The expectancy of pregnancy for "normal" infertile couples

Transcription

1 FERTILITY AND STERIUTY Cpight" 198 The American Fertility Sciety Vl. 0, N., December 198 Printed in U.SA. The expectancy f pregnancy fr "nrmal" infertile cuples Serge Russeau, M.D.*t Julien Lrd, M.D.:j: Yves Lepage, Ph.D. Jacques Van Campenhut, M.D.:j: Universite f Mntreal, Mntreal, Quebec, Canada The prgnsis f unexplained infertility was studied fr 7 cuples. The cumulative rate f pregnancy was %, with 81% achieving a full-term pregnancy. The type and duratin f infertility, the age f the wman, and the previus use f cntraceptives did nt significantly mdify the results. This study indicates that a cmplete investigative prtcl shuld include laparscpy. It als suggests cautin in the applicatin f untried empirical treatments t nrmal infertile cuples. Fertil Steril 0:78, 198 Cuples with n knwn cause fr their infertility after systematic investigatin are reprted t have a 0% rate f pregnancy. 1 Hwever, the literature n nrmal infertile cuples is very cnfusing, because sme authrs reprt data n cuples wh cnceive during the initial investigatin, while thers include cuples nt cmpletely investigated. The previusly reprted bad prgnsis had been determined prir t the advent f the inclusin f laparscpy in the standard infertility investigatin prtcl. Therefre, the real prgnsis fr these cuples requires reevaluatin, especially since Drake et al., in 1977, when including laparscpy in their examinatin prtcl, determined the incidence f unexplained infertility t be.% instead f 10%. In additin, it is imperative that we knw the rate f pregnancy fr nrmal infertile cuples withut treatment in rder that judicius cun- Received May 10, 198; revised and accepted July, 198. *Reprint requests: Serge Russeau, M.D., Clinique de Fertilite, Hpital Ste.Justine, 17 Cte Ste-Catherine, Mntreal, Quebec HT lc, Canada. tclinique de Fertilite, Hpital Htel-DieulSte.Justine. :f:clinique de Fertilite, Hpital Ntre-Dame. Departement de Mathematique. 78 Russeau et al. Nrmal infertile cuples seling may be prvided. Als, this infrmatin is necessary s that the temptatin t apply empirical treatment in the management f these cuples is avided. In this study, we tried t determine the expectancy f pregnancy fr ur ppulatin f nrmal infertile cuples. We als attempted t determine the influence ff actrs knwn t mdify the fertility index, such as the type and duratin f infertility, the age f the wman, and her previus use f ral cntraceptives (OCs). MATERIALS AND METHODS One thusand five hundred cuples were investigated at the Fertility Center f Hpital Ntre Dame, Mntreal, frm 1971 t We have retrspectively studied all cases f unexplained infertility amng this ppulatin after they had undergne cmplete investigatin accrding t Wrld Health Organizatin (WHO) criteria. The fllwing tests were nrmal in all these cuples: sperm analysis; pstcital test; tubal insufflatin; premenstrual endmetrial bipsy; hystersalpinggram; and laparscpy mnths after hystersalpinggram. We have excluded frm the series all subfertility cases such as thse assciated with submucus

