Current Reviews. Sterility Investigation

Transcription

1 Current Reviews WILLIS E. BROWN, editor-in-charge Sterility Investigation BARRENNESS is a major concern of women. The importance of this biologic failure is manifest in the special social customs and laws evolved to provide for this contingency in all cultures. Advances in medicine have followed a typical pattern of exploration and analysis of the gross or symptom complexes, the establishment of a syndrome, and its fractionation into several specific entities with individual etiologies, pathologies, and therapies. Such is the case with infertility; as research and experience increased, our focus changed from the "sterile woman" to infertile marriage-to a study of the partners. The old terms, "sterile" or "sterility," were early modified by the use of such qualifying words as primary, relative, absolute, and so on, attempting to identify those women who could not conceive from those who had not but might conceive. Primary and secondary sterility have been introduced to indicate the never-gravid from those who could not conceive again. The terms "infertile" or "subfertile" have received more attention and connote a clinical state where permanent sterility has not been certified. Following the widespread use of the Sims, Huhner, and other tests to measure the role of the male in this syndrome, our concepts shifted to an infertile mating and our terminology reflected this by popularizing "infertile marriage" or "infertile couple." Finally, our studies have come to include those women and marriages where conception occurs but blighted embryos result in habitual abortion or stillbirth. While this is not strictly within the province of infertility or sterility, nevertheless the marriage is barren and the home childless. The most startling advances in medicine have come as the result of 557

2 558 CURRENT REVIEWS Fertility & Sterility special interest in some aspect of biology or its allied sciences. Thus the students of fertility have come from diverse fields bringing skills, knowledge, interest, and disciplines as they serve the common goal-reproduction. From this special interest has emerged a body of knowledge and a group of interested clinicians all dedicated to the common end, a newborn at every hearthstone. THE IMPORTANCE OF STERILITY Barrenness is an important clinical and social syndrome. The emotional turmoil imposed on such a couple is not only of great concern to the individuals but may adversely affect diverse physiologic and emotional processes and manifests itself in apparently unrelated areas of both medicine and social behavior. An example is the psychoneurotic woman who, impelled by her desire for a child, exceeds the bounds of social acceptability and filches a newborn from another's cradle. Infertility or barrenness is a distressingly common state. Sutterlin l indicates that there are approximately 3,000,000 (12 per cent) infertile couples in this country. Llewellyn-Jones 2 and Jeffcoate 3 indicate that from 8.5 to 15 per cent of marriages are infertile in England. Barlovatz/ while giving no figures, implies it is an important entity in Central Africa. Sargent 27 suggests that there are 500,000 husbands in the United States needing and desiring treatment for infertility. It would appear that infertility is increasing. Whether this represents a true increase in infertility or an increase in registration of the problem is unknown. It is perhaps pertinent to compare the 3 million infertile marriages with the 1-2 million diabetics, or 1.5 per cent; a daily average of 500,000 hospitalized patients with psychoses, and approximately 2 million psychotics in the population; or a 1.5 per cent incidence of cancer. The clinical experience of Turner 5 and others indicates that approximately 65 per cent of infertile couples suffer permanent sterility and that 35 per cent exhibit various correctable defects. It is our duty as physicians to categorize these unfortunate couples and to extend to them the full benefit of our experience and knowledge through adoption, therapeutic insemination (both homologous and donor), or the establishment of fertility-fecundity and fruitfulness. Infertility (or sterility) is not a scientific or clinical diagnosis but is a description or statement of a frustration syndrome. It is no longer accept-

