A long process

Today I was informed that I forgot to post about my doctor's appointment. Well to tell the true... I was in pain so I didn't want to sit at the computer that long. I think I really like this Doctor... He is honest even if you don't like the answers.

But here is what he basically said...(from his webpage) we should identify the cause/causes of infertility. The cause/causes of infertility basically fall into four major groups and that’s it! We know a couple can have one cause, all four, or any combination of the four. They are all equally important so the area we talk about first should not be thought more important than the area we talk about last. Firstly, we know that some women have one of three types of bacteria in the reproductive tract (vagina, cervix, uterus, or fallopian tubes) which, if present, can affect fertility. These bacteria may offer no signs or symptoms. Gonorrhea can cause damage to the fallopian tubes by either blocking them or scarring them so they cannot either pick up the egg at the time of ovulation or cannot properly transport the egg down the tube to come in contact with sperm. Chlamydia can affect the fallopian tubes in a similar way and also may cause enough inflammation or irritation on the lining of the uterus (endometrium) that implantation of the embryo may be adversely affected. Mycoplasma hominus and its’ “cousin”, Ureaplasma uryliticum, have been shown to attach themselves to sperm and ride on the back of the sperm out into the fallopian tube, where fertilization takes place, and reduce the sperms’ ability to fertilize the egg. Now, if these bacteria frequently fail to cause signs or symptoms, how are we ever going to know if our patient has them? The answer is that we do cultures. A small cotton “Q-Tip” is inserted into the cervical opening, pulled out, sent to the lab and within two weeks we will know if these bacteria exist. If they do exist, we will treat both the wife and the husband with an appropriate antibiotic for ten days and then re-culture to confirm the treatment was successful. The presence of these bacteria in the reproductive tract is not an “absolute” regarding pregnancy, but may play a major part and therefore must be diagnosed and treated. The second area of the causes of infertility asks the question, “Does the husband have adequate numbers of normal, motile sperm and, just as the wife is ovulating, do they live well in the cervical secretions to pass through those secretions and get out in the fallopian tubes where fertilization takes place”? We like to do a post coital test on a day the patient is just ready to ovulate, but hasn’t yet ovulated. For example, if the cycle is 28 days, we will do the test on cycle day 12 (no matter what day of the week cycle day 12 might fall). In a 30 day cycle, we do the test on cycle day 14, etc., etc. This test is also known as the Huhner test, the Sims-Huhner test, the PC test or the PK test. We simply ask the couple to have intercourse at home, two to four hours before their appointment. Then, at the appointment, we place a speculum in the vagina, extract cervical mucus from high in the cervical canal (similar to a PAP smear), place that mucus on a glass microscope slide, and immediately look under the microscope to determine if we have adequate numbers of sperm and, are they alive and do they have good directional kinetics (move purposefully in a basic straight line). If we see this, we probably do not have a sperm or a sperm-cervical mucus problem. If we see any problems or see any significant variation in the shape of the sperm, we will order a semen analysis to be done at a laboratory. If we see very few sperm, we may have a problem with decreased numbers of sperm, or, the numbers may be adequate but the sperm may not able to get through the cervical mucus. Again, a semen analysis is helpful in sorting out the problem. At times, we may see a lot of sperm in the cervical mucus but they are either barely moving or dead. We then have a “true” sperm-cervical mucus problem. The treatment of the various conditions causing a sperm or a sperm-cervical mucus problem will not be fully addressed here but look for a complete essay on these problems in the future. Suffice it to say that many problems are treated by doing husband intra uterine inseminations (HIUI) at the time of ovulation. Many times we suggest the husband see a urologist. The third area of infertility asks the question, “Are there any structural areas that may be the cause of infertility”? Specifically, are there any intrauterine problems such as a septum, intrauterine fibroids (myomas), or intrauterine polyps which may affect the ability of the embryo to implant or may allow such a poor implantation that an early pregnancy loss will occur. Are the fallopian tubes open (patent)? A hysterosalpingogram (HSG) x-ray is the best procedure to evaluate these areas and is done as an outpatient by a radiologist. Also, the patient may have pelvic endometriosis or adhesions with or without pain or menstrual cramps and these conditions can only be diagnosed by direct visualization of the pelvis usually by doing an outpatient laparoscopy (bandaid-bellybutton surgery). The fourth, or last, area of infertility asks the question, “Are you ovulating properly”? Note that I have not asked if you are ovulating but if you are ovulating properly. What do we mean by that question? During the “menstrual month”, there are times that your body must meet certain criteria. The first of these times is on cycle day (CD) 12 based on a 28 day cycle. On CD 12 you should have developed, on one ovary or the other, a cyst that we call the follicle. In Greek, the word follicle means ‘little cyst’. This follicular cyst contains the egg of the month and the wall of this follicular cyst secretes the chemical hormone estrogen (estradiol). Estrogen, in turn, circulates throughout the body and acts on the lining of the uterus (endometrium) and causes it to grow back as it just fell off with blood a few days earlier during the period. On CD 12, if we do a vaginal ultrasound, the follicular cyst should measure at least 18 X 18 mm., the endometrium should mInsure at least 9 mm. in thickness, and the blood estradiol level should be at least 150 units (pg/ml) or higher. If the follicle is too small, the lining too thin, and the estrogen level too low, this is related to a condition called follicular immaturity. With follicular immaturity, the egg itself is immature when it is ovulated and will not fertilize well. The next segment of time your body must meet certain criteria is after you ovulate. Once you have ovulated, the follicular cyst collapses but continues to secrete estradiol and begins to secrete the second ovarian hormone, progesterone. Progesterone is responsible for changing or converting the endometrium into the type of tissue that is perfect for proper implantation when the embryo falls into the cavity of the uterus three to five days later. The blood progesterone level seven to ten days later should be 10-15 units (ng/ml). If the progesterone is too low then either the embryo will not implant or may implant so poorly that a miscarriage will occur.

Well needless to say...I'm alittle sore from exams and tired! I think his nurses can only do early appointments...and since we live an hour and half away...6:30am comes early! So, I'm sorry for not posting sooner...but I will post something when we know more...but if you have anyone that has fertility problems and would like to read more here is Doctor Cline's website! reproductivehope.com