Diagnosing Common Factors of Infertility

• infertile couple-overview
  ovulatory factor
  • polycystic ovarian syndrome
  • other anovulation
  • corpus luteum dysfunction
  
  peritoneal factor
  • endometriosis
  • peritoneal adhesions
  
  tubal factor
  • tubal blockage (surgical)
  • pelvic inflammatory disease
  
  uterine factor
  • uterine scarring
  • uterine septum
  • uterine agenesis
  • unicornuate uterus
  • uterus didelphys
  
  cervical factor
  • cervical mucous dysfunction
  • cervical mucous gland absence
  • cervical stenosis
    male
    • oligospermia
    • aspermia
  • unexplained

Background

Approximately 15% of couples trying to get pregnant have difficulty conceiving. This difficulty may be due to medical conditions, birth defects, genetic problems, medications, aging, conditions present since birth, environmental problems or behavioral habits. The problem can be based either in the woman or in the man. Sometimes no cause can be found. Many times (65%) these infertility factors can be overcome and pregnancy can be achieved.

Goals

The goal in infertility diagnosis is to examine each component of the steps in becoming pregnant, from adequate sexual contact and frequency of intercourse to proper corpus luteum function and poor sperm penetration. Each link in the pregnancy chain is tested. More than one link can be weak. While the process is being tested, care is taken not to perform studies that would interfere with pregnancy during that cycle. The diagnostic process can take months because of the sequencing of tests;it may also be expensive and usually is not covered by insurance plans. All of this can take a psychological toll and should be planned for during the diagnostic work-up.

Difficulty getting pregnant

infertility- therapy

• ovulation induction
• in vitro fertilitzation
• gamete intrafaloppian transfer
  artificial insemination
  • partner
  • donor
• male-surgical
• male-medical
• intracytoplasmic sperm injection

Background

Infertility treatment has advanced in recent years and now there are some highly technical treatments available. If the ovaries don't function correctly (ovulate) there are medicines to stimulate ovulation. If the passageway from the ovary to the endometrial implantation site is blocked, eggs can be gathered from the ovary and mixed with sperm and a fertilized ovum put back into the uterus by the vaginal route so that the whole process bypasses a blocked faloppian tube. Sperm can be concentrated if the count is low or donated by someone else if there is no sperm. Eggs can also be donated if needed and both eggs and sperm and even fertilized embryos can be frozen for a later time. If for some reason the sperm doesn't penetrate the egg for fertilization, it can be injected using a microscope and micro-manipulation techniques.

All of these advanced technologies are complicated and somewhat expensive. On the other hand their development has enabled many couples to have children who would otherwise be without. It is important to look at the success rates of various institutions or physician practices who offer these services.

Goals

It is always more desireable to fix a problem permanently rather than temporarily. If physiologic problems of ovulation or sperm count can be treated or anatomical abnormalities corrected, this should be the first course of action. If these problems cannot be permanantly overcome, advanced procedures effecting fertilization outside of the uterus should be attempted. Most of these technologies have only a 20-30% chance of pregnancy success for each time they are attempted so that couples have to be prepared to undergo these attempts at least several times.

Anomalous vulvovaginal exam

• mullerian aplasia
• vaginal atresia
• atresia of the uterine cervix
• transverse vaginal septum
• imperforate hymen
• longitudinal vaginal septum
• incomplete mullerian fusion

Background

Many anatomical anomalies of a woman's genital tract are ones that developed before birth (congenital). Most of them interfere with pregnancy in some way and not all can be surgically corrected with enough success to enable getting pregnant. Often genital defects are associated with urinary tract anomalies so in the presence of one defect, others should also be looked for.

Goals

The primary goal in this category is to accurately define what anomalies are present so that if surgical correction is needed, an exact plan can be developed. Usually imaging techniques such as magnetic resonance imaging (MRI) is used. Ultrasound may be helpful but MRI seems to be more accurate. Ultimately, diagnostic surgery may be needed to define a defect precisely. Urinary tract imaging such as an intravenous pyleogram is commonly used to delineate any urinary tract associated defects.

Anomalies of bladder and urethra

Background - importance and magnitude of problem
Diagnostic goals - for overall category

• patent urachus
• urethral diverticula
• exstrophy of the bladder
• epispadias

Background

Birth defects involving the urinary tract usually are discovered as a newborn infant because they often cause urinary problems. Often, surgery to correct these problems is performed in early infancy. It is unusual to find a reproductive age woman with congenital urinary problems who has not previously been diagnosed and treated.

Goals

As with most anatomical defects, the primary goal is to precisely define the defect. This is usually done by a combination of physical exam, imaging and sometimes diagnostic surgery. Then a plan for surgical correction can be developed.

Anomalous urogenital imaging study - adult

Background - importance and magnitude of problem
Diagnostic goals - for overall category

• renal agenesis: unilateral
• renal hypoplasia
• simple renal cyst
• polycystic kidney
• ectopic kidney
• horseshoe kidney
• duplication of collecting system and ectopic ureter

Background

Often, congenital upper urinary tract anomalies are found on imaging studies performed for unrelated purposes. Some of those anomalies may be assymptomatic while others may predispose to chronic urinary tract infections or other problems.

Goals

It is important to know about upper urinary tract anomalies in the event that any surgery is required or any trauma to those areas takes place. Then the immediate goal will depend upon the exact anomaly.

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