3 Vol. 6, No.6, 1955 CURRENT REVIEWS 559 able to treat sterility; one must first assay the various causes. Thus infertility as a syndrome becomes qualified as "infertility due to oligospermia," "infertility due to cervical hostility," "infertility due to anovulation," and so on. The present "Current Reviews" will attempt to survey the recent literature on the diagnostic aspects of clinical infertility and to offer perspective and interpretation of those procedures necessary to effective clinical diagnosis and therapy. CLINICAL INVESTIGATION OF STERILITY While custom usually dictates that the woman is the primary patient, Wall, 9 Murphy,13 Stein,14 Hamblen,15 and others emphasize the importance of the proper orientation of both husband and wife in this effort, preferably at the preliminary survey. The importance of the biologic or reproductive unit has been emphasized by many authors and is finding its way into the titles of papers, such as "The Dual Responsibility in the Infertile Marriage"6; "Principles of Investigation of the Infertile Marriage"7; "Treatment of Sterility, Analysis of 400 Couples"8; "Analysis of Clinical Data on 500 Childless Couples"5; "The Management of Marital Sterility"9; and many others. Despite the increasing emphasis on the conjugal unit as a basis of study, the employment of the Sims or Huhner test is infrequently stressed. Only a few (Kleegman,lO Finkler,ll and Sandler12 ) of the long list of papers studied in this review emphasized this fundamental test. The importance of a careful anatomic survey of both husband and wife is pointed out by all authors. The various authors report male infertility as being important in from 10 to 40 per cent. The role of the male both in infertility and habitual abortion is described by McBurney,16 Nufiez,17 Nicoll,18 and others. The role of constitutional or functional factors is stressed by Turner 5 and Finkler.19 An analysis of these reports and others provides evidence of interest. The number of women or couples coming to these authors who have had partial or incomplete studies is of interest. Overstreet20 emphasizes the number of infertile couples who have sought medical help and received only inadequate or incomplete diagnostic studies. GrayS notes the frequency with which patients do not complete diagnostic studies for one reason or another. This problem is found in other countries, as reported by Ferreira 21 from Brazil and by Jeffcoate22 from England. It is important, therefore,

4 560 CURRENT REVIEWS Fertility & Sterility that a comprehensive plan of study be outlined to the infertile couple and their cooperation for a complete study obtained. The incidence of multiple factors has been repeatedly emphasized and the reports of Gray,S Turner/ Kleegman,lO Simard,23 and others show multiple factors varying from 40 to 80 per cent. It is therefore incumbent upon the physician to make a complete diagnostic survey to evaluate all potential impediments to fertility before undertaking therapy based on the first or obvious finding. While subsequent "Current Reviews" will consider in detail the various problems of infertility and their investigation, it seems wise to outline a simple plan of office procedure. (Details of infertility investigation have been outlined by the Research Correlating Committee of the American Society for the Study of Sterility.24) A PLAN 1. Since the wife usually presents herself, it is well to proceed with a preliminary survey of the woman including history and examination. 2. A survey conference with both husband and wife should be scheduled at the next mid-interval, to be preceded by planned coitus for a Huhner test (for details see Kleegman,lO Finkler,ll and others). At this conference proper orientation of the husband in the infertility complex is possible and his understanding usually enhances cooperation. The Huhner test not only gives valuable information but serves to bring the husband directly into the investigation of the reproductive failure. It provides a valuable clinical assay of male performance or fertility index through evidence of: a. Patency of male apparatus b. Relative appraisal of semen quality (number of spermatozoa and incidence of abnormal forms) c. Sperm survival d. Cervical and vaginal hostility A tubal patency test* should be carried out at this visit. Good results are obtained with all such explorations, and anyone of them may be used for preliminary survey. I personally employ a modified insuffiation test, reserving other technics for detailed study as indicated. 3. During the next two weeks special studies and laboratory tests (including BMR, blood count, etc.) on both partners can be completed., * Details of the special studies will be presented in subsequent "Current Reviews."

5 . ). Vol. 6, No.6, 1955 CURRENT REVIEWS The wife is asked to return for endometrial biopsy on Day of the cycle. 5. A summary conference is scheduled for both husband and wife soon thereafter for presentation of data with perspective, prognosis, further studies* needed, or a therapeutic regimen recommended. This infertility survey should not consume more than a few weeks. From such a survey the majority of factors will be discovered, and the couple will embark on a definite program of further detailed study or therapy. RESULTS Complete investigations of infertile couples have been reported on sufficient series of marriages to permit an appraisal of the results. Ferreira21 reports discouraging over-all results of 2.5 per cent, while others, notably Gray, 8 Turner, 5 and Finklerll indicate successful pregnancies in from 30 to 40 per cent of infertile couples. Of the many factors involved, age of the couple offers a significant correlation. The younger the woman the better the prognosis. It is also emphasized that the longer the duration of infertility (after two years) the poorer the prognosis. Bender25 reports that primary sterility, in which 47 per cent achieved pregnancy, offers a better prognosis than secondary, where only 34 per cent became pregnant. Similar results are reported by Rutherford.26 Simard23 and others emphasize the multiplicity of anatomic factors and indicate their approximate distribution as follows: Uterine-12 per cent; tubal-36 per cent; ovarian-19 per cent; cervical-13 per cent; and male- 7 per cent (usually 20 per cent). This is in essential agreement with others. Finally an appraisal of the profitable duration of therapy has been made by several authors. Turner5 indicates that 83 per cent of the successful pregnancies occur within the first year. This is generally confirmed by Gray,8 Bender,25 and others. Thus prolongation of therapy beyond this interval, unless new factors are identified, is usually fruitless and should be discouraged. SUMMARY Recent literature suggests that infertility is a syndrome of dual responsibility requiring complete and critical appraisal and analysis of both husband and wife. * Details of the special studies will be presented in subsequent "Current Reviews."

