In virtually all instances, before embarking on more intensive therapy, the physician should first complete the basic workup with the couple. The workup may reveal that infertility may be caused by a number of minor factors in both the husband and the wife, each of which alone, would not cause infertility; added together they significantly decrease the couple’s fertility potential. For example, time and energy might be wasted treating a husband with moderate oligospermia when a luteal phase deficiency in his wife has not been diagnosed and simultaneously treated.
The basic workup should uncover approximately 90% of the obvious factors involved in infertility. Often, these will lead directly to the next investigative step. For example, the absence of tubal patency by hysterosalpingogram should be followed fairly promptly by laparoscopy. The presence of anovulation indicates the need for hormonal studies, and then specific therapy for the induction of ovulation. Complete azoospermia means that a testicular biopsy should be considered.
At the same time, a number of minor factors also will be uncovered. Therapy for all of these factors should be instituted simultaneously: progesterone suppositories, when indicated, or improvement of environmental factors for the husband. It is important that physicians allow an interval of time to pass so that they can evaluate the results of correcting these minor factors.
Where only factors of minor significance, or where no factors whatsoever, have been uncovered during the basic workup, the therapist should allow time, itself, to play a beneficial role. The reassurance to the couple of their basic normality provided by the workup, in addition to the salutary effects of minor therapeutic maneuvers and the therapeutic potentialities of the tests themselves, may combine to produce the desired results. There are many patients with borderline situations who after 4 to 6 months begin to be concerned about their fertility. Rather than being reassured at this early time by the physician, they are immediately put on the temperature chart (for timing coitus) by either a physician, a nurse, or advice from a friend. The vicious cycle of infertility-emotional tension-infertility begins. It is this couple who responds well to the positive reassurance of a negative basic workup.
For this reason, the practice of admitting patients to the hospital for a 2- to 3-day crash program, including uterotubogram, D&C, culdoscopy or laparoscopy, and a complete endocrine survey, is to be condemned. There are many objections to this crash program. Endoscopy, particularly laparoscopy, is not a completely benign procedure. It involves considerable expense to the patient and can be a waste of medical energy. Each procedure carries with it the slight chance of infection, even at a subclinical level. There should be a specific indication for each procedure to justify any risk whatsoever.
A number of patients may conceive after the basic workup. Whether this is due to the workup, alone, or to the role of time combined with reassurance is an impossible question to answer.
Additional reasons for spacing the total diagnostic possibilities over a 6- to 8-month period are (1) each diagnostic maneuver may have a therapeutic benefit and (2) a sufficient number of opportunities must be allowed for the union of the egg and sperm to test the value of each test and each new therapeutic approach. During this time the physician should maintain a reassuring manner that keeps the couple’s anxiety at a minimum. If all the tests were completed within a month or two and if conception did not occur within a few short months, a couple might become frustrated and move on to another physician. If the physician involved is a capable, conscientious practitioner with special training in infertility, the patient has nothing to gain by establishing a relationship with one physician after another. A painful and distressing workup would have to be repeated with an accumulation of anxiety and frustration. Spacing the workup over a period of a year is thus not so that the physician can hold on to his patient for material benefits, although the physician will indeed benefit because more pregnancies will occur while the patients are “under his care.”
With this philosophy in mind, the following timetable for the workup is recommended: (1) one should allow a period of observation for 3 to 4 months following the basic workup of the couple with essentially negative findings; (2) if indicated, special tests as outlined in part 5 should be carried out; (3) for those with a negative basic workup at the end of 4 months a laparoscopy should be performed; if positive, infertility surgery or assistant reproductive technology will be considered.
These procedures should consume about 6 to 8 months. At the initial visit or at the end of the basic workup, it would be wise for the physician to discuss this timetable with the couple. The timetable may have to be modified, from time to time, to fit an individual couple’s needs, but this approach will allow the maximum opportunity for the cumulative effect of therapy, diagnostic tests, and time itself. Even if the result is unsuccessful, the physician and the couple have a greater chance of feeling that a thorough job has been accomplished. The couple will be emotionally more amenable to accepting the reality of childlessness or the move to adoption, whichever their choice may be.
Selections from the book: “Infertility: A Clinician’s Guide to Diagnosis and Treatment”. Edited by Melvin L. Taymor, M.D., 1990.