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Fertility - Infertility basics : fertility is a probability of conception

adhesions, infertility

Adhesion of the fibria to the wall : this causes infertility and is missed without a laparoscopy

Fundamental to understand fertility and infertility are MFR (monthly fecundity rate ) and CPR (cumulative pregnancy rate

MFR (monthly fecundity rate ): is the probability of conception in one month

CPR (cumulative pregnancy rate : is the cumulative probability of conception over the next 6 or 12 months
A normal couple in Europe will have a nearly 50% probability of conception the first month (MFR). Since the most fertile will be faster pregnant the remaining population will be less fertile, and after 1 year of infertility the MFR has dropped to 10%/month.  Yet  after 1 year of infertility still 80% of couples will get pregnant spontaneously over the following years

after 2 years of infertility the cumulative pregnancy rate drops to 50%
after 5 years of infertility : less than 20% will get pregnant spontaneously

Which investigations for infertility ?

The investigations for infertility should estimate the probability of conception expressed as MFR and CPR.  This is based upon an evaluation of the

  • ovulation
  • transport of the oocyte
  • implantation
  • cervical function
  • sperm quality
  • basal body temperature  ; presence of endometriosis
  • HSG, laparoscopy
  • Hysteroscopy , endometrial biopsy
  • post coital test
  • sperm test

Unfortunately many of the infertility basics have been forgotten since IVF is a solution to almost all forms of infertility i.e. ovulation

infertility, endometriosis, treatment, therapy

The medico-industrial complex

problems as LUF eventually as a consequence of endometriosis, transport problems as adhesions or tubal mucosal damage, implantation problems as adenomyosis, cervical problems as  immunologic infertility and most of the male factor problems. The availability and the relatively high success rates of IVF moreover have lead to an overuse of IVF while infertility surgery has become disregarded.

Do we always need a diagnostic laparoscopy ?

Ovulation stigma : LUF syndrome

A fertility exploration investigates all infertility factors. Without a laparoscopy it is impossible to know whether there are adhesions (e.g. after infection or surgery) or whether there is endometriosis.sp; The decision to perform a diagnostic laparoscopy therefore is caught between the following dilemma

an early and systematic laparoscopy has the advantage that diagnosis is complete and that eventual mechanical problems are resolved (if surgery can be done simultaneously). It however carries the risk that the laparoscopy reveals a normal pelvis and thus did to help the fertility.

adhesions, infertility

LUF : A corpus luteum without an ovulation stigma

delaying a diagnostic laparoscopy risks to loose time whenever a treatable mechanical problem exist

All decisions are based upon the knowledge that

after 1 year of infertility still 80% will get pregnant spontaneously over the following years

after 2 years of infertility the cumulative pregnancy rate drops to 50%

after 5 years : less than 20% will get pregnant spontaneously

Therefore a diagnostic laparoscopy is planned after 1 year of infertility in Belgium

Fertility surgery should be done during the diagnostic laparoscopy ?

Ideally this should be done but practically ………..

the absence of a CO2 laser : the quality of endometriosis surgery is less, and the intervention takes a longer time with more adhesions .

a ‘slow or less experienced surgeon ‘ has more adhesions because surgery takes longer and because of more surgical trauma

Surgery beyond the level mastered : causes damage (destruction of the ovary) and incomplete excision of endometriosis or unnecessary bowel resections and thus IVF.

Problems of fertility surgery

asrm22During a plenary lecture at ASRM, Prof Koninckx addressed this when he got the award of Distinguished Surgeon. He concluded that

Fertility Centres have become IVF centres with most gynecologists having only a limited surgical experience (basal level)
quality control in surgery should become mandatory (e.g. though video registration ).
He concluded with the one-liner ‘ good surgery will safe a lot of money since it will reduce the number of IVF cycles and since a surgery baby costs 5 times less than an IVF baby.

presentations - click to start presentation

Infertility Surgery Taiwan 7-7-11,

Bulgaria 15-3-11, Moscow 8-7-11

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