Preventive Aspects of Infertility

Transcription

1 Preventive Aspects of Infertility SOPHIA J. KLEEGMAN, M.D. THE EVOLUTION of medicine places increasing emphasis on the prevention of disease. What measures can be adopted to prevent or reduce the incidence of infertility? Habits are established early in life. Therefore, inculcation of good health habits should be part of our educational program both for parents and for school children from the primary grades, since maintaining good general health, particularly in the active growing years, will protect all functions of the body, including reproduction. In order for healthful habits to become a way of life, sound attitudes towards building a healthy body should be inculcated from childhood. Teaching about the damage to health from smoking, excessive drinking, and other habits injurious to general health should be part of our educational curriculum in the schools, and of all parent education programs. These statements are so obvious that they are trite, and yet there is a wide gap between the knowledge we already have and its general application. Adequate health education is not yet sufficiently integrated even into our ahluent society. It is the medical profession which bears the major responsibility to enlarge and strengthen this program. Physicians start people off at the beginning of the two most important interpersonal relationships-the husband-wife, and the parent-child. To date most physicians are inadequately trained to offer education and counseling for family life as needed. 8, 11, 12, 24 Much illness stems from family-centered emotional problems that are seen in largest measure, and could be treated best, by the general practitioner, obstetrician-gynecologist, and pediatrician. 21,23 Medical educators are trying to meet this responsibility and are beginning to take "the leading role in initiating a national program for education of the medical profession in family life aspects of patient care."ll, 12, 20, 21 From the Department of Obstetrics and Gynecology, New York University-Bellevue Medical Center, New York, N. Y. Presented at the 22nd Annual Meeting of the American Fertility Society, Chicago, Ill., Apr. 29-May 1,

2 774 KLEEGMAN FERTILITY & STERILITY The general practitioner needs more knowledge in the management of the amenorrheas, both primary and secondary. At what age should primary amenorrhea be investigated? When is treatment too early or too long delayed? The popular use of "shots" (hormone injections) before any diagnostic measures are taken is one common error. The first step should be a comprehensive diagnostic investigation. Malnutrition, obesity, anemia, and emotional tensions are common findings in this group. Tuberculosis occasionally may be the cause of amenorrhea or anovulatory menometrorrhagia. Imperforate hymen without symptoms after the establishment of menses is rare, but at times there are no symptoms for many months of cryptomenorrhea. With primary amenorrhea, imperforate hymen should be suspected if the girl is maturely developed. Pelvic examination reveals the diagnosis easily. Examination of female infants by the obstetrician at the time of birth would reveal this occasional anomaly long before any damage could be done to the fallopian tubes by cryptomenorrhea. Just as rectal patency is demonstrated at birth by taking the rectal temperature, so the obstetrician could establish the patency of the hymen by taking the temperature once vaginally. In the newborn, the hymenal opening is too small for this to be delegated to a nurse. Sex problems such as low libido, vaginismus,26 frigidity,13 premature ejaculation, impotence,14,15 and homosexuality contribute to infertility, not necessarily per se, but because of marked reduction or even abolition of coitus. Therefore, sex education,20, 24 as is true of all education, should start in the very young years. Since parents are the first and most important teachers, an adequate program for parent education is a necessary prerequisite. A competent premarital examination 9, to, 29 as well as marriage counseling ll, 12, 23 would help not only the total marriage relationship, but also reduce and prevent these sex problems. Education for parenthood 3, 28 would reduce psychological traumas inflicted on children even in "good" homes. The results of these traumas in susceptible individuals lead to most of the endocrine dysfunction due to emotional maladjustments.16 This is particularly true of poor motherdaughter relationship as well as the emotional climate in the home concerning the role of wife and mother.19 PREVENTIVE MEASURES FOR THE WOMAN Once the woman has achieved maturity, 3 areas in which preventive measures can be applied are in illegal abortion, contraception, and surgery.

