Pelvic factor infertility is used here to refer to any structural (mechanical) abnormality that reduces the ability of a mature fertilization capable sperm and a mature fertilization capable egg from meeting and joining to develop into a normal pregnancy.

Normal sperm produced in the testes can have difficulty being released within semen during intercourse due to structural blockages within the male outflow tract. Mature eggs produced by the ovaries can have difficulty being released from the ovary or captured by the fallopian tube due to structural abnormalities of the pelvis. A normally developing fertilized egg (pre-implantation embryo) within the fallopian tube can implant within the fallopian tube (resulting in an ectopic pregnancy) or fail to implant at all within the uterine cavity due to structural problems in these anatomical regions. Once the pre-implantation embryo hatches from its shell (zona pellucida), adheres to the uterine endometrial lining, and implants to develop a communication with the mother’s circulatory system (blood vessels) then it is possible for a normal pregnancy to grow.

Pelvic factor infertility represents the primary cause for up to one third of infertility and a contributing cause in up to one half of infertility within my (Eric Daiter, MD) infertility practice. Diagnosis of pelvic factor infertility is often possible with simple noninvasive tests but minimally invasive advanced operative hysteroscopy and advanced operative laparoscopy may be required for treatment (and diagnosis if endometriosis or mild to moderate pelvic adhesions are involved).

Dr. Eric Daiter and The New Jersey Center for Fertility and Reproductive Medicine encourage the viewer to explore the contents of this site, which reviews the normal events that occur during fertilization and implantation, clinically useful diagnostic tests to detect pelvic factor infertility, the range of pelvic abnormalities that can result in reduced or absent fertility, and treatment options for couples with a pelvic factor infertility problem.

The information within these tutorials is intended to be solely educational. The knowledge and competence that the viewer may expect to develop within the complex medical field of infertility is not a substitute for the medical education that physicians obtain during their medical curriculum and training.

With this in mind, many couples are able to effectively use the knowledge that they gain about human reproduction to guide them through the difficult (and often expensive) process of obtaining medical (infertility) care.

CAVD is an uncommon obstructive post testicular lesion that results in a complete absence of sperm (azoospermia). Most men with CAVD have an intact upper one third to two thirds of the epididymis. This allows normally produced sperm to be collected within this storage depot (the epididymis). CAVD occurs in up to 95% of men with cystic fibrosis (a serious autosomal recessive gene disorder of mucus production that affects several organ systems including the lungs). Up to 50% of men who have only one gene mutation for cystic fibrosis (especially the mutation referred to as the delta 508 mutation) will have CAVD. These men are carriers of the cystic fibrosis trait but do not have clinical cystic fibrosis (since this disease requires the presence of 2 gene mutations).

(2) Retrograde ejaculation into the bladder

This can occur if the bladder neck will not close during emission and ejaculation.

An interruption in the sympathetic nerve supply to the area can result in retrograde ejaculation. This may occur with some medications that affect the nervous system, following radical regional surgery that might damage the nerves (like retroperitoneal lymph node dissection for testicular cancer), or with some systemic illnesses that can affect the integrity of these nerves (such as diabetes mellitus and multiple sclerosis). Prior reconstructive bladder surgery can also result in retrograde ejaculation. This may occur after Y-V plasty of the bladder neck at the time of reimplantation of the ureters (popular in the 1960s) or TransUrethral Resection of the Prostate ("TURP").

(3) Epididymitis

Storage of sperm in an infected epididymis can reduce sperm quality. If suspected, daily ejaculation to reduce the storage time can occasionally be useful.

Case: 27 year old male with azoospermia (no sperm within the semen), a normal hormone evaluation (FSH, LH, testosterone, prolactin), a normal physical examination (degree of virilization, testicular size and scrotal contents), status post (following) Y-V urethrocystoplasty as a child for difficulty urinating.

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

Answer: Retrograde ejaculation into the bladder can occur since the sperm will generally take the “path of least resistance” when moving through the vas deferens during emission.

Normally the internal urethral sphincter will be stimulated during the emission process to result in closure of the bladder neck so that the sperm moves into the posterior urethra. If there has been damage to the (alpha adrenergic) nerves that mediate bladder neck closure or if there has been damage to the bladder neck itself (via prior surgery in the area) then closure of the bladder neck may not occur and the sperm may travel into the bladder rather than into the posterior urethra during emission. Retrograde ejaculation into the bladder is common following Y-V plasties of the bladder neck (usually performed during childhood) and also occurs about 40-90% of the time after men have had a prostatectomy (either TURP or abdominal prostatectomy).

The diagnosis of retrograde ejaculation into the bladder is confirmed by assessing the urine for the presence of sperm after ejaculation. If the diagnosis is confirmed then treatment depends on the presumed cause of the problem.

Men with retrograde ejaculation secondary to nervous system problems often respond to medical management (most often imipramine hydrochloride or pseudoephedrine hydrochloride) so this is usually the initial line of treatment. If medical management fails to produce antegrade ejaculation or if the cause of the problem is more likely anatomical (from prior surgery) then collection of the sperm from the bladder may allow for its use in either inseminations or assisted fertilization.

Sperm collected from the bladder that is intended to be used for attempting fertility should be “optimized” by collecting it in a specific manner.

