Fertility Journal

Forgotten Infertility Management

Have we forgotten the infertility treatment skills that were gained before the availability of modern assisted conception treatments?

Modern infertility management appears to be geared to streamlining patients towards the high tech options available through assisted conception techniques, such as IVF, ICSI, egg and embryo donation. There is no doubt that ICSI has dramatically revolutionised the treatment of male infertility. A man now has the possibility of becoming the biological father of his child even if his sperm count is zero. The surgical retrieval of just a few sperm gives the opportunity of pregnancy through subsequent ICSI. Egg and embryo donation have provided children to couples whose only other alternatives were adoption or to choose to remain childless.

Sadly for many of today’s couples, they might as well still be in the pre-IVF era because funded IVF and ICSI are not available to them through the NHS. Most assisted conception in the UK is in the private sector.

So should we look back in pity at those countless patients who were born at the wrong time, namely before the availability of our current treatment options? Well believe it or not, infertility treatment in the “olden days” of the 1970s and early 80s was pretty successful. In fact I had more success through my infertility clinic then than I have had since 2000.

Let me explain. Before the ready availability of assisted conception, infertility clinics would continue to manage and treat patients if there was a realistic chance of success, because the only other options were adoption or to give up. Persistence often paid dividends.

Although it is a generalisation, there is a tendency in modern infertility management to bypass a problem rather than to try to correct it. Examples of this are:

  • difficulties with ovulation → IUI / IVF
  • poor sperm quality → Donor Insemination / IVF / ICSI
  • blocked fallopian tubes or pelvic adhesions → IVF

Let us briefly look at how these problems were managed in the past.

Difficulties with ovulation
The assessment of ovulation today includes ultrasound scans to track the growth of an egg follicle until it disappears after ovulation and a progesterone assay taken one week later.

But even if an egg is fertilised, implantation and pregnancy cannot occur if the luteal phase (the number of days between ovulation and the start of the next period) is too short (less than 11 days). This also applies if the progesterone level falls too soon.
There is no doubt that the Basal Body Temperature (BBT) Chart is the simplest, cheapest and least time consuming method of assessing the length and normality of the luteal phase as well as the apparent normality of ovulation. The early morning waking temperature rises after ovulation and is maintained until just before the next period when it falls. This is very similar to the rise and subsequent fall in progesterone levels during the luteal phase of the menstrual cycle.

I have a vast number of temperature charts collected over a 30 year period. Many of these show that in spite of having a progesterone measurement indicating that ovulation had occurred, the luteal phase was inadequate with a poorly maintained temperature rise. Implantation of a fertilised egg could not have taken place. Subsequent fertility drug therapy (Clomifene) usually corrected the situation by stimulating ovulation with a well maintained temperature rise during the luteal phase and a sustained progesterone output. Pregnancy often resulted.

Clinicians will not use BBT charts nowadays, considering them to be a cause of stress and too crude. But if care and time is taken to instruct the patient on how to take and record her temperature accurately on a good quality BBT chart, the benefits rapidly become apparent. The charts provide a wealth of information. They show the dates of periods, the frequency of intercourse, the timing of ovulation and the length and adequacy of the luteal phase. The patient can add information about the quality of her cervical mucus during the fertile phase of the cycle and the results of ovulation prediction tests. She has more insight into what is taking place. Instruction from the clinic on when to take fertility drugs and the results of progesterone assays can be added to the chart as well. The chart therefore can become an interesting and valuable diary of her cycle without it becoming an obsession.

If a chart is not kept, the inadequate luteal phase in the presence of apparent ovulation (indicated by a single progesterone assay) will be missed. If all other investigations are normal she will be labelled as having “unexplained infertility”. The explanation that was there to be found will not have been picked up.

Poor sperm quality
A correctly collected sperm sample and a timely and expertly performed semen analysis is an accurate method of assessing male fertility. In these circumstances a sub-optimal or poor result is likely to indicate male infertility. A second sample should always be assessed to confirm the diagnosis.

