When a
couple first arrives, they will undoubtedly be warmly greeted by one of
our lovely receptionists. You’ll sign in and if you haven’t already
downloaded and filled out the patient information and history forms,
you’ll be asked to do so at this time. Click here to view
and/or download the forms in question so you can have it all done in
full before you get here. If you’d rather fill out your paperwork here,
then it’s a good idea to arrive at least 15 minutes early for your
appointment. Also, copies of any relevant medical records from your
primary physician should be forwarded to our office prior to your
appointment as they may help your infertility doctor in preparing a
diagnosis. Medical records release forms can be downloaded by clicking here. Fill this sheet
out and fax or send it to your current doctor’s office at least two
weeks prior to your appointment at GYFT.
You will have been scheduled to consult with one of our three
infertility doctors – Dr. Joseph Robinette, Dr. Robert Z. McLees or Dr.
Luis Murrain (learn more about them in Get To Know GYFT). All friendly,
compassionate doctors, they will spend the next 30 minutes listening to
your concerns, discussing your history, and providing information on
the treatment options available to your particular situation. Although
your doctor will likely gain some insight into your infertility problem
during this discussion, a series of fairly standard tests (called a
"work-up") will likely be requested in order to verify his suspicions
and/or make sure he’s not missing something more subtle. This "work-up"
will ordinarily produce a pretty clear explanation for the lack of
fertility in about 85% of the couples we see. For about 15% of couples,
no specific reason for the presenting infertility will be found. In
these cases, more specific tests may need to be added to the "work-up."
Generally these initial tests are fairly inexpensive and can be
completed in a relatively short time (1 to 2 cycles). Granted, the more
involved the testing becomes, the more expensive and time-consuming the
diagnostic phase gets.
Following is
the basic "work-up" your physician is likely to prescribe during your
initial consultation:
The bottom line is you’re having trouble getting pregnant. The answer
as to why is usually found in one or more of five major categories:
Behavioral/chemical factors, ovulatory problems/hormone imbalance,
anatomical problems, male factor problems, and local/cervical problems.
Your doctor will attempt to address the relevance of each category to
your particular situation and with input from you and your medical
history, may quickly begin to focus on one area where he/she has some
suspicions, and dwell less on others. Since your doctor’s job is to
diagnose and treat infertility problems as quickly as possible, you may
find yourself wishing you had more time to discuss his/her thought
process as factors are ruled out and a diagnosis is reached. Since
there is a tremendous amount of information that your doctor sorts
through to narrow down his diagnosis, it would take hours to explain
the assimilation process. Which is why we have created this site.
Following, we will examine the five major areas of infertility in much
more detail than your doctor will be able to in person. Some of these
factors may not apply to you at all, but will at least give you some
insight into the enormity of potential infertility factors and how your
doctor logically arrives at his/her conclusions. Also, the more you
learn, the better prepared you will be to ask relevant questions and
contribute valuable information to your physician during your
consultation. Warning: there is a lot of information following, so
don’t expect to absorb it all in one sitting – feel free to jump around
using the various links to find out just what you want to know.
Behavioral & Chemical Factors
During your initial consultation, your GYFT doctor will likely touch on
some of the lifestyle behaviors that may be
impacting your fertility potential.
|
|
- Nutrition, exercise,
smoking, and drug or alcohol intake all may impact your ability to
conceive. Poor diet, lack of exercise, and drug or alcohol abuse can
contribute to infertility.
|
|
|
- There are a number of
medications, including some used to treat ulcers, heart conditions,
high blood pressure, and cancer that can influence a man’s sperm count
and sex drive. Some medications are known to impair fertility. Your
infertility specialist may be able to recommend alternative
medications.
|
|
|
- Drugs such as marijuana,
anabolic steroids, and cocaine can cause profound, sometimes
irreversible, decreases in sperm production in chronic users.
- There are a number of
lubricants that, if used during intercourse, can affect sperm quality.
