Q:We are facing the prospect of having to undergo investigations in an attempt to determine the cause of our infertility. We have been trying to have a baby for almost three years. Tests done have shown that I appear to be ovulating regularly with
It has been advised by one gynecologist at Western Isles Hospital that my husband see a urologist with a specialist knowledge of fertility problems. The urologist he is advised to see would in fact be connected to the assisted conception clinic, where we could eventually be referred should we choose to embark on assisted conception treatment, such as in vitro fertilization.
Although it was not actually advised that I should have any investigations done at this stage, as my medical history does not indicate any possible damage to tubes or ovaries though infection, I have voiced some concern that there might be a problem which is remaining undetected, as to date I have not had any form of physical examination by a gynecologist. The psychological pressures of infertility are taking their toll on both of us and I sometimes think that just getting something done would seem beneficial.
I have been put on the waiting list for a laparoscopy at Western Isles Hospital, and I am told that I will be seen very soon. Before actually going ahead with the laparoscopy my husband and I have arranged an appointment to meet the senior gynecologist at the hospital to discuss things a bit more fully.
I am apprehensive and extremely anxious about what will be involved and I am concerned as to whether I will be putting myself through something which is not absolutely necessary. My GP, for example, is all for me having the laparoscopy and doesn't seem so interested in my husband's lower than normal sperm count.
Is laparoscopy the best method of checking tubal patency? I have read briefly about hysterosalpingogram, involving dye and x-rays, and gas insufflation. Would ultrasound show anything? Would any of these methods be safer or preferable for any other reason? I am particularly concerned about any risk of damage to my fallopian tubes or ovaries by the tests themselves, through, say, infection, and also risks from general anesthesia.
Finally, can anyone suggest anything that could be done in the meantime to try to raise my husband's sperm count? M M, Western Isles......
A:Most doctors helping a couple investigate infertility are quick to rush into piecemeal investigations, without a systematic overview to determine where the problem lies. Mystifyingly, they also tend to automatically look to the woman as the source of the couple's infertility, even when a man demonstrates a low sperm count.
Because conventional medicine has so little understanding of the cause of infertility, they tend to hand out fertility drugs indiscriminately, at the couple's first sign of problem in conceiving, or subject the couple to a barrage of risky tests.
This has important repercussions, since fertility drugs taken over a year have been associated with an increased risk of ovarian cancer.
Most doctors aren't aware of the scientific evidence demonstrating the role that deficiencies of a variety of nutrients play in a couple's ability to conceive. Three researchers at Biolab, John McLaren Howard, et al, found a correlation between low red cell magnesium and selenium and a history of unexplained infertility or early miscarriage. In their study (Magnesium Research, 1994, 7; 1: 49-57) McLaren Howard demonstrates that a deficiency of magnesium has been scientifically associated with infertility , an increased miscarriage rate and increased incidence of premature or small babies. We know that magnesium deficiency causes increases in smooth muscle reactivity, which can influence the patency (openness) of the fallopian tubes. Magnesium also has a role in regulating the various hormones responsible for ovulation and the preparation of the endometrium for egg implantation.
In their study, McLaren Howard et al found that after supplementation with magnesium or magnesium and selenium, all 12 previously infertile women produced normal healthy babies, conceiving within eight months of normalizing their red blood cell magnesium levels. In some cases, magnesium levels couldn't be brought up to normal levels through magnesium supplements alone, leading the researchers to hypothesize that this could be the result of "leaky" cell membranes due to oxidative damage, caused by inadequate levels of anti oxidant defences. It was these women who required selenium supplementation as well to normalize their red cell magnesium levels.