3 VOL. 17, No.6, 1966 INFERTILITY PREVENTION 775 Illegal Abortion If illegal abortion is complicated by pelvic infection, this may cause subsequent infertility. The incidence is impossible to estimate since the number of induced abortions cannot be ascertained. We do know that a spontaneous abortion is rarely complicated by sepsis. Therefore the number of infected abortions17 gives some clue to what degree this group contributes to secondary infertility. Since at the beginning of marriage, after a pregnancy, or when in poor health for any reason, the woman is under the care of a physician it is his responsibility to instruct the woman how to protect herself from an ill-advised or unwanted pregnancy. The best preventive measure for illegal abortion is a safe and effective method of contraception. 1S l Contraception A safe method of contraception does not cause nor does it contribute to infertility. As stated above, it protects fertility. However, age reduces fertility. Contraception is the most common request of the premarital couple. 9 Most of them do not know that woman's fertility decreases slowly after 30, more rapidly after 35. Concomitantly, the incidence of pelvic diseases such as endometriosis and fibroids increases. This the couple should be told. When a physician finds small fibroids or other stigmata of reduced fertility, he should dissuade the couple from postponing pregnancy. It is seldom justified to tell a woman "You cannot get pregnant," but it is appropriate to say, "In my opinion, if you want a family, you should start now." Surgery At times, ovaries are still needlessly sacrificed for relatively simple cysts which prove to be only physiological and temporary. Large benign cysts can usually be resected so that the normal portion of the ovarian tissue is conserved. If oophorectomy is indicated, a normal tube need not be sacrificed if its circulation can be maintained. Conservative surgery with the protection of future fertility should always be the goal when operating on women during the child-bearing years. When the pathologic involvement is extensive, as in severe endometriosis or large fibromyomas, retention of even a small amount of ovarian tissue, or extensive myomectomies make possible subsequent successful pregnancies. Conservation of the uninvolved part of the tube, when operating for ectopic gestation, yields about 25% intrauterine pregnancies afterwards. 1 27

4 776 KLEEGMAN FERTILITY & STERILITY Furthermore, the ovary on the involved side usually does not need to be removed. It is surprising how well a greatly shortened tube regenerates itself, so that it grows to normal length after such conservative resection. PREVENTIVE MEASURES FOR THE MAN There is still much unknown about the causes of male infertility. Vve see men whose history gives no clue to the cause of their aspermia or seriously deficient sperm. Genetics may give the answer to some of these aspermias.25 Immunization against mumps will probably be developed in time, and that will prevent the 20% incidence of orchitis which occurs if this disease is contracted after puberty. Perhaps boys should be purposefully exposed to mumps in mid-childhood. Cryptorchism requires appropriate treatment at an age early enough to protect the spermatogenic function of the testes.2. 7 In our private practice the incidence of male sterility due to cryptorchism which was not treated early enough is greater than that due to mumps, or venereal disease, or congenital anomalies of the reproductive system. Since varicoceles often reduce fertility of sperm, varicocelectomy is indicated for husbands of infertile couples who have evidence of impaired fertility, especially in view of the subsequent pregnancies which do follow, due to the demonstrable improvement of the sperm.2, 6, 22 Since this is a simple operation, it is suggested that varicoceles, especially if of appreciable size, should be resected whenever found in young men, even before marriage. Prevention of venereal disease in both sexes is an important protection of future fertility. Although the incidence of these infections is low in private practice, recently it has been rising among all levels of the population. Educational and therapeutic programs need to be carried out more vigorously. In addition, the medical profession has the major responsibility of seeing that every infection is reported to the local health department, so that it may be followed to its source. SUMMARY These are some measures which would reduce the incidence of infertility in pertinent groups: 1. Education for sex, marriage, and parenthood for all the people. In addition, physicians need additional training in marriage and family counseling. 2. Adequate resources for effective contraception-the best preventive