Your infertility doctor should be able to recommend a lubricant that
does not interfere with conception.
|
|
|
- If you
are at high risk or have a history of sexually transmitted diseases
(STDs), you are likely to have decreased fertility as well as put your
partner’s and potential child’s health at risk. Several types of
infertility can be directly linked to the presence or past exposure to
a sexually transmitted disease. Thus, your physician may suggest a
panel of STD blood tests be performed on you and your spouse to verify
the presence or absence of any diseases that might be impacting your
fertility. Even if you don’t believe you have been exposed or show any
symptoms of exposure, it is possible to be a carrier for a disease and
not show any signs of its presence.
Click here to learn about the symptoms and dangers of some of the most
common sexually transmitted diseases.
|
You are
encouraged to openly discuss any of these behaviors with your doctor,
if relevant, as they can often be controlled or regulated to improve
your overall health and maximize the chance of pregnancy.
In order for
a woman to conceive, her ovary must be able to produce a healthy egg
and ovulate it at regular intervals, a process known as an ovulatory
cycle. In order to do this, the female reproductive system must produce
adequate amounts of certain hormones (refer to Ovarian
Physiology for detailed information on the
ovulation process and the ways to detect the occurrence of ovulation.
As ovulatory disorders are very common causes of infertility in women,
your doctor will want to discuss the frequency and nature of your
menstrual cycles. Any irregularities in your cycle history may give
your doctor some insight into an underlying problem and may warrant
some simple blood tests to deny or confirm any suspicions he/she may
have.
Hypothalamic-Pituitary Disorders
Some women
fail to ovulate because there is little or no stimulation coming from
the pituitary gland. This can result from a problem with the
hypothalamus and is common in women who exercise vigorously, are under
a lot of stress, or who have anorexia or related eating disorders. Such
women do not produce a sufficient amount of FSH to induce any of the
follicles in the ovaries to begin development. Blood tests can be
performed to verify the presence or lack of FSH and, if absent or very
low, can be treated by either stimulating the pituitary gland to
release more FSH (see GnRH stimulation)
or by simply replacing the missing FSH by administering it directly
(see Injectable Gonadotropins).
Premature Ovarian Failure
Some women fail to ovulate simply because they have very little, very
few, or no eggs remaining in their ovaries. If this happens before the
age of 40, it is termed "premature ovarian failure" or "early
menopause." Some of the reasons a woman might deplete their supply of
eggs at a young age include prior chemotherapy or radiation treatment,
genetic abnormalities, or the obvious complete absence of the ovaries
as a result of prior removal. Sometimes, however, there is no obvious
explanation as to why the eggs have been exhausted. Perhaps some women
waste eggs by the thousands rather than hundreds each cycle and simply
run out sooner than normal women or perhaps they just have fewer eggs
to begin with (see Ovarian Physiology
for discussion of this phenomenon). Regardless of the cause, a woman
with no eggs cannot bear her own genetic offspring no matter how much
we may try to stimulate her ovaries with fertility medications. This
does not mean, however, that she cannot become a mother short of
adoption (see Egg Donation and Gestational Hosting).
Premature ovarian failure can be detected with a blood test and is
indicated with irreversibly high levels of FSH in the blood stream.
Now you may have noticed the "before the age of 40" phrase in the last
paragraph. As a woman approaches the age of 40 and beyond, all bets are
off in terms of fertility potential and, unfortunately, is often
considered the end of the line for most women to become pregnant.
Nationwide statistics show a dramatic decrease in pregnancy rates in
women 40 years and older, even when using the most advanced infertility
treatments. This certainly doesn’t preclude a woman from becoming
pregnant after 40, but should be a clear warning for those women
planning on having children to start trying well before they reach this
age – preferably before the age of 35. This would allow a couple to
still have time to seek infertility help should they unwittingly find
themselves unable to conceive right away. We realize that more and more
couples are facing the necessity of dual incomes and that busy careers
always seem to put family planning off until next year, but in our
experience, we cannot emphasize enough – START EARLY! And it’s up to
you, ladies. Your husband can produce sperm his entire life, so he
doesn’t really have a biological clock winding down his reproductive
life cycle. If you ever planned on having a family together, make sure
he’s aware of the repercussions of waiting too long.
