These days, In Vitro Fertilization (IVF) is considered by many people to be one and the same with infertility care. This belief is heavily promoted by my reproductive endocrinology colleagues who sponsor and maintain expensive IVF programs. However, nothing could be further from the truth.
The reality is, the vast majority of infertile couples do not require IVF to build their families. They are very successfully served by a reproductive endocrinologist who is fully trained in the more traditional fertility enhancing methods that do not include IVF. Less than 15% of couples, if appropriately treated with these techniques, will need to consider IVF as a family building alternative. However, if a fertility clinic sponsors an IVF program, all of their efforts are generally geared towards getting couples from the waiting room into their IVF program as quickly as possible.
As a traditionally trained reproductive endocrinologist, I focus my efforts on first establishing an accurate diagnosis for the couple’s inability to conceive. Once this is determined, I then sit down with the couple, review these findings, and discuss their therapeutic options and the potential for success. Then, based on the desires of the couple, treatment is instituted.
A full initial evaluation includes basal body temperature charting to evaluate the presence of ovulation, the timing of ovulation, and an initial evaluation of the quality of the wife’s ovulation. I perform a semen analysis for the husband to assess his fertility potential. This is later confirmed with postcoital testing, an office procedure similar to a pap test where the presence and activity of sperm at the time of ovulation in the cervical mucus of the wife is determined. The quality of the wife’s ovulatory function is also evaluated with pre-ovulatory estrogen levels (estradiol) and transvaginal ultrasound evaluation of the ovaries and uterine cavity. The physical release of an egg from the ovary is confirmed with a post ovulatory vaginal ultrasound. The quality of the luteal phase (period after ovulation and before menses) is determined by blood progesterone levels, vaginal cytology, and the gold standard, an endometrial biopsy (I personally read this slide for accuracy).
These are all office procedures which have largely been abandoned by my colleagues, resulting in their failure to diagnose ovulatory problems that are frequently the cause of a couple’s infertility. Instead, the diagnosis of “idiopathic infertility” is made and IVF treatment is recommended.
When an ovulatory problem is detected, further hormonal testing is indicated to determine if this is contributing to the ovulatory problem. If a hormonal imbalance is present, this is treated directly. If there is no associated hormonal imbalance, or if correction of the hormonal imbalance does not restore optimum ovulations, then there are numerous oral and injectable fertility medications that can be safely used to correct the ovulatory problem and result in a single fetus conception.
Along with the evaluation of the wife’s ovulations and the husband’s fertility potential evaluating the wife’s anatomic condition is also performed. This is initially done through a hysterosalpingogram, an x-ray study that I perform in the hospital radiology department. This consists of injecting a non-radioactive dye into the cervix which then passes into the uterine cavity and out through the fallopian tubes while X-rays are taken. This generally gives a very clear image of these structures and determines if the fallopian tubes are open.
Laparoscopy is reserved for situations where the entire initial evaluation, including hysterosalpingogram, is normal and the couple is not conceiving, when there is an abnormality noted on the hysterosalpingogram, when the patient previously had a laparoscopy that revealed either endometriosis or pelvic adhesions, or the couple has not conceived after correcting all other fertility problems and 4–6 good cycles have elapsed. In these circumstances, when laparoscopy is performed, significant pathology is found about 85% of the time. When I perform laparoscopy, it is always with the ability to operate extensively. This permits me to frequently correct any anatomic abnormalities that are contributing to the infertility.
With this approach to a couple’s infertility, successful pregnancies are achieved in a high percentage of cases through more natural means without ever needing to consider IVF.