What are the prospects of an infertile marriage? How long should a couple be thwarted in their attempt to initiate pregnancy before being concerned, and how long before being seriously worried? What type of specialist should be consulted and how does one locate a competent, knowledgeable doctor in the field of infertility? What tests are performed to diagnose the cause, or causes, of an infertile mating? If such and such an abnormality is found, what treatment should be tried? It is hoped that this discussion will answer these and other questions.
The Chances of an Infertile Marriage
It has been estimated that about one in ten married couples of all ages in the United States are unable to have a child. There seem to be no inherent social, economic, or racial group differences affecting the ability or inability to create a baby. Existing group differences in fertility are probably dependent upon the employment or lack of employment of contraception. Years ago it was believed that the smaller families of professional and white-collar workers compared to blue-collar workers and laborers was occupational. I assume the greater use of the brain was supposed to syphon off some mysterious fertility prowess from areas below the waist. Research has shown that couples with more money or education than average resort more frequently to measures for both limiting family size and deferment of the first pregnancy. Studies have proved that medically sanctioned methods of birth control do not cause the slightest impairment of fertility subsequent to their use. The prolonged use of contraception, however, may postpone attempts at conception beyond the age of highest fertility.
Effect of Age and Coital Frequency on Conception
Youth is the greatest ally of successful reproduction. Two studies to determine the percentage of childless unions were made of couples who used no birth control in marriage but married at different ages, one sample from the province of Quebec and the other from England and Wales. When the women married before age 20, 4 per cent remained childless; 20-24 inclusive, 6 per cent; 25-29, 10 per cent; and 30-34, 16 per cent. Other studies differently constructed show little decline in the fertility of the woman before age 30, but declining fertility thereafter.
Little attention has been paid to the relationship of a man’s age to his fertility. Perhaps because it is difficult to separate the age factor of the man from his wife’s since their ages are usually closely correlated; young men tend to marry young women and older men, older women. However, MacLeod has reported on the relationship of the husband’s age and his ability to cause his wife to conceive in six months or less. Of men less than 25 years old, 75 per cent impregnated their wives in six months or less; 25-29 inclusive, 48 per cent; 30-35, 38 per cent; 35-39, 26 per cent; and 40 and over, 23 per cent.
The only other general factor in addition to age which seems to influence fertility is frequency of intercourse. As a rule, couples having sexual intercourse four times and over per week are far more likely to achieve pregnancy in less than six months than couples practicing coitus once or less often per week. To be sure, coital frequency is probably correlated to age, so perhaps these two modifying factors of fertility are in large part one and the same.
Usual Time Required to Initiate Pregnancy
Of 5,574 couples whom we studied who achieved a pregnancy, one-third succeeded the first month and more than half within the first three months. Fifteen per cent required four to six months, 13 per cent, seven to twelve months, and 8 per cent, one to two years. More than 6 per cent of those who eventually had a baby took more than two years to begin things. The median time, or most usual time required, was about two and one-half months.
When to Seek Medical Help
I feel that young couples—those in which husband and wife are less than thirty-five—should wait a full year before consulting a physician. On the other hand, if either is above thirty-five, I believe they should see a doctor after six months of unsuccessful trying.
Whom Should One Consult?
The choice of the doctor is important. Treatment of infertility is a relatively new and complicated field, and most family doctors have not had the training to manage it. However, the family doctor can refer the problem to the specialist of his choice or a clinic. Most infertility specialists are members of The American Society For The Study Of Sterility; names of members in a specific geographic area can be obtained by writing to the Office of the Secretary, Dr. Herbert H. Thomas, 920 South 19th Street, Birmingham 5, Alabama. Then too, a first-rate local hospital, especially a teaching hospital, can refer an inquiring couple to qualified members of its staff. Furthermore, there are fertility clinics in many cities of the United States. If you are unable to locate such a clinic in your community, write for help to the Planned Parenthood Federation of America, 501 Madison Avenue, New York City 22. In the New York area, the world famous Margaret Sanger Research Bureau, 17 West 16th Street, is available for consultation.
The Physician’s Examination
The physician will first examine both partners in an infertile marriage for their general health. Sound health enhances fertility and the fertility level of a childless couple can often be improved to the point where pregnancy will occur by improving nutrition, reducing the overweight and building up the underweight, relieving anemia, changing conditions that may be causing fatigue or correcting glandular disturbances. Relieving nervous tension by a relaxing vacation or simply through the feeling of confidence engendered by a sympathetic, knowledgeable physician or clinic may work miracles for the childless.
