The Boston IVF Handbook of Infertility

A Practical Guide for Practitioners Who Care for Infertile Couples, Fourth Edition

Steven Bayer

• Publisher: CRC Press
• Year: 2017
• ISBN:
  9781351241472
• Edition: 4
• Topic: Medicina
• Subtopic: Teoría, práctica y referencia médicas

Based on the gold standard procedures and protocols developed at Boston IVF, this new edition of a bestselling text continues to provide a structured approach to treating the infertile couple that can be of benefit to the gynecologist, reproductive endocrinologist, and reproductive medicine nurse alike. Both clinical and laboratory techniques are included, with material on preconception care. New to this edition are chapters on fertility care for the LGBT community, endometriosis, elective egg freezing, and effective nursing.

1Overview of Infertility

Alan S. Penzias

Significant advances have been made in the field of reproductive medicine over the past several decades. The knowledge that has been gained has provided a better understanding of the science of infertility and has resulted in the development of reproductive technologies that have greatly benefited infertile couples. However, with the introduction of these new therapies, there is a realization that infertility is not a simple medical problem, but there are legal, economic, moral, and ethical issues that must be addressed. This chapter will provide an overview of infertility and discuss its broader impact on society today.

Historical Perspective

Realizing the importance of reproduction, early scientists, philosophers, and others have ventured to gain an understanding of the human reproduction system and the disorders that alter its function. While most of our understanding of human reproduction has been gained over the past 50 years, this could not have been possible without the insight and knowledge from early investigation.

Infertility in the Bible

The earliest references to reproduction date back to antiquity with the biblical directive to “be fruitful, and multiply” [1]. In fact, those words are used three separate times in the book of Genesis [2,3]. It is no surprise therefore that fertility and procreation played a vital role in early life and beliefs. A woman was measured by her ability to bear children, and infertility was viewed as a punishment for wrongdoing, with God being the source of fertility.

Problems with infertility beset our ancestors from the start. Sarah and Abraham were unable to conceive [4]. Sarah considered the problem and asked Abraham to “go in unto my maid; it may be that I may obtain children by her” [5]. Abraham honored Sarah’s request and Hagar conceived. We can probably view this as the first recorded test of male infertility but in retrospect confirmed that the infertility resided with Sarah.

Ancient Greece

Hippocrates (460–380 BC) was one of the first authors of various medical works dealing with gynecology. Six treatises that deal with reproduction were attributed to him. The diagnosis of infertility was based on the concept of free passage or continuity of the external genitalia and the vagina with the rest of the body. In The Aphorisms of Hippocrates, he wrote “If a woman do not conceive, and wish to ascertain whether she can conceive, having wrapped her up in blankets, fumigate below, and if it appear that the scent passes through the body to the nostrils and mouth, know that of herself she is not unfruitful” [6]. In the same treatise, Hippocrates speculated on the conditions needed to foster pregnancy. “Women who have the uterus cold and dense do not conceive; and those also who have the uterus humid, do not conceive, for the semen is extinguished, and in women whose uterus is very dry, and very hot, the semen is lost from the want of food; but women whose uterus is in an intermediate state between these temperaments prove fertile” [6].

Aristotle of Stagira (384–322 BC) was one of the greatest Greek philosophers of his time and was also one of the greatest zoologists and naturalists of antiquity. Although not a physician, he discussed many issues relating to reproduction in his thesis The Generation of Animals. Aristotle gave to medicine certain fundamentals such as comparative anatomy and embryology. A common ancient method of interfering with male fertility was castration. Aristotle knew that castration makes a male infertile despite his belief that the testes are only weights holding down the spermatic passages and not the source of the seed. “For the testes are no part of the ducts but are only attached to them, as women fasten stones to the loom when weaving” [7]. He was probably misled by his observation that a recently castrated bull succeeded in impregnating a cow: “a bull mounting immediately after castration has caused conception in the cow because the ducts had not yet been drawn up” [7].

The Renaissance

Andreas Vesalius (1514–1564), a Belgian physician and anatomist, published his revolutionary book De Humani Corporis Fabrica (On the Structure of the Human Body) in 1543. Vesalius contributed to an accurate description of the entire female genital system including ligaments, tubes, and blood supply. He was the first to use the terms pelvis and decidua. He also was the first to describe the ovarian follicle.

Gabrielle Fallopio (1523–1562) of Modena was a student of Vesalius. He described the oviducts and wrote further on the morphology of the ovaries. His name has been permanently connected with the oviduct or fallopian tube. He also named the clitoris, the vagina, and the placenta.

Lazzaro Spallanzani (1729–1799), though not a physician, made enormous contributions to our understanding of fertility. In his monograph, Fecondazione Artificiale, he showed that conception was achieved as a result of contact between eggs and sperm. He succeeded in fertilizing frog eggs by placing them in the immediate contact with the secretions expressed from the testicles of the male frog. He also performed some of the first successful artificial insemination experiments on lower animals and on a dog [8].

Modern Era

J. Marion Sims (1813–1883) is considered the father of American gynecology. Among his numerous contributions, Sims played an important role in establishing the role of cervical secretions in affecting sperm survival in the genital tract. On the basis of Sims’ work, Max Huhner (1873–1947), in his 1913 book, Sterility in the Male and Female and Its Treatment, introduced the Sims–Huhner test (later termed the post-coital test).

I.C. Rubin introduced the first clinical test to determine tubal patency. Initially, he started by using a radioactive material but realized that this approach had its limitations. He then turned to tubal insufflation using oxygen in 1920. This was later changed to carbon dioxide as it was reabsorbed more easily, caused less discomfort, and avoided the danger of embolism. In the test, the insufflation is usually carried out at a gas pressure of less than 120 mm of mercury. The manometer reading decreases to 100 or less if the tubes are clear; if between 120 and 130, there is probably partial stricture; if it rises to 200 and above, it is suggestive that the tubes are obstructed [9]. This test is no longer performed as there are many more accurate tests of tubal patency available.

In 1935, Stein and Levanthal described a series of patients with amenorrhea, hirsutism, and obesity. They named the condition the Stein–Levanthal syndrome (later termed polycystic ovarian syndrome). They noted that several of these women started to menstruate after they underwent an ovarian biopsy. This led to the development of the wedge resection as a treatment for this condition which proved to be quite effective in the restoration of menstrual function. To this day, we still do not have an understanding as to why an ovarian wedge resection or the modern-day ovarian drilling procedure is effective.

1950s: The Development of the Radioimmunoassay (RIA)

In the 1950s, the RIA was developed by Solomon Aaron Berson and Rosalyn Sussman Yalow. The RIA allowed the detection and measurement of steroid and peptide hormones that are present in the serum and urine in very low concentrations. As a result of this monumental work, Yalow received the Nobel Prize in physiology in 1977. The introduction of RIA was pivotal and developed the foundation to modern-day endocrinology. The information gained helped us to understand the steroid pathways in endocrine organs and also helped with the diagnosis and characterization of endocrine disorders. The RIA also provided an impo...