2 Table 1. The Ppulatin Recrds Primary Secndary Ttal infertility infertility series (n = 9) (n = 8) (n = 7) Age f wmen () 7. ±.. ±. 8. ± Age f men () 9. ±.. ± ±. Duratin f infer ±. tility (m) OC use 19 1 Duratin f use ± 1.8 (m) fibrids, subvulatin, abnrmal luteal phase, cervical stensis, and grade I endmetrisis, and wmen in their fifth decade. All patients wh achieved pregnancy during the time f investigatin were als excluded. Each cuple was fllwed fr at least 1 t 7 years. Thse wh underwent prir investigatin were cntacted by phne and were asked t relate in detail infrmatin with regard t their prgress since their last visit-i.e., marital stability, any treatment they may have received frm ther physicians fr infertility, whether pregnancies ccurred and, if s, their utcme, and illnesses since the cmpletin f investigatin. POPULATION Utilizing the abve criteria, 7 f the 100 cuples (a little ver %) were selected (Table 1) wh had never received any treatment fr infertility. Thirty-nine f the 7 cuples had primary infertility, and the ther 8 cuples had secndary infertility. The mean age was 8. ± years (mean ± 1 standard deviatin) fr the wmen, wh ranged in age frm 1 t 7 years. The mean age fr the men was 9.7 ±. years, with a range varying frm t years. The mean age was 7. ±. years fr the primary infertility cuples and. ±. years fr the cuples with secndary infertility. The duratin f infertility prir t laparscpy was between and 11 mnths, with a mean f 9. ±. mnths. Twenty-ne wmen used OCs, with a mean f 1. mnths prir t laparscpy. STATISTICAL ANALYSIS Using a life-table technique, the cumulative rates f pregnancies were determined accrding t the subprgram Survival f BMDP Bimedical Cmputer prgrams, P series, 1979; and the cmparisn f the cumulative rate f pregnancy between the grups was perfrmed with the Nantel test and the Breslw test. 7 The expectancy f pregnancy was analyzed accrding t the methd f Katayama et al., and the data were analyzed n the Cyber 17 (Cntrle Data Canada Limitee, Mississauga, Ontari) at the Statistical Center f the University f Mntreal. RESULTS EXPECTANCY OF PREGNANCY FOR NORMAL INFERTILE COUPLES Twenty-seven f 7 cuples achieved at least ne pregnancy. The- verall pregnancy rate was 7.%. The cumulative cnceptin rate fr the entire ppulatin was.9% (Table ). A curve was determined fr the cumulative cnceptin rate f all patients frm the day f laparscpy within a -mnth interval (Fig. 1). The expectancy f pregnancy at the time f laparscpy was %. This fell quickly t % mnths after laparscpy, t 1% 1 mnths after laparscpy, and t 17% and 1% at 18 and mnths, respectively. N pregnancy ccurred after 0 mnths in this series (Fig. ). OUTCOME OF PREGNANCIES The ttal number f pregnancies was. Twenty-ne f 7 cuples achieved a full-term preg- Table. Cumulative Cnceptin Rates fr the "Nrmal" Infertile Cuples Nt pregnant at Cumulative pr- Time after lapa- beginninj f Pregnant during Lst t fllw-up Prprtin pregnant prtin pregrscpy interv a interval nant nw < < < < < < "Interval: mnths' duratin. Vl. 0, N., December 198 Russeau et al. Nrmal infertile cuples 79

3 cumulative rate f pregnancy 80 0 expectancy f pregnancy 0 0 Figure 1 The cnceptin rates f the ppulatin mnths nancy, and patients achieved tw full-term pregnancies. Six patients had spntaneus abrtins during the first pregnancy, tw during the secnd. Only ne infant had a fetal abnrmality, hydrcephalus, which respnded successfully t surgery at the age f mnths. The utcme f pregnancy is similar t that f the nrmal ppulatin, which is 81% nrmal full-term infants. Seven patients had secndary infertility f at least 1 year's duratin after achieving an initial successful pregnancy. CONTRIBUTING FACTORS IN ESTABLISHING THE PROGNOSIS Type f Infertility The cumulative rate f cnceptin fr all subjects was.9%, Le., % fr primary infertility cuples and 7% fr cuples with secndary infertility. Age The cumulative rate f pregnancy fr wmen 9 years ld r less versus thse 9 years ld r mre was 8.% versus 9.% (Table ) time elapsed time af. in mnth. laparscpy Figure The expectancy f pregnancy. Duratin f Infertility Befre Laparscpy The cumulative pregnancy rate fr cuples with a duratin since laparscpy f < 1 mnths was 7% versus 9% fr cuples with a duratin since laparscpy f> 1 mnths (Table ). Oral Cntraceptive Use Fr the 1 wmen wh used OCs, the cumulative pregnancy rate was 7%; and it was % fr nnusers (Table ). Althugh differences were nted fr primary and secnd infertility-ages f wmen prir t and after 9 years, and duratins f infertility induced by OCs-these differences did nt reach statistical significance, pssibly because f the sample size. DISCUSSION Based n ur ppulatin, which had undergne cmplete investigatin fr infertility, the prgnsis fr nrmal infertile cuples withut any treatment is gd and is cmparable t the best results achieved utilizing any ther frm f treatment fr infertility. In additin, we were un- Table. Cumulative Cnceptin Rates in Relatin t Maternal Age Time after lapa r08copy Nt pregnant at beginning f interval "" 0 "" 0 "" 9 ",,0 nw < < 1 < 18 < < 0 < Russeau et al. Nrmal infertile cuples

