A practical approach to diagnosing and treating infertility by the generalist in obstetrics and gynecology

Abstract

Purpose: To present a diagnostic and treatment paradigm for infertility designed for the obstetrician gynecologist generalist. Materials and Methods: Simple methods of tubal evaluation, e.g., the hysterosalpingogram (HSG) and post-coital test to evaluate both male and cervical factor are discussed. Treating paradigms will be discussed for ovulatory disorders and luteal phase defects. The role of the OB/GYN generalist on performing surgery in the modern era will be mentioned. Results: If an HSG shows a unilateral hydrosalpinx the generalist should consider performing the unilateral salpingectomy since the advent of in vitro fertilization-embryo transfer (IVF-ET) with a de-emphasis on surgery has made the reproductive endocrinologist/infertility specialist (REI) less skillful in laparoscopic surgery. The REI rarely performs tuboplasty today. Not only does the exclusive treatment in the luteal phase with progesterone save the women money and side effects (including multiple births), but may actually improve pregnancy rates compared to the usual technique of follicle stimulating drugs plus intrauterine insemination. Conclusions: Because the generalist will not be tempted to suggest therapies, e.g., IVF-ET because this effective therapy is the best option for the financial success of the REI, but at the expense of financial depletion of the patient, there is plenty of room for generalists taking over as the first line physicians for infertility rather than just a referral service. Reproductive endocrinologists/infertility will almost invariably perform IUI each month even if not doing IVF which is also profitable to the REI, but costly in time and money to the patient. In contrast, the generalist, aimed with the knowledge that IUI does not improve pregnancy rates if the post-coital test is normal, will save the patient and/or the insurance money if the woman conceives. Obviously certain circumstances, e.g., bilateral blocked fallopian tubes or very severe oligoasthenozoospermia (but not teratozoospermia) will prompt an immediate referral to an REI.