Case of the month Mar '08: Episode #1
When Terra and Miles (not their real names) first came to me, they confessed that they were unsure if they should be pursuing fertility treatment yet. After all, they had only been trying for one year and were both healthy. Terra was 30 and had never been pregnant before in her life. Miles was 33 and had never fathered a pregnancy. They had actually known each other way back in college, but had not started dating until five years ago. They have been married for four years. Miles enjoyed his job, working for the police department in an administrative capacity, not out there in the field chasing bad guys. Terra worked in the HR department of a large company. Her job was quite stressful, but she had developed a good attitude about handling it. Terra said that her brother and his wife had been our patients and his persistent influence was the main reason why they were here. Terra gave me a quick update on how cute her new baby niece was and we started working on their case.
I started out by exploring what they meant when they said they had been trying for only one year. Hadn’t they been married for four years? “Well, yes,” Terra replied, “But in the past year, I read this book about taking charge of my fertility and I started doing cervical mucus checks, charting temperature and using ovulation sticks to time when to get together.” After further questioning, it was revealed that for their entire marriage (with the exception of the first three months), they had not used any contraception. They also reported having sex three times/week even when before they started tracking temperature. I explained to them that “trying” does not refer to actively doing things to track ones ovulation. In the true sense, “trying” refers to any time period when you are having regular sex (at least twice a week) and not using contraception. Using that as the proper definition, they had been infertile for well over three years, and that certainly was not normal.
SPERM ISSUES: Miles had no medical problems, no past surgery and led quite a healthy life. He appeared very lean and fit and rarely drank and never smoked. He was the shining example of someone healthy who was not expected to have any sperm issues. But as we all know, there is no way to absolutely guarantee normal sperm just by looking at someone. Therefore, we needed to start by doing a semen analysis. Plan: Semen analysis.
OVULATION ISSUES: Before I could ask her about her ovulation, Terra took charge and whipped out her checkbook. She did not write a check, but rather showed me the BACK of it, where there was that condensed three-year calendar. On it were circles of the first date of her period for the past 2 years. She proudly proclaimed that her periods were like clockwork and she had the evidence to back that up. She had no medical problems and was 5’ 6” and weighed 137# for an excellent BMI of 22. Her ovulation testing was consistently normal for the past year. Based on this detailed information, I told her that I was over 95% sure she was ovulating normally. We could always get a mid-luteal progesterone to check further, but as for now, I didn’t think it was a priority. Plan: No action at this time.
ANATOMICAL ISSUES: Starting from bottom to top (cervix to uterus to tubes to pelvis), Terra once had surgery on her cervix to remove some precancerous tissue. From her internet research, she already knew that something like that could compromise her cervical mucus. She said she is unsure whether she made a lot of mucus before the surgery, but she knows that she makes very little now, even right before ovulation. Further suspicion of an anatomical problem was raised when she shared that her periods were so painful that she would often leave work if the cramps got too bad. I told her that I would recommend an HSG right away to rule out a tubal problem. I shared with her my concern that she might have endometriosis. I would not be surprised if she had tubal scarring or even complete blockage. She disagreed with me at first, saying that she was more worried about a cervical mucus issue. She insisted on getting a post-coital test. Even after I explained that those tests were rarely done any more, she expressed that she really wanted one. We eventually compromised and made the plan to spend one month doing a post-coital test and an HSG. She agreed to call us on the first day of her next period (expected in a week or so) and get set up for both tests. PLAN: Natural evaluation cycle with PCT and HSG.
Terra and Miles impressed me as being a much more cheerful and optimistic couple than average. While it was still unknown what the reason or reasons were for their infertility of three years, we were soon to learn if the sperm had any issue and we were soon to learn if the tubes were blocked. An ovulation problem was lower on our list of suspects.
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