Polycystic
Ovarian Disease
The vast majority of women who fail to ovulate regularly do have a
functional pituitary gland and plenty of egg containing follicles in
their ovaries. The problem for women like these is often in a hormone
imbalance between the FSH released from the pituitary and the resulting
estrogen response of the follicles. While the specific source of the
problem may vary widely and is not known for many patients, many of
these women will have the clinical signs of polycystic ovarian disease.
This involves the presence of many small follicles within the ovary
usually due to a lack of sufficient FSH stimulation to keep the
follicles developing to maturity. As explained in Ovarian
Physiology, proper FSH levels are necessary
to promote the maturation of one of these follicles to ovulation.
Inadequate FSH levels prevent the development of a dominant follicle
and leave the ovary full of many immature ones incapable of ovulating.
Polycystic ovarian syndrome can be detected using an ultrasound to
visually check for follicles in the ovary, and from abnormal levels of
FSH in the blood stream. Treatment usually focuses on raising FSH
levels to the point where follicular growth and development resumes,
ultimately resulting in the release of a healthy, mature egg (see Clomiphene
Citrate or Injectable
Gonadotropins under Ovulation Induction).
Detecting Hormone Imbalances
Virtually
every hormone affecting fertility can be measured directly in the
blood. We believe this to be the most reliable way of confirming
whether or not a particular hormone is present in the body at
appropriate levels. Because some of these hormone levels vary quite
dramatically during a menstrual cycle, it is important to have them
measured at the right time of the cycle in order to be interpreted
correctly. From the illustration above, you can see there are three
distinct phases associated with the menstrual cycle: the follicular
phase, the ovulatory phase, and the luteal phase. The follicular phase
is that portion of the cycle from the start of menstruation up to
ovulation, the ovulatory phase is ovulation, and the luteal phase is
that portion of the cycle after ovulation up to menstruation. Estradiol
(the primary estrogen we measure in the blood stream) and progesterone
levels can be quite different depending on the phase of the cycle, so
timing of the blood tests are important. FSH and LH are more or less
constant except for right around the time of ovulation.
Estradiol is secreted by developing follicles in response to the
presence of FSH in the body (see Ovarian
Physiology for further details on this
process). The more mature or the higher the number of follicles, the
more estradiol that is detectable in the blood. Estradiol levels
increase as ovulation approaches, decline slightly during ovulation,
then rise again in conjunction with progesterone levels to prepare the
uterine lining, or endometrium, for possible conception (notice how the
endometrium thickens as the cycle goes on in the illustration). Thus,
even though FSH is the hormone that causes a follicle to develop, we
usually do not measure FSH except at the beginning of the cycle, since
the amount of FSH during the cycle is not that important. We need to
look at the affect of FSH on the ovary by measuring the resulting
estradiol level. As mentioned, normal follicular development is
reflected in ever-increasing estradiol production until the time of
ovulation. It would be normal, then, to have your estradiol level
checked at the beginning of the cycle to be sure it is appropriately
low and several times during the follicular phase of the cycle to be
sure it is rising adequately.
As discussed
elsewhere, FSH is a hormone produced by the pituitary gland that
stimulates the ovary to begin follicular development. It usually does
not increase much during a normal ovulatory cycle because the presence
of estradiol (as described above) in the follicular phase actually
restricts the production of more FSH (again, see Ovarian
Physiology for further details on this
process). FSH is more important to measure once every few cycles as a
means of checking for the onset of ovarian failure. Ovarian failure is
the inability of the ovaries to produce egg-containing follicles. Since
follicles produce estradiol and the presence of estradiol keeps FSH
levels low; conversely, the lack of estradiol from having no follicular
growth causes the pituitary gland to keep producing ever-higher levels
of FSH as it tries to stimulate the ovaries to function. So FSH is
essentially a marker hormone – the higher the level, the more difficult
it is to stimulate the ovaries to release eggs. Rises in serum FSH
levels to the point where ovarian failure is indicated usually occur
over time (from a few months to many years) and, once risen, don’t come
back down. So by checking your baseline FSH level every so often, we
are able to foresee potential ovarian resistance or failure and get
more aggressive with our treatment regimen as time becomes more of a
factor.
