Going Beyond the Basic Fertility Tests
by Thomas Vaughn, MD
When a couple has had normal results for the basic fertility testing (as outlined so eloquently by Dr. Natalie Burger in the previous newsletter), the couple will need to make a decision as to whether to complete the diagnostic evaluation with a laparoscopy or proceed to one of the treatments for unexplained infertility. The three treatments for unexplained infertility include: clomiphene/intrauterine insemination (IUI), injectable medication (Gonal-F or Follistim)/IUI, and in vitro fertilization(IVF). Remember - even though a reason may not have been determined for the cause of the infertility, this does not mean that there aren’t treatments available that are quite successful.
Dr. Burger noted that there are four basic tests that are performed to evaluate a couple. These tests include: a semen analysis from the male partner, a physical examination and pelvic sonogram, a hysterosalpingogram and some laboratory (blood) studies to evaluate ovarian function. If these are normal, or something may have been discovered, corrected, and conception has still not happened, the couple is considered to have unexplained infertility. The next step is to consider a diagnostic laparoscopy or to proceed with the available treatments outlined above.
In the 1970s, there were two clinical studies where physicians offered laparoscopies to couples who had completed the basic testing and were considered to have unexplained infertility. These women had no symptoms other than that they were sexually active and unable to conceive. They had not reported any excessive pain, history of recurrent pelvic infections, or history of having had pelvic surgery in the past. In both clinical studies, 40% of the women were found to have something abnormal. In the group of women who had abnormal findings at laparoscopy, 2/3 of these women had endometriosis, 1/3 had adhesions, and some women had a combination of each.
Because of these studies, laparoscopy became a routine diagnostic procedure for evaluating couples with infertility. This was really important in the 1970s and early 1980s because there were no other diagnostic tests or treatments available for this group. Patients were simply told that if they did not become pregnant over the subsequent three to six months following their laparoscopy, they needed to consider adoption. As a consequence, this procedure became quite popular. With the advent of superovulation/IUI and IVF, treatments did evolve that could significantly improve the chances of becoming pregnant in couples who otherwise had unexplained infertility.
A laparoscopy is a minor surgical procedure performed in an outpatient surgical unit while the patient is under a general anesthetic. A small incision is made just below the belly button for a camera to visualize the pelvic cavity. One or two additional incisions are made in the pubic hair area so that the ovaries and uterus can be moved around while they are being visualized. This ensures that all areas have been thoroughly investigated for signs of endometriosis and/or adhesions. These incisions are usually closed with an absorbable suture that dissolves and thus do not require being removed at a later date. Patients typically leave the after a few hours. Patients should take off from work the following day to fully recover from the anesthetic and surgical procedure. Usually patients are ready to resume treatment in the following cycle.
One of the most important things about undergoing a laparoscopy is to realize that it is best to have a physician who is trained to not only perform the procedure and make the diagnosis, but also to be able to correct the problem that has been found. Most of the cases of endometriosis and/or adhesions can be corrected with a laser at the time of the diagnostic procedure.
When a patient is trying to decide whether to undergo a laparoscopy or move to one of the treatments for unexplained infertility, there are several important considerations. Some patients might prefer to undergo the initial treatment with clomiphene/IUI, “gambling” that they are normal inside and hoping that they become pregnant before needing to consider a laparoscopy. If couples do not conceive, they may undergo a laparoscopy at a later date. On the other hand, some patients may feel that they do not want to undergo treatment until they have been completely evaluated and thus choose to undergo a laparoscopy first. Some patients are influenced by their insurance coverage. It is not uncommon for patients to have insurance coverage for diagnosis of their infertility, but not have coverage for treatment. These patients may choose to undergo the diagnostic laparoscopy first to be sure that everything has been evaluated prior to undergoing treatment.
When a couple with unexplained infertility has come to this decision in their evaluation for infertility, it is a good idea to make an appointment to visit with your physician to discuss the pros and cons of all options for your particular case.
Going Beyond the Basic Fertility Tests