WORCESTER MEDICINE
President’s Message
Infertility
Infertility/Decreased Fertility: Significant Positive Changes in the Last 30-40 Years
Spiro Spanakis, DO
Julia V. Johnson, MD
H
app y N ew Y ear to all ! O vershadowed by the pandemic, and unsettling current events in 2021, I hope 2022 brings health and harmony to you and your families. Despite the pandemic, the Society continues to be active on many fronts. At our recent business meeting, more than 20 scholarships were awarded to deserving medical students as they face the rising costs of medical education. I encourage you to contribute to the Worcester District Medical Society scholarship fund on our website. Recently, the district’s medical student committee, chaired by student doctor Bennet Vogt, sponsored a successful virtual anti-racism and health equity forum. The event enlightened us all and provided a wonderful platform for discussion. Special thanks to Dr. Anne Larkin for her support of this committee and the event. I also want to, again, congratulate Dr. Kavita Babu, M.D., the recipient of our Dr. A. Jane Fitzpatrick Community Service award and Dr. Thomas Halpin, the recipient of our WDMS Career Achievement award. As I prepare this message, the district’s delegation to the Massachusetts Medical Society is preparing for its virtual interim meeting. Becoming a member of our delegation is an excellent way to meet new colleagues, learn about issues facing medicine and better understand the legislative process and important ways we, as individual physicians, can make a difference. We always have unfilled seats on our delegation so we please contact the WDMS office via email at mwright@wdms.org, if you are interested in learning more about this opportunity. I am pleased to announce Dr. Kimiyoshi Kobayashi, UMASS Memorial Health’s chief quality officer, will be the society’s 226th orator. Please watch for announcements about this and other upcoming events. +
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L o u i s e B r o w n wa s b o r n i n 1978, the first child conceived through IVF, there has been marked improvement in the diagnosis and treatment of infertility for men and women. Although insurance companies in many states do not recognize this common disease, it effects at least 12% of women and 15% of married men in the U.S. Fortunately, the awareness of this disease, and the effectiveness of treatment, has increased. In 2017, the American Medical Association joined the World Health Organization in recognizing decreased fertility/infertility as a common disease of reproductive aged women and men. Now, 15 states offer some coverage for this disease with Massachusetts being one of the first to mandate private insurance coverage for infertility. The causes of infertility are complex, yet the evaluation has been simplified significantly during my years as a Reproductive Endocrinologist/Infertility (REI) Subspecialist. The causes of infertility include low sperm count or motility or ‘male factor’ (35%). ‘Female factor’ (45%) includes the most common cause, tubal or uterine disease (30%) with the next most common as ovulatory dysfunction (15%). The remaining causes are unexplained (20%). In the early years, testing was complex, involving cervical mucus testing, endometrial biopsy, specialized sperm testing and repeat hormonal testing. Currently, a doctor obtains a simple set of tests to confirm multiple factors, including: ovulation (ovulation predictor kit or progesterone level in the luteal phase), assurance of a normal uterus and fallopian tubes (ultrasound or hysterosalpingogram), hormonal tests to evaluate ovulatory disorders or rule out premature ovarian dysfunction, and a semen analysis. All testing can be done in a month at modest cost by an experienced REI at UMass Memorial. And treatment is now also straight forward. In the past, complex surgery was done to fix scarred fallopian tubes with poor success and ovulation induction was overused with the risk of multiple gestation. There was no treatment for male infertility except trying intrauterine inseminations (with limited success) or donor sperm. Now, the only reason for surgery is severe pain (endometriosis), to clip fallopian tubes (and increase pregnancy rates) or remove lesions from the uterine cavity (polyps and fibroids). Only oligoovulatory and unexplained infertility patients use ovulation medications and then only in limited amounts. For women with ovulation dysfunction (such as PCOS), 50% become pregnant within six months; if very mild, male factor is added and an intrauterine insemination can be considered. For other causes, if surgery is not indicated first, then IVF may be the best treatment with pregnancy rates per cycle of 40-50% for women under age 35. The success with IVF treatment has increased from 8-10% per cycle when I started in 1988 to 40-plus percent per cycle currently. IVF treatment is highly successful for male factor, tubal factor, uterine factor, ovulatory dysfunction and unexince
JANUARY / FEBRUARY 2022
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