The Medical Record
A second step is the compilation of a medical history of both husband and wife by interviews with each. Many facts may be relevant. For example, mumps in the male involving the testicles as well as the parotid glands may offer a clue. Among women, previous abdominal surgery sometimes leaves scar tissue which may create an obstacle. As mentioned earlier, gonorrhea, if not promptly treated in either sex, may create similar difficulties.
The doctor will seek to learn, ordinarily in separate talks with husband and wife, about the couple’s sex knowledge and sex habits: frequency of intercourse and if the couple can pinpoint the most fertile portion of the month in the wife’s cycle for intercourse. Does the wife find intercourse painful or unpleasant, and does she get up to douche, wash, or void immediately after relations? Then, some couples use certain kinds of lubricants, such as Vaseline, which may injure sperm cells and reduce likelihood for conception.
Tests for Husband
After gathering the pertinent historical data, the specialist proceeds with a series of tests. He usually starts by examining the sperm content of the husband’s semen—the whitish, sticky fluid ejaculated at orgasm. The specimen is collected directly into a wide-necked, dry, clean bottle or jar and the man must be very careful none is lost for the first few drops of the ejaculate contain the bulk of the sperm cells. If the first few drops are lost, a normal specimen may test as defective. It can be collected at home and taken within a few hours to the doctor’s office where it is tested to determine whether it meets certain requirements. To be normal it must be about a teaspoonful in quantity, have a sticky but not ropy consistency and there must be sixty or more million sperm cells per cubic centimeter, of which 80 per cent must show a progressive type of swimming movement in the seminal fluid. Then too, at least three-fourths of the cells must appear normal in configuration when stained and studied under the microscope.
If the first specimen tests below normal, it is likely several additional specimens will be checked. If the results are consistently deficient and still not so woefully deficient to make improvement by therapy possible, the physician may suggest treatment. His efforts include measures aimed at improving general health: better diet, physical exercise or sports, etc. If a glandular deficiency is found—for example, in the thyroid gland—corrective medication can be given. Un- fortunately, to date, the various pituitary hormone injections have proved very disappointing. Perhaps when the next edition is written, this sentence can be erased.
If sperm cells are completely absent from the semen specimen, two possibilities present themselves. Either no spermatozoa are being produced in the two testicles, or they are being produced but their egress through the penis is blocked so that they cannot appear in the ejaculate. Such blockage usually occurs in the tiny tubules of the epidymis, where the testicle joins the vas deferens, the conducting tube which conveys the sperm cells upward. A biopsy, the removal of a fragment of tissue from the testicle for microscopic study, will determine whether the absence of spermatozoa is due to failure in their formation or blockage. If sperm cells are being formed, a bypass operation around the point of blockage is successful in about one-third of the cases.
Tests for Wife
There are several requirements for fertility in the wife: normal ovulation (egg production); proper functioning of the tube for picking up the egg; unobstructed passage through the tube for the ascent of spermatozoa and descent into the uterus of the fertilized egg cell and implantation of the early conception into the lining of the uterus, specifically prepared by naturally occurring.
The occurrence of ovulation can be determined by several tests. One is the relatively simple method of taking and recording the temperature daily under standard basal conditions—called the basal body temperature, BBT. The temperature is taken each morning, immediately on awakening, before the slightest activity, and recorded throughout the month on a piece of special graph paper. The BBT is relatively low during menstruation and for a week or so thereafter. Then it rises four to six-tenths of a degree either in one jump or in steps over two or three days and remains elevated at this new level until 24 hours before the next period. Such a sustained temperature rise during the second half of the menstrual cycle is proof of ovulation. If the BBT is constantly erratic with no clear-cut relatively low temperature the first half of the cycle and high temperature the second half of the cycle, one can assume ovulation did not occur that month.
Another test for ovulation involves an endometrial biopsy in which minute pieces of the uterine lining are removed with virtually no discomfort just prior to menstrua- tion or during the first 12 hours of the flow. These fragments are studied microscopically; if ovulation has occurred that month, the tissue will show a so-called ‘secretory pattern,’ which is the body’s preparation for the reception and implantation of an egg. If ovulation does not occur the uterus omits this article of its story and characteristic secretory changes are absent.