6 562 CURRENT REVIEWS Fertility & Sterility The etiologies of infertility are multiple, and complete study of both husband and wife is essential. A simple, logical plan followed completely will provide most of the needed data for proper diagnosis, prognosis, and therapy. The essential steps and data are: 1. Anatomical and functional examination of husband and wife. 2. Conjugal examination (Sims, Huhner tests) 3. Tubal patency 4. Ovulation (endometrial biopsy) The fertility index can be enhanced and conceptions obtained in approximately 40 per cent of infertile marriages by meticulous attention to details of diagnosis and treatment. 1. SUTTERLIN, F. W. Some aspects of human infertility. Virginia M. Month. 78:239, LLEWELLYN-JONES, D. Female fertility. Brit. M. ]. 2: 180, JEFFCOATE, T. N. A. Infertility. Brit. M. J. 2:167, BARLOVATZ, A. Sterility in Central Africa. Fertil. & Steril. 6:363, TURNER, V. H., DAVIS, C. D., ZANARTU, J., and HAMBLEN, E. C. Analysis of clinical data on 500 childless couples: Fertility results. South M. ]. 44:628, BROWN, R. C. Dual responsibility in the infertile marriage. Practitioner 169:115, SANCTUARY, J. C. T. Principles of investigation of the infertile marriage. Practitioner 169:121, GRAY, L. A. Treatment of sterility: Analysis of 400 couples. Obst. & Gynec. 4:177, WALL, R. L., JR. Management of marital sterility in general practice. North Carolina M. J. 18:294, KLEEGMAN, SOPHIA J. Diagnosis and treatment of infertility in women. M. Clin. North America 85:817, REFERENCES WILLIS E. BROWN, M.D. Little Rock, Ark. 11. FINKLER, R. S., and BECKER, S. F. Sterility: A study of diagnosis and therapy with special emphasis on endocrine factors. ]. Newark Beth Israel Hosp. 4:79, SANDLER, B. Male factor in human sterility. ]. Obst. & Gynaec. Brit. Emp. 60:67, MURPHY, D. P., and FARRIS, E. J. Some observations upon the diagnosis and treatment of sterility. S. Clin. North America 84:1711, STEIN, I. F., and COHEN, M. R. An adequate sterility investigation. S. CUn. North America 88:171, HAMBLEN, E. C. Facts for Childless Couples (rev. 4th prtg.). Springfield, Ill., Thomas, McBURNEY, R. D. The male factor in sterility and abortions. West.]. Surg. 62:295, NUNEZ, A. C. Infertility due to impaired fertility of the male. Med. espan. 30:281, (English abstract in Excerpt. Med., Sect. X 8:36, 1955.) 18. NICOLL, G. A. Management of male infertility problems. Hawaii M. J. 12:284, 1953.

