(This couple has given permission to share their story. Their names have been altered. The dialogue words are not 100% exact, but are loosely reconstructed from memory, with the intent of conveying an accurate representation of their clinical story)
I introduced myself to my patients, AIMEE and BOYD on the day of their initial consultation. All I knew about them at this point, from observing them and from briefly glancing at the blank chart was that Aimee was 33, Boyd was 35 and that they were a healthy Caucasian couple who had been infertile for three years. I listened to their story.
AIMEE: We’ve been married for five years. At first, we weren’t ready to have kids right away, so we used condoms for a while and I was on birth control for a while. That was for the first two years. Since then, for the past three years, we’ve used no protection at all, but still haven’t gotten pregnant. Two years ago, we got tired of waiting and we went to see our OB. She’s been working with us, but she finally told us to come see you.
I asked them what they expected, back three years when they first started trying. Did they expect to get pregnant pretty easily?
BOYD: Well, we’re both pretty healthy and nobody in our families has ever had problems having kids, so we didn’t expect it would be THIS hard.
AIMEE: Well, I was 30 when we started trying. I’m 33 now and just getting a little impatient. I’ve always been good about finding information on the internet and I know all about charting. (She produced a packet of color-coded charts detailing her cycles for the past two years). I knew it might not happen right away, but three years is just too long.
I agreed.
Before delving into the medical details, we spent time on some additional background information. Boyd and Aimee had met at church and had gotten married after dating for one year. Aimee was a nurse and neither loved her job nor hated it. Boyd was a high school teacher. He also coached the baseball team. Their marriage was good and their lives were not stressful at all, other than for the fertility issue, and a brief stressful time when Aimee’s grandmother recently passed away. They have a Labrador retriever and they spend a lot of time with friends, although it has gotten a little tougher, since her friends all have babies now.
As usual, I explained to them the detective process behind finding the causes of infertility – how we look at the three key areas: SPERM problems. EGG problems. ANATOMICAL problems. Because Aimee and Boyd had been working with their OB already, most of the basic workup had already been done.
SPERM ISSUES:
Boyd has a BMI of 27 and is a healthy Caucasian male. His sperm was already tested.
Count: 190 million sperm per cc
Motility: 60%
Volume: 3.6 cc
Morphology not assessed. DNA testing not done.
COMMENT: Boyd’s test is normal. In fact, it is slightly above average.
EGG ISSUES:
Aimee has had regular periods all her life every 31 days. She has consistently had positive ovulation testing. Her BMI is 25.
COMMENT: No obvious problem here.
ANATOMICAL ISSUES:
An HSG had been done two years ago. Results show a normal uterine cavity and open tubes on both sides. They had brought their films as instructed by my staff. I reviewed the films with them and agreed that everything looked good. I also learned that Aimee’s OB had performed a laparoscopy on her a year ago and found some minimal endometriosis, which was then thoroughly cauterized. The tubal dye test confirmed that both sides were patent. Everything else had looked normal. This agreed with the HSG findings. Despite the endometriosis finding, Aimee has never had painful periods.
COMMENT: It’s not clear whether the endometriosis is the problem or just a red herring. The fact that it was just "minimal" suggests that is not likely to be a major factor.
Next, I reviewed what her OB had done since then. Aimee had taken Clomid already for six months with doses ranging from 50mg to 150mg. She had ovulated each time, or at least had a surge, according to her urine testing. They had made sure to get together the night of a positive test and also the night afterwards. After six cycles, her OB told her it was time to see me.
I performed an exam and ultrasound on Aimee and found nothing remarkable. Her uterus was tipped backwards, but contrary to myth, this should have no obvious detrimental effect on fertility. Her ovaries had estimated volumes of 27cc and 20cc, which I explained to her was very good and suggestive of young healthy eggs.
In summary, we have a couple in their mid 30’s with three years of infertility. The only finding of significance is the history of endometriosis found during the laparoscopy.
OK, class.
Are there any additional tests you would want?
What treatment options would you offer?
Click here for episode 2