Other tests less frequently used to detect ovulation are daily examinations of the mucus of the cervix during mid-cycle to determine if it goes through a ‘watery’ phase and daily vaginal smears, to seek for ‘cornified’ or mature cells, only observed during a month in which ovulation takes place. Still another way is to identify in the chemical laboratory the presence of the substance pregnanediol in 24-hour collections of urine.
If examination of the biopsy specimen shows a secretory lining, but of poor quality, taking progestin hormones in the latter half of the cycle is said by some authorities to increase the secretory state sufficiently to support normal implantation of the fertilized egg.
When ovulation is proved consistently absent month after month, certain hormones or a new experimental drug may be given in the attempt to induce ovulation. X-ray treatment of the ovaries and pituitary gland to stimulate ovulation has been virtually discarded. Occasionally failure to ovulate, particularly when menstruation is also absent, is associated with a thickening of the surface tissues of the ovaries and can be cured in properly selected cases by surgery.
The underactivity or overactivity of the thyroid gland may be associated with infertility, sometimes of ovarian origin. A basal-metabolism test or determination of the PBI (protein-bound iodine) can be used to assay accurately thyroid function. The patient with abnormal thyroid function can be rendered euthyroid (neither high nor low) by appropriate drugs.
Tests and Treatments for Blockage of the Tubes
If tests indicate normal ovulation, the next step is to determine whether the ovum is being blocked in the tube during its passage downward from ovary to uterus and sperm cells in their journey upward. Fallopian tubes which have no obstruction in their four- or five-inch length are termed ‘patent.’ Patency, or lack of patency, is demonstrated either by the Rubin test or hysterosalpingography.
The Rubin (named after its originator the late Dr. I. C. Rubin, my mentor several decades ago at the Mount Sinai Hospital) or insufflation test introduces the gas, carbon dioxide, into the uterus under pressure. When there is a clear passage from the uterus through the tubes into the abdominal cavity, the gas escapes freely into the relatively large and capacious abdomen from whence it is rapidly absorbed. If both tubes are closed, the gas cannot pass upward into the abdominal cavity and the pressure quickly builds up because it is being introduced into a small closed system from which it cannot escape. The physician, observing the pressure recorded on a gauge, can thus determine the absence or presence of tubal blockage of the gas. Blockage does not necessarily mean that both tubes are closed, since a temporary muscle spasm of the tubes may occur and produce in effect, a false result. The expert physician will generally make this test serveral times during various phases of the cycle before concluding that the tubes are truly sealed closed by scarring, adhesions, or some congenital defect.
Often the Rubin test itself corrects a minor blockage, perhaps by straightening out a kink, destroying minor adhesions, or dislodging a thick plug of mucus.
The name of this second test for tubal patency is derived from three Greek words meaning uterus-tube-picture. A radiopaque fluid, instead of a gas, is injected into the uterus and an X-ray picture then taken of the lowermost portion of the abdomen. If the tubes are open, the fluid flows freely out into the abdomen; if they are obstructed, the picture shows the point of blockage. Hysterosalpingography, like the Rubin test, occasionally has curative value, since the fluid injected may correct a minor tubal obstruction.
With modern X-ray equipment, the amount of radiation delivered to the target area is minimal and virtually without danger to the ovaries. The test is usually performed a day or two after the cessation of the menses, in order to avoid radiation of a newly fertilized egg or the dislodge-ment by the injected fluid of an egg in the process of implanting.
If the tubes are proved non-patent, surgical correction may be possible in cases appearing favorable for such a procedure on X-ray. Plastic surgery may release adhesions or bypass an obstructed area. Sometimes closed fimbria at the ovarian end of the tube may be teased open, or, if not, the fimbriated end can be amputated and an open tube left in its place.
Hysterosalpingography can only reveal the approximate state of closed tubes. ‘A look and see’ through a small, surgical abdominal incision or by culdoscopy will reveal the exact situation. Culdoscopy consists of inserting a periscope-like, lighted, visual apparatus through the vagina into the pelvic cavity. An operator experienced in the use of the culdoscope can usually see the pelvic organs quite perfectly in this manner. Culdoscopy is a hospital procedure, carried out under sedative drugs, but usually not under anesthesia. If findings on culdoscopy indicate the wisdom of performing an operation, it is usually not done through the culdoscope, but through an abdominal incision under anesthesia.
