Case of the month May '08: Episode #2
ANTHONY and CORA are a young couple who have not been able to conceive yet. They have already had the basic workup done. The current thinking is that the problem lies not with the sperm or eggs themselves, but with their ability of the sperm and eggs to physically come together. Cora’s tubes have been damaged by endometriosis. Instead of being able to scoop up eggs easily, there is a good chance that Cora’s eggs are failing to make it into the tube.
I explained to the couple that every month when a woman ovulates, there is a random chance that the egg will make the journey successfully from the ovaries into the tubes. If the tubes are scarred, then the target is smaller. If the ovaries are stuck far away from the tubal openings, then the journey is a lot farther. If there is inflammatory endometriosis, then the journey is more perilous and there is a good chance that the egg won’t survive long enough to make it to the target. Because Cora’s tubes are scarred, the chance of the egg getting in is small and therefore, they are unlikely to get pregnant on their own.
ANTHONY: Doc, I don’t understand. If Cora’s tubes are open then why can’t her eggs get in.
Since Anthony understood football better than anatomy, I explained it this way.
Imagine you a field goal kicker in football. Typically, you are asked to kick the ball and make it through the uprights which are 18 1/2 feet apart. This can be easy or difficult, depending on the distance from the goal posts.
Now imagine that someone took the upright bars and squeezed them together so that instead of being 18 1/2 feet apart, they were now only 1 1/2 feet apart. You can see how difficult it would be to squeeze the ball through that narrow gap. This is what happens with scarred tubes. Not only that, with there being endometriosis, the egg has to travel through inflammatory areas on its way into the tube. rather than through calm air. This increases the risk that the egg will be damaged or sidetracked on its way to the target. An egg traversing a scarred, inflamed pelvis is like trying to kick a football through the swirling crosswinds of a snowstorm.
So, every month, you get one ball to kick to try and score. If you miss, you’re done for that month and have to wait to play again next month. Anthony and Cora have been trying for several years, and so far, all their attempts have missed.
One way we can help boost their chances is to do super-ovulation and IUI. This helps to increase the odds that sperm and egg will come together (shorten the distance of the kick) and it also helps to make multiple eggs per month (you get to kick more than one ball each month). In this couple’s case, we can certainly try this method, but it’s also possible that their task is so difficult that even having seven balls to kick will still result in failure after failure.
There is also another option - In Vitro Fertilization. With IVF, the rules change to greatly favor success. With IVF, we don’t have to do any kicking. Instead, we get to gather about 20 footballs, put them in a container and walk to the goalpost and then reliably pass them through the goal posts one by one.
In their case, either choice is reasonable. We could try one cycle of IUI or we could go straight to IVF. They chose to do IUI. I answered their remaining questions. Then, Cora was instructed to call with her next period.