It is staggering that doctors so often dismiss low sperm counts as important in infertility, or believe there is nothing you can do about them. In a 1985 review article, Dr Stephen Davies demonstrated the relationship between low sperm count and low zinc levels (Davies S. Zinc, Nutrition and health a review, Yearbook of Nutritional Medicine 1984-5, ed J Bland, Keats publishing, New Canaan, Conn, 1984; 113-152). Other studies show that as semen is very rich in essential fatty acids and their byproducts like prostaglandins, men low in EFAs also tend to have a depressed sperm count. In fact, in general men need more zinc and EFAs then women, both of which are in short supply in the typical Western diet.
You are prudent to worry about the various risks of laparoscopy. The study you mention shows a complication rate of 1.1 per thousand for simple investigative procedures. The main problem is perforation of a gastrointestinal or urinary tract by a surgical instrument, usually when gas is used to inflate the abdomen beforehand (New Eng J of Med, 6 May 1993). All but one of the women with complication in this particular study had diagnostic or minor laparoscopy.
Any investigation using x-rays near your reproductive organs is inadvisable because of the links being made between radiation and Down's syndrome (WDDTY vol 5, no 6). Some of the more advanced ultrasound equipment can diagnose whether you've got problems with your tubes. Although ultrasound can disrupt the menstrual cycle temporarily, of the three it causes the fewest side effects.
However, before you rush to specialists whose only likely advice for unexplained infertility is the assisted conception route, you might consider contacting Foresight, the Association for Preconceptual Care (Send a self addressed, stamped envelope to 28 The Paddock, Godalming, Surrey, or ring 0483 427839 and they will give you information plus a list of Foresight doctors). They believe that a great deal of infertility results from poor nutritional status or undiagnosed infections, and they claim extraordinary success in sorting out many cases of infertility. In a recent study of 418 Foresight couples with histories of infertility or miscarriage, 81 per cent went on to conceive healthy babies. This compares with the success rate with an assisted conception of, at best, 30 per cent.
A Foresight doctor will do a complete history and take a number of tests. These include a test for blood pressure; a variety of blood tests (for zinc, red cell magnesium, copper and lead levels, essential fatty acid levels, for venereal diseases, abnormalities of red and white blood cells, rubella immunity and abnormalities of thyroid function). They look at basal temperature, considered a good way of testing your thyroid function, which can affect your sex hormones and sex glands; and a urine sample, to test for diabetes or kidney problems.
You will also need a gynecological exam, to test for cervical cancer, prolapse, vaginal infections, cervical damage and pelvic abnormalities.
One often overlooked and highly common problem in infertility and recurrent miscarriage is genital infections, such as mycoplasmas, bacterial infections, chlamydia, candida albicans, haemolytic streptococci, E coli and the like. Foresight recommends that women be tested for these with a cervical swab, and that men undergo a genito urinary examination, for these infections, as well as to assess sperm count.
A couple will also need sweat tests (in which a patch is placed on the back for an hour), plus hair mineral analysis (taking a tiny sample of hair). These two tests are considered the best among nutritionists to test for mineral levels, particularly magnesium and zinc.
In the UK, Biolab, again, performs these tests (071 636 5959); in the US, Jonathan Wright in Seattle, Washington: (206 631 8920).
Aside from recommending what can seem like a daunting batch of vitamins and minerals, Foresight doctors then advise couples to follow a low allergy, high protein, varied diet, made up of whole foods, whole grains and fresh (ideally organic) fresh fruits and vegetables. They also advise couples to cut out smoking, drugs and alcohol, since alcohol in moderation can cause fetal birth defects and can severely effect sperm count. Indeed, many couples find that as soon as they cut down on alcohol, the man's sperm count soars.
If you are taking drugs for medical reasons, such as diabetes, eczema, asthma, migraine or epilepsy, Foresight doctors will explore alternative methods of treating them, in order to avoid or minimize drug taking during the vital few months of conception and early pregnancy.
For more information about this approach, you may wish to get hold of the recently revised Planning for a Healthy Baby, by Foresight founder Belinda Barnes and Suzanne Gail Bradley (Vermilion, London, 1994: Random House, 20 Vauxhall Bridge Road, London SW1V 2SA).