INFERTILITY
Management of the Couple

Infertility is frequently the result of a combination of subfertility in both partners of the couple rather than sterility of either the male or the female. It is clear that an interaction occurs between the fertility potentials of the two partners which determines the fertility potential of the couple. This concept leads to an appreciation of the fact that improvement of the fertility potential of either partner of an infertile couple will result in an increased chance of pregnancy. Thus, male and female infertility should not be evaluated or treated separately. Both the male and female partner of the infertile couple should be seen and evaluated by a physician or by a team of physicians simultaneously. This is the couple approach to management of infertility practiced by TIRME.

In addition to an appropriate team of doctors, management of infertility requires that the team have in-house access to various sophisticated laboratory and specialized diagnostic procedures, particularly when ART is utilized and in-vitro fertilization (IVF), Gamete Intrafallopian Transfer (GIFT) or Zygote Intrafallopian Transfer (ZIFT) are involved. These include hormonal determinations, ultrasonography, procedures like sperm storage, sperm preparation for insemination, availability of donor semen when required. Many of these facilities must be available daily (including weekends and holidays).

In some cases of infertility, surgical intervention is required (for example: laparoscopy, laser surgery, microsurgery, etc.). For this purpose, TIRME collaborates with highly trained gynecologic surgeons and male reproductive system surgeons to provide all necessary surgical needs to its patients.

Management of Infertility

In order to properly understand the various procedures carried out for diagnosis of problems leading to infertility, one has to appreciate what is required for pregnancy to occur:

1. Fertile semen must be placed in the appropriate location of the female reproductive tract at the appropriate time of the menstrual cycle.

2. The spermatozoa must be able to penetrate and survive in the female’s ovulatory cervical mucus.

3. The female must be able to mature and release a healthy egg.

4. The pelvic structures must be sufficiently free of disease to allow the released egg to be picked up by a fallopian tube.

5. The fallopian tubes must be patent and healthy to allow sperm transport to occur to effect fertilization as well as to transport the fertilized egg to the uterus.

6. The uterine lining must be appropriately prepared by female hormones to permit attachment of the embryo to the uterine wall, and the uterus must be healthy to allow the pregnancy to progress.

Specific Steps in Management of an Infertile Couple:

The Initial Visit

The initial visit is frequently the most important step in the evaluation. At this time the physician meets the couple, obtains a medical history from both, examines past records and test results, performs complete physical examinations on both partners of the couple, and designs a diagnostic plan for both. The laboratory evaluation of the male is limited to the assessment of his ability to produce sperm unless the history or physical examination discloses information which may suggest more complete evaluation. In the female, appropriate laboratory studies are selected depending on history and physical examination, and a program is designed to evaluate ovulatory activity. If there is a suspicion of a tubal problem, evaluation of tubal integrity is scheduled.

Diagnostic Evaluation

On the average, two menstrual cycles (approximately two months) are utilized to investigate the ovulatory process. In addition to appropriate laboratory tests the basal body temperature chart is obtained for evaluation of the ovulatory function. During this time the evaluation of the male is completed and, when indicated, an evaluation of the uterus and fallopian tubes carried out. The ability of the sperm to penetrate and survive in the wife’s cervical mucus is also determined during this time.

Establishment of the Diagnosis

After the two cycles of evaluation, a working diagnosis is usually established. During a conference with the couple, details of the diagnostic findings are discussed and a plan for therapy is outlined. If the results of the diagnostic evaluation suggest the need of some form of surgical intervention, be it diagnostic or therapeutic, the latter is also discussed and an appropriate surgeon selected.

Treatment

The form of therapy depends entirely on the findings obtained during the diagnostic evaluation. The progress of treatment is carefully monitored by appropriate testing; changes in treatment are made as indicated. Assisted Reproductive Technology (ART) is utilized where necessary.

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