Terra and Miles have infertile for three years. They have already made the big decision to seek medical help and are currently in the middle phases of the diagnostic process. So far, Miles’ semen analysis is unremarkable and we are about to learn more about Terra.
This month, she had her HSG done on day #9 of her cycle. This is sometimes referred to as a "dye test" because it consists of injecting radio-opaque dye into the uterus and taking a series of x-ray pictures to see where the dye goes. In Terra’s case, her results were normal. The dye entered her uterus and outlined a normal triangular shape. It then flowed into her tubes on both sides, eventually spilling out copiously into the pelvic cavity. Terra described mixed feelings. While it was a relief to find out that her tubes weren’t blocked and that there were no tumors in her uterus, she was disappointed that we still didn’t have an answer as to why they were not conceiving.
We turned our attention to her evaluation cycle, where we did serial ultrasounds to see exactly what was happening with her follicles. The following data describe her activity throughout her cycle.
Day 03 Both ovaries quiet.
Day 10 Right ovary: 14mm x 14 mm follicle. Left ovary 18mm x 18mm follicle.
Day 13 Right ovary: 11mm x 10 mm follicle. Left ovary 24mm x 18mm follicle. PCT done. Ovulation test positive.
Day 15 Right ovary 10mm x 10mm follicle. Left ovary nothing = ovulated!
Day 21 Progesterone level = 28 ng / ml. Very good.
I explained to Terra the information we gained from this cycle. She started out with the potential to have a rare double ovulation this month. This was entirely on her own with no Clomid and no injectable medications. The follicle on the left kept growing and successfully ovulated. The follicle on the right fizzled out. This is pretty normal. Most women will have more than one follicle start to develop, but rarely do they end up with more than one making it all the way to ovulation, at least not without help from medications.
On Day 13, I did a post-coital test. This is a fancy name for a procedure which consists of grabbing a little bit of the cervical mucus and checking it for how stringy it is. Her mucus was actually relatively thick, which is not the optimal state to be on the days prior to ovulation. I also looked at the mucus under a microscope and saw an occasional twitching sperm. Terra and Miles had gotten together, as instructed, on the evening of Day 12 and had come in on the morning of Day 13 for this test. Normally, you would expect a lot of happily motile sperm, but not in this case. So what does it all mean?
In order to answer that question we need to consider another important questions. Why do we do medical testing? The usual answer people give is that we do testing in order to see if something is abnormal. That might be what the majority of people think, but it is not the best answer. The actual best reason to do medical testing is in order to guide our decisions. This is the reason RE’s rarely do PCT’s any more. Some of the older guys still swear by it, but it makes little sense to do it. Why? Let’s consider Terra’s situation. Her PCT is poor for two reasons. One, the mucus is not optimally clear and stringy. Two, the sperm have not survived well in it. This tells us that her cervical mucus might be a contributor to their infertility. This also goes along with the fact that she had had a LEEP procedure in the past, which most likely removed some of the normal mucus-producing glands. But what if her PCT had been normal? What if the mucus was fantastically stretchy and clear and what if there were too many sperm to count busily swimming around? Then, we would have a situation called unexplained infertility where there is no obvious problem with ovulation, no obvious problem with the sperm, no obvious problem with the tubes and uterus and no obvious problem with the mucus. In these situations, there is no obvious problem with anything. Yet, the couple is not getting pregnant. One solution for this is to do insemination. But what about in Terra’s case where the mucus is clearly bad? What’s the answer? The same — insemination.
Therefore, the obvious argument is this. If a normal PCT and an abnormal PCT both result in the same recommendation, then why bother doing it? Good question. As I said earlier, I did not recommend it, but did it at Terra’s request. Bear in mind that a PCT costs next to nothing. I have to consume one microscope slide and one cover slip and it takes me an extra 10 minutes to do it. Therefore, we were more lenient about doing something that really wouldn’t change my recommendation. Had we been talking about a thousand dollar test that did not change our management, I would have argued more vocally to skip it. But for Terra, it was important, because now she felt a lot more confident about going forward with insemination.
In summary, Terra and Miles have completed a basic infertility workup. Given the normal sperm, the normal HSG and normal confirmation of ovulation, they have unexplained infertility, unless of course we wish to dwell on the matter of the abnormal PCT. In any case, the recommendation is IUI, with an expectation of about 50% chance pregnancy within three cycles. Excitedly, Terra understood that we would wait to see if this natural cycle results in a pregnancy. After all, their baby dance timing was confirmed to be perfect this month. Also, her tubes were probably the cleanest they have been in a long time due to her getting the flushing from the HSG this month.
However, two weeks later, Terra called with her period. She was not pregnant. But she was now ready to do her first (and hopefully, only) IUI cycle.