7 Vol. 6, No.6, 1955 CURRENT REVIEWS FINKLER, R. S., and BECKER, S. F. Female sterility. Postgrad. Med. 14: 433, OVERSTREET, E. W. Sterility. West. J. Surg. 60:230, FERREIRA, C. DO A., BITTENCOURT, L., and MOREIRA, A. Ten-year report on the sterility outpatient department of the Institute of Gynecology of the University of Brazil. Arq. clin. ginec. 5:109, (English abstract in Am. J. Obst. & Gynec. 69: 925, 1955.) 22. JEFFCOATE, T. N. A. Management of infertility. J. Obst. & Gynaec. Brit. Emp. 61: 181, SIMARD, R. Analytical study of 220 cases of sterility. Am. J. Obst. & Cynec. 67:297, American Society for the Study of Sterility, Research Correlating Committee Evaluation of the barren marriage: Minimal procedures. Fertil. & Stern. 2: 1, BENDER, S. End-results in primary sterility. Brit. M. J. 2:409, RUTHERFORD, R. N., BANKS, A. L., and LAMBORN, H. M. One-pregnancy sterility. Am. J. Obst. & Cynec. 61 :443, SARGENT, J. W. Male infertility. Wisconsin M. J. 51 :477, FURTHER REFERENCES ABARBANEL, A. R. "Unexplained" infertility and culdoscopy: Observations in X 6:208, 1953.) (English abstract in Excerpt. Med., Sect. fifty consecutive cases. Urol. & Cutan. LARDARO, H. H. Highlights in sterility Rev. 55:339, and infertility. New York J. Med. 54: ADAM, G. S. Observations on female infertility. M. J. Australia 41: 164, LINDSTROM, W. C. A method of manage 1765, BEILLY, J. S., and GREENBERG, M. W. ment for the infertile couple. J. Oklahoma M. A. 45:244, Observations in sterility. New York J. Med. 51 :621, MACLEOD, J. Male contribution to human FARRIS, E. J. Male fertility. Brit. M. J. infertility. Ann. ostet. e ginec. 75:900, 2:1475, (Abstracted in Excerpt. Med., FRIEDMAN, L. L. Evaluation of female Sect. X 7:303, 1954.) sterility. Minnesota Med. 36:938, GERSH, 1. Role of the urologist in the problem of infertility. J. Urol. 66:450, GERSH, 1. Male infertility in marriage. Rocky Mountain M. J. 51 :521, GUTTMACHER, A. F. Fertility of man. Fertil. & Steril. 3:281, ISRAEL, S. L., and WEBER, L. L. Treatment of sterility. J. Indiana M. A. 44: 119,195l. KARLOVSKY, E. D., and THOMS, H. Clinical studies in infertility: A statistical survey. Yale J. BioI. & Med. 25:405, LAMBILLON, J., and DRUMEL, G. Sterility among the native population in Leopoldville. Bruxelles-med. 32:2282, MACLEOD, J., and GOLD, R. Z. Male factor in fertility and infertility: VII. Semen quality in relation to age and sexual activity. Fertil. & Stenl. 4: 194, MCCORMICK, C. 0., JR. Male factor in sterility. Am. J. Obst. & Cynec. 61: 1020, McDONOUGH, J. J. Diagnosis and treatment of sterility in the female. Ohio M. J. 47:336, McLANE, C. M. Recent trends in study of infertility. Ann. New York Acad. Sc. 54:864, RUBIN, 1. C. Diagnosis and treatment of sterility in the female. J. Internat. Call. Surgeons 21 :427, RUBIN, 1. C. Forty years' progress in treatment of female sterility. Am. J. Obst. & Cynec. 68:324, 1954.

8 564 CURRENT REVIEWS Fertility & Sterility SHARMAN, A. Therapeutic-experiments in female infertility. ].A.M.A. 148:603, SIMMONS, F. A. Diagnosis and treatment of the infertile couple. South. M. ]. 46:33, SWYER, C. 1.~. Outcome of pregnancy in women attending a fertility clinic. Fertil. & Steril. 4:416, THOMAS, H. H. Management of fertility problems. ]. M. A. Alabama 22:334, THOMAS, H. H. Investigation of the infertile couple. Clin. Med. 61 :701, TURNER, V. H., and DAVIS, C. D. Operative aspects of female sterility. North Carolina M. J. 12: 101, WALDER, H. J. Male sterility. Minne- 80ta Med. 36:935, WILSON, R. B. One thousand cases of infertility: Clinical review of five-year series. Fertil. & Steril. 4:292, A.uthorized Binding Arrangements have been made by FERTILITY AND STERILITY for subscribers to have their journals bound into distinctively designed books. Six issues, January-February through November-December, bound in best grade green washable buckram, imprinted with your name on cover, cost but $3.55 per volume. Bound journals serve as an immediate reference for research and information. Properly displayed, they create a psychological impact on the patient, implying the time and effort spent to keep up-to-date on the most modern techniques and treatments. Ship journals parcel post. Within thirty days after receipt, bound volumes will be shipped prepaid anywhere in the U.S.A. Send order with full remittance to Publishers' Authorized Bindery Service, 5809 West Division Street, Chicago 51, Illinois.