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Pelvic Factor

Normal Events

Pelvic Factor Detection

Pelvic Abnormalities
  • Abnormal Male Outflow
  • Vaginal Problems
  • Cervical Problems
  • Uterine Problems
  • Proximal Tubal Disease
  • Bilateral Tubal Ligation
  • Distal Tubal Disease
  • Pelvic Adhesions
  • Endometriosis

Clinical Evaluation

Treatment Options

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External Female Genitalia  |   Vagina

External Female Genitalia

Case: 23 year old G0 with a history of regular menstrual intervals every 26-28 x 4-6 days, a normal hormone evaluation (TSH and Prolactin concentration), a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, a normal postcoital test (PCT), and a husband with unproven fertility yet a normal semen analysis. On further investigation, the woman informs me that “sex” is predominantly (almost always-- even when trying to get pregnant) completed with oral rather than vaginal intercourse since the husband has a difficult time achieving ejaculation within the vaginal vault.

Question: What further testing or treatments should be considered in this situation?

Answer: Successful human reproduction (pregnancy) that results from sexual intercourse normally requires that sperm traverse the female vagina, uterine cervix and uterine cavity into the fallopian tube (where fertilization of the egg takes place).

Vaginal intercourse with ejaculation of sperm (within semen) into the vaginal vault is required for sperm to traverse the female reproductive tract and enter the fallopian tubes. On occasion I will be asked whether sperm that is ejaculated into the outside region of the vaginal orifice could make its way into the vagina and to the fallopian tubes. I don’t really know (but generally doubt) whether this is possible unless semen containing sperm is then dragged (digitally or otherwise) into the vaginal vault to the uterine cervix so that sperm could move from the semen into the cervical mucus.

Oral and anal intercourse generally cannot result in pregnancy. In some civilizations or groups of people these alternatives to vaginal intercourse are routinely used to effectively avoid pregnancy.

If the male partner cannot complete vaginal intercourse but can produce a semen sample into a clean container then I would suggest timed natural cycle intrauterine inseminations (if this is the only identified abnormality). In this situation, intracervical or vaginal application of semen (containing live sperm) may also be effective at accomplishing fertility.




Case: 21 year old G0 with a history of regular menstrual intervals every 28 x 4 days, a normal hormone evaluation (TSH and Prolactin concentration), a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, a normal postcoital test (PCT), and a husband with proven fertility (one pregnancy in a prior relationship) and a normal semen analysis. On further investigation, the woman tells me that they have been timing sexual intercourse almost exclusively during menses (the menstrual flow) since they understood this to be the most fertile period of the month.

Question: What further testing or treatments should be considered in this situation?

Answer: Successful human reproduction (pregnancy) requires fertilization of the egg by the sperm. Normally, at ovulation a mature egg is released from the ovary and is “fertilizable” for about a day (sometimes up to 2 days). Sperm normally remains active within the cervical mucus for about 2-3 days (sometimes up to 5-7 days). Therefore, vaginal intercourse should ideally be completed within 2 (or so) days prior to or 1 day following ovulation to optimize reproductive success (pregnancy).

Ovulation normally occurs about 14 days prior to the subsequent menstrual flow (since the luteal phase of the menstrual cycle is relatively fixed at about 14 days). Therefore, if the woman consistently has intermenstrual intervals of 28 days then ovulation should occur around cycle day 14. In this situation, intercourse designed to optimize pregnancy rates should occur between cycle days 13 and 15 (of course it is usually possible to confirm the general day of ovulation with one of the commercially available ovulation predictor kits). Intercourse during the initial days of the menstrual cycle (during menses) is therefore very unlikely to result in a pregnancy. Simply redirecting the timing of intercourse may be all that is required to enhance fertility in a situation such as this one.