The P.C. Test
The initials stand for post-coital (after intercourse); the test is also frequently referred to as the Sims-Huhner after the two physicians who popularized its use. For even if normal ovulation occurs and the tubes are proved patent, pregnancy cannot result unless the husband’s sperm cells can make the four- or five-inch journey to the trysting site, the midportion of the tube, where fertilization takes place. Since conditions in the woman may prevent passage of the sperm, the physician checks this possibility. The woman comes to the doctor’s office shortly after intercourse without contraceptives. Samples of fluid from the vagina and mucus from high up in the cervix are sucked up into separate glass tubes and examined under the microscope. A live, motile state of the sperm cells in the vaginal sample is not highly significant, but they should be plentiful and actively moving in the sample of cervical mucus. Because the ability of spermatozoa to penetrate cervical mucus and enter the cervical canal varies in different phases of the menstrual cycle, ‘p.c.’ tests are usually made about two weeks before a next expected period when the mucus is at its optimum for sperm penetration. If only dead sperm cells are found in the cervical mucus on repeated tests, it is likely that the woman’s cervical secretions are hostile to sperm cells. Treatment with antibiotics and hormones may alter this unfriendly situation. The possibility that such immobilization of sperm cells may be due to a complicated immune reaction is being studied.
Then too an abnormal anatomic position of the cervix, the fact that it points too far forward or too far back, may decrease the likelihood of impregnation. Varying position during intercourse, the man on top or behind, may change a negative to a positive p.c. test. If not, some surgical procedure, such as the abdominal suspension of a markedly retroposed (tipped back) uterus may be indicated.
Surgery As Applied to Infertility In the male. 1. Very infrequently the urethra, the excretory tube leading through the penis, has an opening at the base of the penis instead of its tip (hypospadias) and therefore the semen is delivered externally. A plastic procedure corrects the ejaculatory orifice. 2. Bypassing an obstructed epidymis is sometimes surgically feasible. 3. If the testicles are retained in the abdomen, either hormonal or surgical correction must be carried out before puberty. 4. If the man has been sterilized by vasectomy (a tie or ligature placed around the vas deferens on each side and a small segment removed) the procedure can be undone surgically in about 50 per cent of the cases.
In the female. 1. Attempts to restore patency of the Fallopian tubes is successful in 50 per cent of the cases if only adhesions are responsible, but in only 10 to 20 per cent of the cases if the tubes are sealed closed from disease. 2. Surgical removal oftumors of the uterus, if they are deemed responsible for failure to conceive or repeated , yields a high success rate in cases favorable in all other respects. 3. Surgical correction of a congenitally malformed uterus. This may involve combining two small uteri, as found in the occasional patient, into a single organ, or the elimination of a partition which either completely or partially divides the uterus into two chambers. Success rate high. 4. An operation to constrict the point of union between the uppermost portion of the cervix and the lowermost portion of the uterus. It is the point where the two join. Sixty to 70 per cent of patients who have had repeated late miscarriages (18-26 weeks) are enabled by this type of surgery to carry the baby to eight or nine months. 5. If the capsule of the ovary is thickened and neither ovulation nor menstruation occurs, either peeling the ovary or splitting it and removing a central wedge of tissue and sewing the split halves together causes ovulation in most cases. 6. If the woman has been sterilized by a tube tying operation (neither uterus nor tubes removed) she has 50 per cent likelihood of having her fertility restored. 7. Suspending a uterus which is tipped back in a fixed position. Rarely indicated, success unpredictable.
It is very difficult to assess accurately the importance of mental and emotional factors in infertile matings. Of course, sometimes they are obvious. For example, if the husband is either incapable of maintaining a firm erection or ejaculating, or if conscious or subconscious factors cause the vagina to clamp closed at the time of attempted intercourse so that it is too painful for the wife to permit entry. Such difficulties with intercourse are almost never physical. Obviously, these are serious problems because they not only prevent pregnancy but also satisfactory marital relations. In such situations an experienced gynecologist should be consulted and if he feels the problem is outside his competence he may refer the couple to a psychiatrist or some physician specializing in marriage counseling.
