fertility is the probability of conception which decreases over time
Fundamental are MFR (monthly fecundity rate ) and CPR (cumulative pregnancy rate
- MFR: is the probability of conception in one month
- CPR: is the cumulative probability of conception over the next 6 or 12 months
Since the most fertile couples will be faster pregnant, the remaining population will be progressively less fertile, i.e. a lower MFR. After 1 year of infertility, the MFR has dropped to 10%/month.
When to start a fertility investigation
- 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
The investigation for infertility
The investigation for infertility estimates the probability of conception ( MFR and CPR) by Investigating
- transport of the oocyte
- cervical function
- sperm quality
- basal body temperature; the presence of endometriosis
- HSG, laparoscopy
- Hysteroscopy, endometrial biopsy
- post-coital test
- sperm test
Always a diagnostic laparoscopy?
- During laparoscopy, endometriosis, adhesions, uterine fibroids, uterine septa, hydrosalpinx etc, can be taken care of, if the surgeon has the skills
- Without a laparoscopy, many factors as adhesions or endometriosis cannot be diagnosed
- IVF without a diagnosis results in a lower CPR
- IVF with severe endometriosis results in a frozen pelvis
- The decision to perform a diagnostic laparoscopy is caught between
- an early and systematic laparoscopy and a complete diagnosis and treatment of mechanical problems
- the risk that laparoscopy reveals a normal pelvis and was not useful
- missing a treatable mechanical problem risks to loose time exist
The problems of infertility treatment
- the infertility basics are considered less important since IVF is a solution for all
- the quality of reproductive surgery has decreased over the years
- up to the point of starting IVF without a diagnosis or without a laparoscopy
problems such as LUF eventually as a consequence of endometriosis, transport problems such as adhesions or tubal mucosal damage, implantation problems such as adenomyosis, cervical problems such as immunologic infertility and most of the male factor problems. The availability and the relatively high success rates of IVF, moreover, have led to an overuse of IVF while infertility surgery has become disregarded.
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.