Book Review

Infertility: Evaluation and treatment

N Engl J Med 1995; 333:264-265July 27, 1995

Article

Infertility: Evaluation and treatment
Edited by William R. Keye, Jr., R. Jeffrey Chang, Robert W. Rebar, and Michael R. Soules. 922 pp., illustrated. Philadelphia, W.B. Saunders, 1995. $150. ISBN: 0-7216-3970-4

A gynecologist friend of mine suggested that the treatment of infertility could be more practical and efficient. A couple who had not achieved pregnancy should appear in the specialist's office on day 1 of the woman's menstruation with a sample of the man's ejaculate. If sperm were present, in vitro fertilization would be attempted; if sperm were not present, either donor insemination or adoption would be recommended. That the treatment of infertility is huge in scope is shown by this book. However, considering the enormous number of tests available and the multiple options for treatment, my cynical friend may have a point.

This book is directed to all those who care for couples with impaired fertility, including physicians at all levels, psychologists, social workers, laboratory scientists, and technicians. It is organized in six sections, covering infertility in overview, the evaluation of infertile couples, medical and surgical treatment of infertile women, male infertility, and assisted reproductive techniques. These 61 chapters have been produced by 78 contributors, who include almost all the well-known workers in the field of infertility. As can be expected, there is some overlap, but I found this interesting and even useful, since there is no one answer or approach in working with infertile patients. There is an occasional lapse in the high level of overall quality, and there are a few major disappointments. The reader must be reminded that technology is advancing on a daily basis, that a new technique or method can become the norm in a matter of months, and that knowledge obtained from a book such as this must always be complemented with facts and results gleaned from the contemporary literature. This having been said, the book contains an enormous amount of information on all aspects of infertility and should long serve as a reference and guidebook.

There are certain high points. Numerous factors influence fertility, including whether one smokes, behavior, diet, psychoemotional factors, and the environment, and this point is nicely emphasized. The chapter is useful because the perspective of the patient is too rarely considered. Much has been written about the psychological aspects of infertility, and Applegarth's chapter is a good summary. Olive's chapter on evaluation of the infertility literature should be required reading for all those who work in infertility, who write or review manuscripts, or who are infertile. Collins performs a similar service in writing about unexplained infertility; his bottom line is statistical evidence of efficacy, and his analyses indicate that the efficacy of much therapy as we know it, and as described in this book, is unproved.

Detail is abundant. In particular, the chapter on cervical-factor infertility contains enormous amounts of information, is impeccably documented and referenced, and could stand alone as an information source. The same can be said for the section on surgical treatment of infertile women, which includes imaging, with good discussions of instrumentation and technique, impressive illustrations, and sufficient how-to-do drawings. Color versions of many of the black-and-white photographs in this section are included as an inset, to advantage. In contrast, the chapter on the normal menstrual cycle suffers from a lack of current information and is disappointing in the light of what could have been included.

Male infertility constitutes a whole section. Tests of sperm numbers, morphology, and function are well described. There is a veritable battery of available diagnostic tests, but missing is a critical discussion of how these results translate into therapy. None of the options for medical treatment survive the type of analysis described by Collins or Olive. Intrauterine insemination is described in detail, but whether it improves pregnancy rates continues to be argued. To my mind, controlled ovarian hyperstimulation, leading to ovulation of increased numbers of oocytes, combined with intrauterine insemination of washed and prepared sperm, is not treatment of underlying infertility. The benefits of surgical treatment of varicocele are unproved, despite the following statement from page 630: “Although there have been controlled studies indicating that varicocelectomy has no beneficial effect on fertility rates, a review of the published uncontrolled studies encompassing thousands of infertile patients treated with varicocelectomy demonstrated the beneficial effect of varicocelectomy.”

Implantation is integral to pregnancy, and endometrial inadequacy has been proposed as a cause not only of miscarriage but also of infertility. Surprisingly, this book, which has chapters on luteal-phase deficiency, recurrent abortion, and endometrial biopsy, contains no discussion of endometrial development or of implantation. The index contains no reference to integrins, cytokines, adhesion molecules, growth factors, or binding proteins, many of which are progesterone-dependent and at least some of which are considered important in implantation. Thanks are due to Winkel for addressing this issue peripherally in his chapter on lesions affecting the uterine cavity, but the field of endometrial function deserves more.

In vitro fertilization and its variations are well covered in overview, as well as in some detail. Meldrum's chapter on the choice of program and technique is useful, and Jaeger's on the legal and ethical challenges of assisted reproduction is topical and important. However, this field is moving at a rate almost too fast even for the journal literature, so the virtual lack of descriptions of the micromanipulation techniques in current vogue, such as intracytoplasmic sperm injection, or of epididymal sperm aspiration as a treatment of vas occlusion is not really a fault. It simply emphasizes that the contemporary literature must complement the foundation laid by this work.

This book is an admirable endeavor, highly successful in fulfilling its aims and without major flaws.

Anne Colston Wentz
Northwestern University Medical School, Chicago, IL 60611