Endocrine and metabolic diseases: Treatment of infertility and menopausal symptoms.

The development of effective treatment has a marvellously encouraging effect on the incidence of a disease. When, as has happened with the occasional spectacular overkill of gonadotrophin treatment of infertility, the media takes an intense interest in the treatment, the number of patients seeking it rises still more steeply. There are, however, more worthy reasons for the rising pressure. The large number of abortions has greatly reduced the availability of babies for adoption and forced wouldbe parents to exhaust every possibility of having a child of their own. Oral contraceptives have contributed a new cause of infertility by way of post-pill amenorrhoea, and failure of ovulation can now be simply and securely diagnosed by a single, judiciously timed plasma progesterone assay. Good infertility clinics practise a strict investigative routine, and the existence of simple, effective treatment for one form of infertility is no good reason for short-circuiting such a routine. At the least it must be established by seminal analysis that the husband is fertile and by tubal insufflation that the wife has patent Fallopian tubes. In addition, anovulation needs to be proved. In the case of women with secondary amenorrhoea this may be taken for granted but primary amenorrhoea warrants much more extensive investigation of its own accord. Even with secondary amenorrhoea overt disease should be excluded. Occasionally the cause of anovulation is untreatable-such as menopause praecox. This condition is a likely cause of infertility when amenorrhoea is accompanied by high levels of follicle-stimulating hormone (FSH) in the blood or urine. Few doctors have not fallen into the trap ofan unsuspected pregnancy. Investigation of the infertile couple needs in the first instance to go no further than establishing that the husband is fertile and that the wife has patent tubes and is not menopausal or pregnant. Then amenorrhoea or oligomenorrhoea is sufficient evidence of anovulation or infrequent ovulation to warrant an attempt to induce ovulation with antioestrogens.