Treating Infertility

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Treating_Infertility_coverMisleading Diagnoses of the Cause of Your Infertility

The Simple, Unexplainable Effect of Age

In 1982, the French reported in the New England Journal of Medicine a large study of 2,193 “normal” women (whose husbands had no sperm whatsoever in their ejaculate) undergoing artificial insemination with fertile donor sperm. These were “normal” women, and they were being inseminated with completely normal sperm. There is no logical reason why they shouldn’t all have gotten pregnant. Yet it was very clear that the “normal” women under thirty had a high pregnancy rate, and the “normal” women over thirty showed decreasing pregnancy rates as they got older. A study from Ontario published seven years later in the Journal of Fertility and Sterility looked at more than two thousand couples with “unexplained” infertility. The chances of getting pregnant with simple, conventional methods of treatment were directly related to how young the woman was. No other factor studied was significant except for the age of the woman.

The decline in fertility as women get older is related to the aging of their eggs. You are born with all the eggs you will ever have, about two hundred thousand to four hundred thousand by the time of puberty, and every month about a thousand of them die. Thus as you get older, your eggs will decrease in both number and quality. Yet some women remain fertile into their forties, and others lose their fertility in their twenties. The table on the previous page shows you how to determine at what particular age you will lose your fertility, so that you can plan to avoid that dilemma.

As long as insurance companies require a “pathological diagnosis” in order to pay for treatment, and as long as major surgery results in no difficulty in getting insurance payment (whereas in-vitro fertilization usually is not covered), women run a good chance of having inappropriate surgery that could very well reduce rather than improve her egg supply.

The Endometriosis Myth

The most commonly overused “diagnosis” for infertility is endometriosis. Endometriosis is a condition whereby some of the lining of the uterus has leaked back into the abdominal cavity and has implanted in tiny nodules either in the abdominal wall, on the outside of the fallopian tube, or possibly in the ovary. When doctors perform a laparoscopy as part of an infertility investigation to see if the woman has a normal uterus, tubes, and ovaries, most of the time the examination is normal. Nonetheless the diagnosis of “endometriosis” is frequently inserted in the operative note simply because the insurance company is much happier to pay for laparoscopy when they see a “pathological” diagnosis, and doctors feel more comfortable that way. The euphemism that avoids outright deception is to call it “minimal lesion” endometriosis. Doctors are often so eager to find a diagnosis to determine the “cause” of infertility (not to mention the desire for patients to get insurance reimbursement) that many couples walk out of their long series of expensive infertility tests thinking incorrectly that they now know why they haven’t gotten pregnant. This might be harmless if it weren’t for the fact that it may lead to unnecessary or improper treatment, and could delay further the proper treatment. With infertility in older women, any delay caused by trying inappropriate though harmless treatments can be devastating.

The Male Factor and Varicocele Myth

There are many other popular “diagnoses” that may lead to inappropriate treatment. The doctor may
obtain a sperm count on the husband and find that it is “low.” The husband may then be put on all kinds of
totally ineffective drug treatments such as Clomid, Pergonal, human chorionic gonadotropin, or testosterone.
But worst of all, he may be given that all too common diagnosis of “varicocele.” Very few men
escape seeing a urologist for infertility without suffering through this diagnosis.

A varicocele is a varicose vein of the testicle (usually on the left side) that is present in 15 percent of all males on the planet. It is just a common, normal anatomic variant, but it has been argued that 40 percent of infertile men have varicoceles, and it is implied, therefore, that varicocele is the cause of the infertility. But most of these so-called minimal lesion varicoceles are not really varicoceles at all, and are no different from what is found in a normal, fertile male population.

The varicocele has little to do with male infertility. A careful study from Australia of 651 infertile men with varicocele was published in the British Medical Journal in 1985 demonstrating absolutely no difference in pregnancy rate among couples in which the husband had the varicocele operated on versus those who did not have the varicocele operated on. Similar studies have been repeated in Belgium, Sweden, and Germany. Furthermore, 15 percent of men who request a vasectomy (because they already have had all the children they want) are found on physical examination to have an obvious varicocele, and in my experience, that is the same as the incidence of varicocele in infertile males.

What happens to infertile couples once the diagnosis of varicocele is made in the man? Typically, the men get operated on, sometimes on one side, sometimes on both sides, and then they wait six months to see if the sperm count improves. Since sperm counts, like the weather, vary from month to month around a mean average value, it only makes sense that if you get one or two sperm counts before this unnecessary surgery, and one or two sperm counts after this unnecessary surgery, at least half of the men will appear to have some improvement. But this is just an illusion created by the variability of sperm counts, and the failure to make equal note of those whose sperm counts seem to have actually gone down after varicocelectomy. Because of the intrinsic variability of sperm counts, half of the patients will appear to have reduced counts after treatment, and half will appear to have improved counts.

Furthermore, many couples can conceive naturally in spite of the husband’s very low sperm count. Manuel and Flora were a couple from South America who were married twenty-two years earlier, when she was only seventeen years old. Four years later she became pregnant and had a wonderful little baby boy, but she was never able to become pregnant again. A sperm count performed in their local city was zero. It wasn’t until eighteen years later, when Flora was thirty-nine years old and Manuel was forty-five, that they came to see me in St. Louis, and the enigma was solved. Manuel had zero sperm on the first semen analysis; however, after performing many semen analysis over a period of time, we finally found a few rare motile sperm on just one of those occasions. Testicle biopsy revealed that almost the entire testicle was nonfunctioning, except for a tiny island of normal sperm-producing tubules. Obviously, when Flora was very young, at age twenty-one, after four years of regular intercourse, a single sperm from Manuel was finally able to fertilize one of her eggs, resulting in a baby boy. As she became older, however, Manuel’s extremely severe infertility, compounded by the naturally decreasing quality of her eggs, made this couple infertile.