ANTHONY and CORA (not their real names) came for their consultation wearing matching colors and holding hands. He was 27. She was 25. They were smiling much more enthusiastically than the average couple do on the first consultation visit, with no hint of the usual nervousness. Two things I noticed right away. They sat on the couch nestled cozily against each other, rather than with the usual spacing between them. Also, Anthony’s 220-pound frame was more than double that of Cora’s petite body.
I learned a little more about this cute couple. Anthony worked as a financial advisor and used to play high-school football back in Illinois. Cora had been a cheerleader at the same high school and currently worked as a headhunter, or as she put it, a corporate recruiter. They had been high-school sweethearts and had married shortly after graduating from the same midwest college. They had only recently moved to Southern California. For the first year of marriage, they had practiced contraception by the rhythm method. They answered no when I asked if Cora ever took birth control pills. Anthony chimed in and added that BCP’s were not allowed in their faith. I casually asked what their faith was, and he replied that they were strict Catholics. After some more pleasantries, I casually asked if they were Italian and he replied that they were Sicilian. He then asked if I was Chinese and I said I was Taiwanese. Now that the formalities where in order, we all had a good laugh and proceeded to the medical part.
After two years of infertility, they had seen their OB, who had ordered preliminary tests, done surgery and then had referred them to me. They always had a suspicion that they might have fertlility problems because Cora had undergone surgery two times already for her extremely painful periods. Once was in college and the second time was her laparoscopy two months ago. Her OB had told her that she had severe endometriosis including large chocolate cysts in both ovaries. We acknowledged this as a likely contributor to their problem, but in the interest of being thorough, we went through the customary detective process, combing through the three major suspects of SPERM problems, EGG problems and ANATOMICAL problems.
SPERM ISSUES:
Anthony had already done a semen analysis. He had never been involved in any pregnancies in his life. His calculated BMI was 28, but it may have been slightly misleading as he was heavily muscled, and he did not seem that obese. He was a regular drinker, but did not smoke.
Count: 159 million per cc.
Motility: 50%
Morphology: 100% normal (This was what the HMO lab had reported, but is unlikely to be accurate, as nobody’s sperm is 100% normal)
COMMENT: Anthony’s test is normal.
EGG ISSUES:
Cora has always had regular periods every 28 days. She had done ovulation testing in the past a few times and they all indicated that she had a surge. Her BMI is 21. I had measured her ovarian volumes and they were actually quite good. It was fortunate that all that surgery had still left her with a significant amount of healthy-looking ovarian tissue.
COMMENT: It doesn’t seem like there’s any obvious problem here, especially at such a young age.
ANATOMICAL ISSUES:
I read Cora’s most recent operative report. During the laparoscopy, a 4 cm endometrioma had been removed from her right ovary. Another 4 cm endometrioma had been removed from her left ovary. Her OB reported seeing an obliterated cul-de-sac. This meant that the normal space between the back of her uterus and the back of the pelvic cavity was filled up with a wall of scar tissue. This was not a good sign. Her tubes were reported to be edematous (swollen) and the fimbria, which are the delicate fingerlike projections at the ends of the tubes, were all but gone. When the dye was injected, a trickle of blue came out both tubes, indicating that they were patent. There were scattered areas of endometriosis throughout her pelvis, on her uterus, on her pelvic side walls, on the bladder and on the ovaries. These had been cauterized. There was no mention of her uterine cavity and apparently, no hysteroscopy had been performed. So we couldn’t be 100% sure that the uterus was normal.
COMMENT: These findings are signficant. The fact that the tubes don’t look healthy is concerning. An obliterated cul-de-sac is another bad sign. The only redeeming news was that the tubes were both open, albeit barely.
Cora reported that her painful periods were still bad, but not as excruciatingly so, as they had been prior to the second surgery. The consultation took a lot longer than expected, due to Cora’s bubbly personality and her energetic manner of speech. A typical question and answer would go something like this.
ME: Anthony, do you have anybody in your family who has given birth to children with birth defects, learning disabilities or any other genetic abnormalities?
ANTHONY: No. All pretty normal.
ME: How about your side of the family, Cora?
CORA: Birth defects? No, we have a pretty big family and I want to say that everyone who has had kids so far has had healthy ones. I’m pretty sure. Hmmm. Let me think. My older brother and his wife have 2 kids who are both healthy. The boy is really bratty, but he’s cute and very strong. I kind of play favorites and I like the girl a lot better, because everyone says she looks a lot like me. I haven’t seen them in a while because they’re up in Chicago. Let’s see, my other brother is not married yet. He’s been dating his girlfriend for a long time, but I’m really not sure when they’ll get married. My older sister just had a baby. I haven’t had a chance to see her yet, because they live in New York and she just delivered around last Christmas. Her husband’s a pilot, really nice guy, so you would think they would come visit soon with free airfare or whatever. In fact, I’m guessing they might be coming down to visit in another year or so, but if not, I’m hoping we can go see her some time, right, Anthony? She also has painful periods like me, and it took her and her husband a long time to get pregnant. Although I don’t think her periods as quite as bad as mine. And then I have two younger sisters and neither of them are married or even close to it. I think I have a cousin whose kid was born with something wrong with his lip, but they fixed it and he looks fine. I think he probably got it from the other side of the family and not from our side, because her husband’s family like to drink — A LOT. They can even outdrink Anthony’s family and that’s pretty hard to do, right, honey? Haha, I like to tease him about that. So, no, I don’t think we have any birth defects in our family.
At first, it took me some getting used to, but I’ve learned to politely cut her off when we were pressed for time. Otherwise, my staff and I enjoy her entertaining stories as long as we have time. (Right, Cora 
?)
In summary, we have a couple with 2-3 years of primary infertility. The most obvious explanation for their problem is Cora’s severe endometriosis, which has left her with damaged tubes (that are still somewhat patent) and a badly damaged pelvis with a lot of scar tissue.
How would you counsel this adorable couple regarding their options?
