This is the latest 3part series entitled Evaluation of the infertile couple. To read more articles by Dr. Jacobs, please visit Infertility Answers, Inc., where he writes about pregnancy loss and LaMothe br endometriosis.Sharon sperm need to meet the eggs. In nature, taking place in the female reproductive tract. In intercourse, the sperm are deposited in the cervical mucus. Remember, estrogen stimulates the production of cervical mucus secretion. The cervical mucus has a characteristic molecular structure, in which molecules are long chains that are aligned to create quot; autopistasquot; for sperm to travel through the cervix into the uterine cavity. Although the cervical mucus may resemble egg white, is very different. I have seen the recommendations of nonprofessionals that poor women with cervical mucus must put egg white into the vagina as a substitute. Do not do that! The uterine cavity in the nonpregnant state, is not really a bore. This is a potential space, giving rise to the fallopian tubes where fertilization occurs. Assuming all is normal. The sperm are in the fallopian tubes to greet an egg shortly after sex. Since we are evaluating an infertile couple, we can not assume all is normal.Obviously we need to complete this passage to be intact. There are a number of ways to evaluate the uterine cavity and fallopian tubes. The least invasive is to perform a hysterosalpingogram or HSG. The HSG is a radiographic study performed by injecting an Xray contrast dye into the uterine cavity while observing on a fluoroscope. The contrast material outlines the uterine cavity and must pass through the fallopian tubes and free spill into the pelvic cavity. Radiologists spend a small catheter with a balloon tip into the uterus and inflating the balloon. I do not like this technique. Inflating a balloon in the uterus hurts, and the balloon can hide things you have to do. Instead, use an older technique of applying a cannula, a sort of glorified straw to the opening of the cervix. Through the cannula slowly injecting the radiographic contrast and take pictures of the uterus and fallopian tubes. If the cavity is not formed normally, may increase the risk of miscarriage. The polyps, benign fleshy growths in the cavity can impair the ability of an embryo from implanting. Fibroids, benign fibrous tumors of the uterine wall may interfere with pregnancy if they are right in the endometrium (lining of the uterus). If the tubes are blocked, well, I think it's pretty obvious that prevent pregnancy. There are some other more subtle findings that radiologists often are not identified. Sometimes we kinking of the tubes. That implies that there is some scarring around the tubes, often associated with endometriosis. After the injection of radiographic contrast and take photos, I delete all the instruments, and take 1 more shot of my patient's pelvis, while she is standing. I want to see the distribution of Xray contrast material in the pelvis. If my patient has scarring of the pelvic cavity, the contrast material does not all go to form a layer on the pelvic floor. They get stuck in the pockets that can be identified as she is upright.I have covered the basic tests of the infertile couple. There is other evidence to discuss with patients. I recommend this test to my patients because I think IVF is cheap insurance. If my patient does not need IVF, I think this test provides useful information, but I am less sure about the economic value. I offer to those who do not need IVF, but did not feel justified in pushing it.Let make me provide some background on this final test. There are 4 families of adhesion molecules that enable our cells to stick together, so you do not end up as puddles on the floor. One of these families of adhesion molecules called integrins. There are 3 integrins in the endometrium regulated by progesterone, the hormone produced after ovulation. These 3 integrins come and go at different time points during the 2week interval between ovulation and menstruation follows. All 3 are present when an embryo is implanted in the endometrium about a week after ovulation. One of them is present only at that time, so use it as an indicator of endometrial receptivity How likely is an embryo and grow.There stay there are 3 things we know we can hurt the production of our integrin marker. One is the low levels of progesterone. Well, that s very simple. If you need to integrin progesterone, and progesterone is low, you probably will not have the integrin. The second thing that hurts the production of integrin is the collection of fluid in the fallopian tubes, which were severely damaged by an infection such as chlamydia or gonorrhea. The liquid in the tubes contains inflammatory proteins that impair the production of the integrin. The third thing that can interfere with the production of this integrin is endometriosis. So far, all my patients who have not done this integrin and should have had endometriosis. Since I started the treatment of endometriosis in this subgroup of patients who did our integrin, pregnancy rates of my IVF jumped 10 percentage points. That's important increase.Once evaluation of infertile couple is complete, we can begin to develop a treatment plan. Sometimes it may be necessary to address one or more intermediate issues such as trying to improve semen parameters, or the treatment of endometriosis. The only times I treat endometriosis, today, is whether my client has not been discussed integrin, or in an effort to relieve menstrual principal, which may be associated with endometriosis. Again, do not think it appropriate to begin treating a patient without knowing what I'm trying. The evaluation process can be performed on the length of a menstrual cycle, and, if done diligently, can actually save time and money.Dr. Jacobs is a reproductive endocrinologist practicing in Carrollton, Texas, a suburb north of Dallas. He completed his residency training in obstetrics and gynecology at Baylor College of Medicine in Houston, and remained at that institution to become Baylor teammate first accreditation of an advanced training program in Reproductive Endocrinology and Infertility. Dr. Jacobs has served on the faculty of several medical schools and was director of reproductive endocrinology at Texas Tech Health Science Center in Amarillo. Today, in addition to his clinical activities catering to infertile patients and those with recurrent pregnancy loss, he is chairman of IVF at Baylor Medical Center in Carrollton.Barry Jacobs, MD, M. 4323 Josey Lane, Suite # 201, Carrollton, TX 75,010 www.texasfertility.comPhone: 9723949590 Fax: 9723949597 br br