Vagina

Case: 26 year old G0 with a history of regular menstrual intervals every 29 x 4 days, a normal hormone evaluation (TSH and Prolactin concentration), basal body temperature (BBT) charting suggesting ovulation about 13-14 days prior to the onset of a subsequent menstrual flow, dyspareunia (painful sexual intercourse) that appears to be due to (an involuntary) spasm of the muscles around and outside the vaginal vault, a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, a normal postcoital test (PCT), and a husband with unproven fertility yet a normal semen analysis.

Question: What further testing or treatments should be considered in this situation?

Answer: The woman in this case report has painful coitus (sexual intercourse) that is most likely due to spasm of the muscles within the pelvic floor and around the vaginal orifice. This pain can be triggered by an unconscious aversion to vaginal penetration in general, including (but not limited to) sexual intercourse, application of vaginal medications, or insertion of a tampon.

Dyspareunia (painful intercourse) can be due to many different causes. Inflammation of the bladder or urethra (canal leading from the bladder to the outside through which urine is discharged externally), insufficient vaginal lubrication, pelvic inflammatory disease, an infection within the uterine cavity, and endometriosis are potential causes of pain during coitus. If the cause of the pain is not identifiable (following an evaluation) or if the pain is clearly triggered by a psychologic (unconscious) inhibition then a treatment option that may be helpful is to (1) frankly discuss the possibility that the woman believes sex to be undesirable or evil, (2) work through the expectations of both partners with regard to sexual intercourse, and (3) relieve muscle spasm through progressive dilatation of the vaginal orifice (opening) with fingers or dilators.

Dyspareunia due to vaginismus (involuntary spasm of the vaginal and paravaginal muscles) is not desirable but probably does not interfere significantly with fertility (as long as vaginal penetration and intercourse can be completed).




Case: 25 year old G0 with a history of regular menstrual intervals every 27 x 4 days, a normal hormone evaluation (TSH and Prolactin concentration), basal body temperature (BBT) charting suggesting ovulation about 13 days prior to the onset of a subsequent menstrual flow, lack of (female) orgasm during sexual intercourse, a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, a normal postcoital test (PCT), and a husband with unproven fertility yet a normal semen analysis.

Question: Is an apparent female orgasmic dysfunction associated with infertility?

Answer: In some animal species it is believed that (female) orgasm may be important in terms of moving sperm through the female reproductive tract. In human reproduction, no significant association between female orgasm and fertility is generally thought to exist. Certainly, medical procedures that place sperm within the female reproductive tract (such as intrauterine and intracervical inseminations) are not associated with female orgasm and do have a good overall rate of success.

Orgasmic dysfunction is reportedly very common among females. Some research suggests that 15% of sexually active women have never experienced an orgasm. Counseling is often available for these women and should be seriously considered since the counseling can often be effective at relieving the difficulty.




Case: 37 year old G0 with a history of regular menstrual intervals every 29 x 5-6 days, a normal hormone evaluation (TSH and Prolactin concentration), an encouraging ovarian reserve (basal FSH and estradiol concentrations), use of vaginal lubricants (KY jelly) to decrease discomfort associated with sexual intercourse, a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, an abnormal postcoital test (PCT) timed 1 day prior to ovulation with 0-1 motile sperm and 10-20 nonmotile sperm per high power field, and a husband with proven fertility (two pregnancies in a previous relationship) and a normal semen analysis.

Question: What further testing or treatments should be considered in this situation?

Answer: The abnormal postcoital test results may be due to “hostile cervical mucus,” “cranky sperm” (that does not like the “friendly” mucus), or the use of vaginal lubricants that are spermatotoxic.

I would generally encourage either repeating the PCT after discontinuation of the vaginal lubricant or timed intrauterine inseminations. If the PCT is normal without the use of (spermatotoxic) lubricants then their use during intercourse (at least intercourse that is specifically directed at trying to conceive) should be discouraged. Alternatively, the PCT could be repeated after intercourse with a different lubricant... in my practice, it appears that “astroglide” has little effect on PCT results (although there are some reports in the literature suggesting that astroglide is spermatotoxic).



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