4 Table. Cumulative Cnceptin Rates in Relatin t Duratin f Infertility Befre Laparscpy Time after lapa rscpy Ntpregnantatbegllurlng f interval,.; 1 > 1,.; 1 > 1,.; 1 > 1 m rn m rn < < < < < < able t demnstrate a statistically significant cntributin fr ther factrs that have been suggested as influencing fertility rates. Hwever, ur results are in accrdance with the general view that the age f the wman and the type and duratin f infertility may have prgnstic influence. Vessey et al. 8 and Linn et al. 9 have published data suggesting that the use f OCs prir t investigatin may have sme effect n fertility. This effect appears t be irrelevant after 0 mnths f bservatin. In ur series the mean duratin f infertility was 9. mnths; s it appears nt t be a cntributry factr. Althugh the ppulatin we have studied is relatively small, it wuld nevertheless seem t us that the prgnsis fr nrmal infertile cuples is mre ptimistic when the wman is < 0 years f age, has secndary infertility with a duratin f < years, and has used OCs befre presentatin. Althugh it wuld be difficult t draw cnclusins with such small samples, perhaps multicenter studies might help t clarify the situatin. Effrts directed t the determinatin f causes f unexplained infertility are at present directed tward utilizatin f sphisticated investigatins such as culture f fastidius rganisms, immunlgic examinatin, determinatin f hrmnal prfiles, and in vitr fertilizatin f hamster eggs. Hwever, these investigatins shuld be preceded by a nrmal basic wrkup. There is n sense in perfrming immunlgic studies if the pstcital test r semen analysis is nt first perfrmed. We d nt accept the view that the bservatin f ne mtile sperm in the cervical mucus is enugh t classify a pstcital test as nrmal. Cuples with ne mtile spermatzn in a cervical mucus analysis can achieve pregnancy but cannt be classified as a nrmal infertile cuple. We d nt think that laparscpy and hysterscpy can replace a satisfactry hystersalpinggram. In ur view, the prgesterne assay des nt replace the premenstrual bipsy in the diagnsis f cervical stensis, endmetritis, r luteal phase defects. Our definitin f nrmal infertile cuples is predicated n a cmplete investigatin accrding t the WHO criteria and includes laparscpy fr all f the wmen. Recently, Lentn et al. lo published data n 9 cuples. Hwever, the cumulative rate f pregnancy was less than that which we reprt. Unfrtunately, Lentn et al. did nt use laparscpy fr all cuples. Recently, Templetn and Penney,ll wh use laparscpy, reached cnclusins similar t urs. Hwever, their higher incidence f unexplained infertility may reflect variatin in ppulatin selectin. In additin, the results f varius, ften empirical, therapies used fr these cuples shuld be evaluated with the life-table technique s that meaningful cmpari- Table. Cumulative Cnceptin Rates in Relatin t Oral Cntraceptive Use Time after laparscpy Nt pregnant at beginning f interval Users Nnusers Users Nnusers Users Nnusers m < < 1 < 18 < < 0 < Vl. 0, N., December 198 Russeau et a1. Nrmal infertile cuples 771

5 sn can be made with ther studies. The results f such studies shuld be cmpared with cumulative pregnancy rates in series f untreated cuples. The prgnsis established by us fr unexplained infertility, i.e., a % cumulative pregnancy rate withut treatment, is very satisfactry and suggests cautin in the utilizatin f varius treatments given t these cuples in an attempt t achieve fertility. Ackrwwledgment. This reprt is dedicated t the Memry f ur clleague, the late Dr. Jacques Van Campenhut. REFERENCES 1. Behrman SJ,Kistner RW: A ratinal apprach t the evaluatin f infertility. In Prgress in Infertility, Secnd editin, Edited by SJ Behrman, RW Kistner. Bstn, Little,Brwn & C., 197, p. Katayama PK, Ju KS, Manuel M, Jnes GS, Jnes HW Jr: Cmputer analysis f etilgy and pregnancy rate in cases f primary infertility. Am J Obstet Gynecl 1:1, Jnes GS, Purmand K: An evaluatin f etilgic factrs and therapy in private patients with primary infertility. Fertil Steril 1:98, 19. Drake T, Tredway D, Buchanan G, Takaki N, Daane T: Unexplained infertility: a reappraisal. Obstet Gynecl0:, Wrld Health Organizatin, Task Frce n the Diagnsis and Treatment f Infertility, Special Prgramme f Research, Develpment and Research Training inhuman Reprductin: A survey f the prevalence f varius types f infertility. Prject n. 789, 1980, P 1. Nantel N: Evaluatin f survival data and tw new rank rder statistics arising in its cnsideratin. Cancer Chemther Rep 0:1, Breslw N: A generalized Kruskal-Wallis test fr cmparing K samples subject t unequal pattern f censrship. Bimetrika 7:79, Vessey MP, Wright NH, McPhersnK, Wiggins P: Fertility after stpping different methds f cntraceptin. Br Med J 1:, Linn S, Schenbaum SC, Mnsn RR, Rsner B, Ryan KJ: Delay in cnceptin fr frmer "Pill" users. JAMA 7: 9, Lentn EA, Westn GA, Cke ID: Lng-term fllw-up f the apparently nrmal.cuple with a cmplaint finfertility. Fertil Steril 8:91, Templetn AA,. Penney GC: The incidence, characteristics, and prgnsis f patients whse infertility is unexplained. Fertil Steril 7:17, Russeau et al. Nrmal infertile cuples