5 VOL. 17, No.6, 1966 INFERTILITY PREVENTION 777 measure for illegal abortions and their complications, many of which reduce or destroy fertility. 3. A voidance of surgery of the reproductive organs to "improve" fertility unless it is of unquestionable necessity-primum non nocere. This is particularly applicable in the case of small ovarian cysts which time so often proves to be physiological. 4. Conservative surgery of ovaries (cysts), tubes (ectopic gestations), and uterus (fibroids) to a degree far greater than is practiced currently. 5. A wider program of education for the prevention of venereal diseases and adequate resources for prompt treatment when they occur. 6. Early and adequate treatment for cryptorchism. 7. Varicocelectomy for all young men with large varicoceles, to prevent or to improve the impaired fertilizing capacity of sperm. 59 E. 54 St. New York, N. Y REFERENCES 1. ABRAMS, J., and F ARFL, D. M. Salpingectomy and salpingoplasty for tubal pregnancy. Survey of the literature. Obstet Gynec 24:281, AMELAR, R. D. Infertility in Men. Davis, Philadelphia, BOSSARD, J. H. S. Parent and Child. Univ. of Penn. Press, Philade~phia, BUXTON, L., and SOUTHAM, A. A critical survey of present methods of diagnosis and therapy in human infertility. Amer I Obstet Gynec 70:2, p. 741, CARTER, B. In Discussion, Buxton, L., and Southam, A.4 6. CHARNY, C. W. Effect of variococele on fertility. Fertil Steril 13:47, CHARNY, C. W., and WOLGIN, W. Cryptorchidism. Hoeber, New York, CROSS, R. G. Marriage guidance in the treatment of infertility. Int I Fertil 9:401, DICKINSON, R. L. Premarital consultation. lama 117:1687, DICKINSON, R. L. Atlas of Human Sex Anatomy. Williams & Wilkins, Baltimore, GOLDEN, J. S. Management of sexual problems by the physician. Obstet Gynec 23:471, HERNDON, C. N., and NASH, E. M. Premarriage and marriage counseling. A study of the practices of North Carolina physicians. lama 180:39.5, KLEEGMAN, S. J. Frigidity in women. Quart Rev Surg Obstet Gynec 16:243, KLEEGMAN, S. J. Infertility due to impotence. Presented at the Annual Meeting of American Society for the Study of Sterility, April KLEEGMAN, S. J. "Psychosexual Factors in Infertility." In Proceedings of the Third World Congress on Fertility and Sterility. Excerpta Med., Amsterdam, 1961, p KLEEGMAN, S. J., and KAUFMAN, S. A. In Infertility in Women. Davis, Philadelphia, 1966, Chapters 35 and KLEEGMAN, S. J. Abortion in the United States. Calderone, M. S., Ed. Hoeber, New York, 1958, pp KLEEGMAN, S. J. "Contraception and the Physician." In Manual of Contraceptive Practice. Calderone, M. S., Ed. Williams & Wilkins, Baltimore, 1964, pp

6 778 KLEEGMAN FERTILITY & STERILITY 19. KROGER, W. Evaluation of personality factors in the treatment of infertility. Fertil Steril 3:542, LIEF, H. What medical schools teach about sex. Bull Tulane Med Fac 22: 161, LOCK, F. R. The challenge of change. Obstet Gynec 24:481, MACLEOD, J. Seminal cytology in the presence of varicocele. Fertil Steril 16:735, MUDD, E. J. "Marriage Counselling Instruction in the School of Medicine Curriculum." In Marriage Counselling in Medical Practice. Nash, E. M., Jessner, L., and Abse, D. W., Eds. Univ. North Carolina Press, Chapel Hill, SANDLER, B. Sex education for medical students. Manchester Med Gaz 44:22, SCHEINFELD, A. Your Heredity and Environment. Lippincott, Philadelphia, SIMS, J. M. On vaginismus. Trans Obstet Soc (London), SKULJ, V., PAVLIC, Z., STOILJKOVIC, c., BACIC, G., and DRAZANCIC, A. Conserva tive operative treatment of tubal pregnancy. Fertil Steril1.5:634, SPOCK, B. Problems of Parents. Houghton, Boston, STONE, A., and LEVINE, L. The Premarital Consultation. Grune, New York, STURGIS, S. H., et al. The Gynecology Patient: A Psychoendocrine Study. Grune, New York, The American Fertility Society 23rd Annual Meeting, April 14-16, 1967 Shoreham Hotel, Washington, D. C. Following the official greeting by President Charles J. Collins, the Society's next Annual Meeting will be highlighted by the presentation of more than 30 scientihc papers and a number of open discussions geared to participants who may wish to "ask the experts." Also featured will be The Samuel L. Siegler Lecture, The Upjohn Lecture, The Squibb Lecture, and The Ayerst Lecture. In addition, the Annual Business Meeting will be held. The conference will close with the President's Luncheon. The Program will appear in subsequent issues of the Journal. Further information may be had by writing the Program Chairman, Dr. Anna L. Southam, The Ford Foundation, 477 Madison Ave., New York, N. Y