The question how often mental and emotional factors are responsible for barrenness when sexual intercourse is normal and all tests in husband and wife are negative cannot be answered categorically. It seems to happen. Everyone who has written on infertility points out the fact that long-standing cases are cured when the husband and wife cross the threshold of a well-known specialist or a highly regarded clinic. Pregnancy often occurs even before routine tests are completed and advice given. Since pregnancy is not contagious, the only influence at work under such conditions is thought to be a reduction in tension through replacement of anxiety by confidence. The supposed association between child adoption, in cases in which all hope of having one’s own child is given up, and the prompt occurrence of pregnancy is similarly explained, reduction in tension and anxiety. Perhaps relief of psychic factors explains some cases, but the matter of coincidence or happenstance should at least share the credit.
Many physicians feel so strongly that psychic infertility is such a real entity that they refer patients to psychiatrists routinely when other forms of infertility treatment have failed.
If the wife has been found apparently fertile and her husband irremediably sterile, or if delivery or reception of the husband’s fertile appearing sperm cells is impossible through intercourse, conception may still occur through artificial insemination, called by some therapeutic insemination.
There are two types of artificial insemination: homologous, when the husband is the semen donor (A.I.H.), and heterologous, when the semen is donated by someone else (A.I.D.). A.I.H. is only performed if intercourse is impossible or if the husband’s semen is subnormal, and it is thought that giving the sperm cells a two-inch boost on their five-inch journey might accomplish fertilization. Occasionally A.I.H. is done if the mucus in the woman’s cervix seems ill suited to act as a ladder for ascending sperm cells.
Donor insemination, sometimes referred to as semi-adoption, offers advantages to actual adoption. The wife and husband have all the experiences of pregnancy and delivery. Then too, genetically the child is at least half theirs.
Very infrequently A.I.D. is performed for a reason other than substituting fertile semen for the husband’s sterile seed. This reason is genetic. For example, if the woman is Rh negative, the husband Rh positive, and the woman so highly sensitized that a live child is impossible, then by using A.I.D. from an Rh-negative donor, a normal pregnancy results. Occasionally if husband and wife each have recessive bad genes which have expressed themselves by a particular abnormality in their child, the substitution of another biological father by A.I.D. virtually eliminates the likelihood of such a defect.
Donor insemination is not morally acceptable to all and is officially condemned by the Catholic Church. Further, the legal status of a child so conceived has not been clearly defined by the courts. Some legal minds think it is legitimate; while others have doubts. Therefore donor insemination should not be undertaken without serious, mature consideration by both the couple and the doctor. It may be a splendid technique for couple ‘A’ and dangerously ill advised for couple ‘B.’
Should donor insemination be decided upon, the choice of the donor is of prime importance. Many doctors use married house officers and medical students of known, good heredity who, in addition to having normal semen, have proved their fertility by fathering their own children. Usually a donor is chosen for his similar body build and coloring to the husband. His blood Rh must also be in agreement with the recipient.
To forestall any possible emotional complications the donor and recipient must never know each other’s identity. This must be known only by the physician.
The physician selects the most fertile day or days of the cycle for the insemination on the basis of the woman’s menstrual history, BBT chart, etc. The donor ejaculates the semen specimen directly into a bottle and the physician either calls for it, or it is delivered to his office. Within an hour, the recipient comes to the doctor’s office and by means of a glass syringe and metal cannula, the donated semen is deposited within and around the cervix, the mouth of the womb. From one to three inseminations are carried out in one month depending on the doctor’s and the patient’s preference. The greater the number of inseminations per month, the higher the likelihood for success. About 80 per cent of recipient women become pregnant, as with normal sex relations usually within the first three months.
The semen is bought from the donor for $15.00 to $25.00 a specimen, depending on the fee standard for the community.
A Message to the Infertile
If you are one of those luckless couples unsuccessfully trying to have a baby for a year or longer, what are your chances? A decade or two ago, I would have said that if you seek expert medical counsel and help, your chance of having your baby is 25 per cent. Today I can say at least 33 per cent and more likely 40 per cent. Perhaps a decade hence the chances will rise to 50 per cent.
Above all do not feel guilty or blame your mate if the news is bad and one of you is irremediably sterile. This is the way the dice fall. It’s luck, just bad luck, not faulty management. Face up to your fate, and either adopt a child or remake your life and your point of view so that the two of you can live happily and fully without one. You have things in life—perhaps the love and respect you and your mate feel for each other—that other couples, though blessed with children, may lack.