Gabriela and Ross (they asked me not to use their real names) came in to see me for help in conceiving. They had discovered me quite randomly, having been referred by Gabriela’s co-worker’s brother’s wife, who had been our patient and who had successfully given birth to twins conceived by IVF. Gabriela was 36-years-old and described her work managing a business as being very stressful. Ross, who was 41, described his engineering job as being laid-back and interesting. The two of them got married a little over a year ago, after having met at a relative’s wedding one year before that. They described their lives as being secure and happy, other than for their being childless still. They never used any contraception after their marriage and while they didn’t predict for themselves to get pregnant instantly, because of their age, they didn’t really expect that they would still be childless a year later. They were resigned to keep patiently trying on their own, until fate intervened and Gabriela struck up a conversation with her coworker who was happily sharing the story of his brother’s newborn twin baby girls. Gabriela says she took it as a sign and had excitedly gone home that day and told Ross they were going to go see a fertility doctor ASAP.
INITIAL CONSULTATION: They came together for their first visit. After getting acquainted, we got to work gathering clues to help solve their problem. I began, as I usually do, by tackling the three primary areas where fertility problems could lurk – the husband’s genetic contribution (the sperm), the wife’s genetic contribution (the eggs) and the playing field where the two meet (the wife’s cervix, uterus, Fallopian tubes and pelvic cavity).
SPERM ISSUES: Ross had never been involved in any pregnancies in his life. This was not a surprise, as this was his first marriage and he had not had any situations in his past where he could have fathered a pregnancy. He was healthy, other than for having a BMI of 29, which he described as being typical of how heavy he had been for the past 10 years. There was nothing new or different lately with regards to his level of health. The couple described having sex once to twice a week. The sex was not painful nor difficult in any way. In the past few months, they had started charting Gabriela’s temperature and using ovulation kits to help with the timing. He was not on any medications. I told them it was good news that they didn’t have any risk factors for sperm problems. However, the next step would still be to check a semen analysis. They were reminded that any perfectly healthy male without any past record of having gotten anyone pregnant could still have a surprisingly bad semen analysis. The only way to know is to test. PLAN: Semen Analysis.
OVULATION ISSUES: The next question to address was Gabriela’s ovulation status. She reported that all her adult life, she had regular periods that came every 28-32 days. There were three months in which she did ovulation kit testing. It showed positive each time. She answered no when asked if she ever noticed milk coming from her breasts. (This would be a warning sign for elevated prolactin hormone, another contributor to infertility). She reported a normal energy level and no symptoms that would be suspicious for an underactive thyroid, except for one. She reported gaining 20 pounds in the past three years. When questioned further, she expressed frustration and puzzlement about her weight. She was not eating any differently than when she was younger. She had not been more physically active in the past than she is now. So she was especially perplexed about the weight gain. I asked her if she had any diabetes in her family and she replied that her mother had been diagnosed with diabetes at age 40 and her sister had had diabetes of pregnancy. I told her that she does not fit the classic description of PCOS, because she is having regular periods and having positive ovulation testing. However, there are many clues that point to her having the insulin resistance component of PCOS so I told her we would do some testing. PLAN: Check thyroid status. Check for insulin resistance.
ANATOMICAL ISSUES: On ultrasound exam, she had a normal uterus. It was not unusually large, nor were there any fibroids seen. The uterine lining was seen very clearly. Her ovaries were interesting in that they had a classic PCOS appearance, with many strings of cysts around the periphery. I told her that at some point, we might have to check if her tubes are clear, but since we have some easier things to address first, that we would put off the testing (with an HSG) for now. The plan might be different had she had any high risk factors for tubal problems, such as extremely painful periods, previous pelvic infection or previous pelvic surgery, but without those, given the rest of her situation, an HSG was not the first priority at this time. PLAN: Nothing at present.
So, to summarize at this point, we have a nice couple with no past pregnancy at all for either partner, who have been having regular unprotected sex for over a year, but yet, remain infertile. We explored the three basic areas of fertility problems and came up with a plan for further testing on two of them, while postponing any action on the third. The couple will have the proper tests and come back to discuss the results afterwards.