Gynaecologists are curiously reluctant to examine the male of the species even when the sperm count is zero. There is a tendency to either refer men with a diagnosis of infertility to a urologist or to refer the couple directly for assisted conception.

Before the days of IVF, time was spent in assessing the lifestyle of infertile men. Obesity, a sedentary occupation and long hot baths could lead to excessive heat to the genital area. Smoking and alcohol were all factors that could be dealt with vigorously rather than by polite suggestion!.

Testicular cooling simply by wearing loose underwear is usually ineffective. I have found that 50% of men with low sperm counts respond dramatically to twice daily cold water therapy to the testicles. As sperm development takes 74 days, treatment needs to be continued for at least this length of time before a further semen analysis is carried out.

The additional use of folic acid, selenium and zinc by the man as well as anti-oxidant therapy with vitamins A, C and E can remove free radicals from the seminal fluid that can have a detrimental effect on sperm development.

The post-coital test (PCT)is an indirect assessment of sperm quality and also an assessment of sperm survival. The PCT is timed so it is carried out close to the estimated time of ovulation. A mucus sample is taken from the canal of the cervix several hours after the patient last had intercourse and examined under the microscope. The mucus at this time of the cycle is usually profuse. A PCT is positive if the mucus is shown to be very flowing and contains many progressively motile sperm. Under high power magnification, a perfect PCT will have at least 20 sperm showing vigorous progressive movement in every area examined on the slide. Indeed sometimes the sperm can be present in such numbers in the mucus that the sample resembles a neat semen sample.

A positive PCT implies that the sperm count is satisfactory, that the sperm are sufficiently motile to be able to reach the cervical canal and that there are no major cervical mucus hostility factors present that could immobilise or kill the sperm.

The PCT is negative if no sperm or only dead sperm are seen in the mucus. Although a negative PCT does not necessarily imply that there is a serious problem, it can be the first indication that something is wrong.

If the test has been correctly timed, the absence of sperm could imply a poor or zero sperm count or an ejaculation problem. If all the sperm in the mucus are dead this may indicate a problem with excessive acidity of the mucus or the presence of a sperm antibody. If the mucus is thick and glue-like rather than clear and flowing there may be a problem with ovulation.

All these factors may be further investigated and many of them corrected. The poor sperm count can often be improved; cervical mucus can be made alkaline with dramatic improvement in sperm survival and motility; thick mucus can be improved with pre-ovulation oestrogen tablets or the use of gonadotrophin fertility drug injections (FSH & LH) to produce the “ovulation cascade” of flowing mucus; sperm antibodies can with time be removed from the mucus.

Instead the PCT is now rarely performed. It has been abandoned because if it is positive and all other tests are normal, the next move is assisted conception. If it is negative there is an infertility factor at the level of the vagina and cervix . So rather than treat this the next move in modern infertility management is to by-pass the problem and move on to assisted conception.

Blocked fallopian tubes
For severely blocked and distorted or absent fallopian tubes, IVF is undoubtedly the solution. Eggs are stimulated to grow in the ovaries. These are retrieved by ultrasound and fertilised in the laboratory. 1 –2- embryos are then transferred through the cervix into the cavity of the uterus. In these situations the major tubal factors are by-passed.

If the tubes are blocked but not distorted, the woman has essentially become sterilised. If the ovaries are enveloped in adhesions, eggs cannot reach the open ends of the fallopian tubes. While IVF can by-pass the problem, surgery may resolve it permanently. The same is true for women who have deliberately chosen to be sterilised. If after skilled microsurgery techniques one tube remains open, this will give her 6-7 opportunities a year of becoming pregnant rather than the one opportunity from IVF. The overall success from tubal surgery is around 30% and compares very well with IVF. The success rates for reversal of sterilisation (excluding diathermy and cautery methods of sterilisation) in my own hands is above 75%.

Conclusionhere is a trend in modern medical practice to abandon past successful treatments and techniques. As a result many skills are at risk of being lost.

Rather than persist doggedly with assisted conception, it is sometimes worthwhile to step back and see if there are not some very basic and successful treatments that are cost effective and accessible to all who require them.

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