1. The urinary pH should be alkalinized to a pH of about 8 (similar to that found in semen).


2. Any infection of the bladder should also be treated prior to these procedures (to reduce the subsequent entry of bacteria into the uterus during insemination).

A treatment routine that seems to be effective is to (1) identify and treat a urinary tract infection prior to the collection of sperm from the bladder, (2) administer sodium bicarbonate (650 mg four times a day) for 1-2 days prior to the procedure (to increase the pH of the urine), (3) administer prophylactic antibiotics (cipro 500 mg every 12 hours) for two doses prior to the procedure, (4) empty the bladder with a sterile catheter and irrigate the bladder with 100 cc of “sperm washing medium” (an inert buffered balanced sterile solution that often contains human tubal fluid), (5) place about 30-50cc of sperm washing medium in the bladder and remove the catheter, (6) have the man ejaculate (into the bladder), (7) collect the post-ejaculation specimen (sperm in predominantly sperm washing medium), and (8) immediately wash the sperm sample several times prior to insemination or assisted fertilization...

A number of couples that have undergone (permanent) sterilization procedures eventually find themselves in the position of desiring further children. Unfortunately, reversal of these (permanent) surgical techniques is not always possible (regardless of the surgical talent and experience of the operating surgeon).

Following tubal reanastomosis (reversal) the outcome of surgery can be measured either in terms of tubal patency (a large percentage of the tubes remain open) or restored fertility (not all open tubes will function properly). Additionally, the chances for a tubal (ectopic) pregnancy are increased (up to 25% of pregnancies) after tubal surgery.

Tubal sterilization can be performed using a number of different techniques, each with differing ability to be reversed at a later time. The common procedures include...

There are three main theories describing mechanisms, which may cause endometriosis. These include:

• retrograde flow,
• vascular spread, and
• metaplasia of the coelomic epithelium.

The pre-ovulatory cervical mucus plays a key role in fertility. The vaginal vault is normally a hostile environment for sperm.

Available Drawings:

• Cervix

Available Case Reports:

• Cervix

Case: 30 year old G0 with a history of regular menstrual intervals every 27 x 4-5 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, a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, an abnormal postcoital test (PCT) on cycle day 11 revealing no motile sperm per high power field 8 (eight) hours after intercourse, and a husband with proven fertility (one pregnancy in a previous relationship) and a normal semen analysis.

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

Answer: If an abnormal postcoital test result is identified during the basic infertility evaluation then I consider intrauterine inseminations (IUIs) as a simple, relatively painless, low cost, and effective treatment option.

The reason for the abnormal postcoital test result is rarely identified since further diagnostic testing to identify whether the problem involves “hostile cervical mucus” or “cranky sperm” is generally not suggested because the results do not generally change the management plan (ie., IUIs).

Alternative treatments of abnormal cervical mucus (to make it more friendly to sperm) include alkaline douching, preovulation estrogen treatment, and robitussin (a mucolytic agent). I only suggest treating an abnormal postcoital test with these alternative treatments as a last resort, when IUIs are not (readily) available. For example, I had a patient who treated her hostile cervical mucus with baking soda douches just prior to intercourse since she lived a far distance from my office (a several hour drive) and her husband had a disability that made the possibility of IUIs very difficult. This patient did indeed become pregnant with alternative management.

One downside to the treatment(s) for an abnormal postcoital test is that ovulation normally only occurs monthly and the reproductive efficiency of a normal fertile couple is only about 20-25% per cycle (of trying). Therefore, the effectiveness of any cervical mucus treatment (to bypass a mucus barrier to sperm) in otherwise "unexplained infertility" is determined by the couple achieving a pregnancy and this normally takes several months (even for a normal fertile couple) to accomplish. Many couples are very disappointed if they try a "medical" treatment of abnormal cervical mucus and find that they are not pregnant within 3-6 months such that they need to re-consider ("starting over" with) IUIs.

(1) a detailed menstrual and medical history should be obtained, including

Any pregnancies (and outcomes) for either partner. A prior ectopic pregnancy is an important risk factor that suggests significant tubal disease.

Pain with menses (dysmenorrhea), sexual intercourse (dyspareunia), or any persistent (recurrent) pelvic pain.

History of any pelvic infection (excluding vaginitis or vaginal discharge), including treatment and clinical course. Important pelvic infections include appendicitis, PID, sexually transmitted diseases, an infected IUD, and uterine infections (endometritis).

Success with COH/IUI depends on the (existing) extent of damage to the pelvic organs. The pelvic damage can often be improved (minimized) with surgery.

With COH/IUI the woman (hopefully) will produce several mature eggs (more targets for the sperm) and the IUI brings the sperm into close approximation to these mature eggs. When COH/IUI is selected to treat infertility in the presence of pelvic factor abnormalities, it is important to realize that the (pregnancy) success rate is (maximally) only about 20-30% per cycle. A normal fertile couple has a (pregnancy) success rate of about 20-25% per cycle (of trying).

Therefore, the infertility specialist usually recommends 3-6 cycles of COH/IUI to (cumulatively) achieve optimal success with this treatment option. If the damage to the pelvis has been severe, or the couple does not become pregnant with COH/IUI, then In Vitro Fertilization is often suggested (required).