Fertility depends on a healthy sperm reaching a freshly laid egg and impregnating it, and the fertilized egg digging into a healthy endometrium and being maintained in a healthy state until term. By visualizing the path the sperm must follow to reach the egg, one can identify many important causes of infertility. Male fertility, however, depends on a healthy pituitary gland and testicles, and female fertility depends on a healthy ovary and pituitary.
Thus, in the man, hypopituitarism, testicular atrophy (as in mumps), vas deferens obstruction (due to gonorrhea or tuberculosis), prostatitis and other prostatic disease, hypospadias, and other abnormalities of the urethra may cause infertility. Failure of copulation may cause infertility; the causes of this disorder are discussed in the sections on frigidity and impotence (see pages 188 and 267).
In the female genital tract, the sperm may encounter antibodies, vaginitis, vaginal deformities, cervicitis, cervical carcinoma, endometritis, carcinoma of the endometrium, a retroverted uterus and other deformities, and obstruction of the tubes by a tubo-ovarian abscess or endometriosis. The ovary may not be able to develop an egg because of hypopituitarism or ovarian diseases, such as Stein–Leventhal polycystic ovaries, ovarian cysts, and tumors (especially hormone-secreting tumors of the ovary that prevent the variation in estrogen–progesterone concentration necessary during the cycle that allows maturation of the egg). There may be no ovaries present from birth (Turner syndrome), or there may be acquired ovarian failure (surgical removal or early menopause). Thyroid disorders (hyper- and hypothyroidism) are known to cause infertility. Adrenocortical tumors and hyperplasia may also cause infertility.
Approach to the Diagnosis
The workup of infertility first involves doing a sperm count on the man. If that is normal and the examination of the woman discloses no gross abnormality, a temperature chart is kept by the patient or the Spinnbarkeit test is used to determine if ovulation occurs. Thyroid function studies and serum/prolactin, FSH, LH, estradiol, and progesterone levels may all be measured if ovulation is proved not to take place. Other tests such as tubal insufflation, hysterosalpingogram, and a trial of clomiphene will be useful in selected cases. Establishing the time of ovulation and ensuring copulation at that time often solve the problem. Cauterizing a chronic cervicitis may lead to fertility. Counseling about emotional problems may be necessary.
Other Useful Tests
1. Gynecology consult
2. Sonogram (tubo-ovarian abscess)
3. Endometrial biopsy (polyps, neoplasm)
4. Laparoscopy (pelvic tumor, abscess)
5. CT scan of the brain (pituitary tumor)
6. Chromosomal analysis (Turner syndrome, etc.)
Case Presentation #57
A 23-year-old white woman and her husband have been trying to get pregnant for 2 years. Her periods are regular, but she has occasional vaginal discharge. The husband's sperm count is normal.
Question #1. Utilizing anatomy and physiology, what would be your list of possible causes of this woman's problem?
General physical and vaginal examinations are normal except for erythema and induration of the cervix.
Question #2. What is your diagnosis now?
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Indigestion |
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Infertility |
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Infertility |
