FSH: In those women over 35 I recommend this blood test to determine ovarian status.

VDRL:This test rules out the presence of syphilis, which may affect the fetus as well as pose a serious health hazard to you.

HIV & Hepatitis Screening: Testing for the AIDS virus and hepatitis may be done as part of your initial evaluation.

Pap Smear: Although not specific to fertility problems, a Pap smear should be performed during every workup to eliminate the possibility that you have or may soon develop cancer of the reproductive organs.

CBC:A complete blood count will give a reading on your general health. It will also indicate if you have an infection, systemic disease, or iron deficiency.

Urinalysis: This test will help rule out renal disease or genitourinary tract infections as potential fertility problems.

Prolactin: This test is likely to be abnormal if you have irregular periods or note a clear or milky breast discharge.

Thyroid Hormone: I run this test if the physical exam suggests hyper- or hypothyroidism.

Testosterone, DHEAS, 17 Hydroxyprogesterone, & Fasting Insulin: These tests may be helpful if you have irregular periods and excessive hair growth.

Sed Rate: The sedimentation rate in your blood will often reveal an infection when cultures show up negative.

Rubella Titre: I always test for immunity to German measles, since contracting this disease during a pregnancy often leads to severe deformities in the fetus.

Sickle Cell Screen: If you are Black, this test will indicate if you are at risk of having a child with sickle cell anemia.

Semen Analysis: Your workup is not complete until your husband's semen has been evaluated. Performing extensive testing and treatment on you will be to no avail if he is not contributing adequate sperm.

You, as a couple, are part of my assault team. Without your input, understanding and participation, my efforts will fail. You will decide how much of your resources you are willing or able to spend, and how long you want to pursue your goal. Together we'll decide how aggressively to attack the problem. Margaret and Richard B. knew that due to Margaret's age they had only a few fertile years left. They had good insurance coverage, so they wanted to check everything out as soon as possible, with money as no object. Shelley and Michael T., in contrast, had already been through a year or more of tests, had many bills to pay, and Michael was feeling so pressured that he was ready to quit entirely. They chose to proceed more slowly—one step at a time. The fertility treatment plan we worked out for these two couples differed considerably.

To help you understand the types of decisions you may be facing, the next chapters will cover specific tests and treatments for the five main suspects in female infertility.

For more information on your initial visit to your physician read the
INCIID Routine Fertility Workup or IVF.com Homepage.

Miracle Babies and Other Happy Endings
for Couples with Fertility Problems
Copyright © 1986 Mark Perloe M.D., and Linda Gail Christie.