As mentioned in an earlier section, progesterone is a hormone secreted
by the corpus luteum following ovulation. Progesterone is carried by
the blood to the uterus and, with estrogen, help prepare the uterus for
possible conception. In pregnancy, progesterone protects the implanted
embryo and fosters growth of the placenta by working to decrease the
frequency of uterine contractions and prevent the expulsion of an
ongoing pregnancy. Inadequate levels of progesterone can result in
menstrual and conception difficulties in non-pregnant women and
spontaneous abortion, or miscarriage, in pregnant women. Fortunately,
there are several methods of supplementing your body with progesterone
when natural levels prove inadequate. In fact, progesterone
supplementation is routinely given to all of our newly pregnant
patients as a preventative measure against early miscarriage.
Prolactin is
a hormone secreted by the pituitary gland and is normally present in
low levels in non-pregnant women. High levels of prolactin can cause
anovulation, which can be lowered with proper medication to levels
where normal ovulatory cycles can resume or at least allow for better
response from ovulation induction methods.
Thyroid disorders are a result of problems with the thyroid gland and
can also impair a woman’s ability to ovulate. Appropriate replacement
of thyroid hormone can often correct problems of this nature.
Your doctor may determine that any or all of these hormones be checked
during your work-up cycle. Because some of them can fluctuate
dramatically during a cycle, you may be instructed to have your blood
drawn on particular days of the cycle, so be prepared to adhere to a
fairly strict schedule of blood draw appointments. In this way, the
test results will provide your doctor with the most accurate picture of
how these critical hormones are performing over the course of your
cycle.
LH is one hormone you may have noticed mentioned in this site and
elsewhere as an important component of the reproductive endocrine
system. This is true, but is also a hormone we no longer find necessary
on which to perform blood tests. The reason is that LH’s primary role
in the reproductive process is to trigger the follicle to release its
egg as a result of a sharp increase in the level of LH at the midpoint
of the ovulatory cycle. Thus, the actual value of LH in the blood is
not that important to us, just the fact that the surge is taking place
is what we want to know. Ovulation predictor kits can detect this surge
quite reliably and at less expense than a blood test. For many
infertility treatment regimens, the LH surge becomes completely
irrelevant because we have the means to control the time of ovulation
ourselves using certain medications (this can be important since the LH
surge may occur at inopportune times or not at all if left to the
body’s discretion). HCG, in particular, is a "surrogate" LH that has
the same stimulatory effects on the ovary that LH does and can be
provided by injection to trigger ovulation at the optimal time in the
cycle as determined by your doctor. In some cases, it may be desirable
to shutdown your body’s production of LH and FSH altogether (see GnRH
Analogues under Injectable Gonadotropins for
indications).
Anatomical Factors
For the purpose of our discussion, problems with the anatomy of the
female reproductive system are often broken down into three groups:
tubal, uterine, and pelvic. Numerous infertility issues arise from
physical abnormalities of the reproductive organs, any of which could
be genetic, the result of disease or injury, or the result of prior
surgical procedures. Anatomical factors are important to diagnose
since, although they cannot always be repaired, treatment can certainly
be tailored to work around the problematic area.
Tubal Factor
Tubal factors describe any blockage or damage to the fallopian tube
that prevents an egg, once ovulated, from reaching the uterus and are
among the most common anatomical factors causing infertility. These
factors may be the result of current or past infection from STDs
(particularly chlamydia and gonorrhea, endometriosis(see below) or
appendicitis; the result of a prior surgical procedure which caused
pelvic adhesions or scar tissue; or the result of damage from birth
control methods such as IUD use or tubal ligation. Because damaged or
blocked tubes may prevent an egg from getting through the tube to the
uterus, but may not prevent sperm from reaching the egg and fertilizing
it, women with tubal factors are at high risk for having an ectopic
pregnancy.
Tubal damage can often be irreversible, but can be surgically repaired
in some less severe instances. Your infertility doctor will be able to
determine the extent of any tubal damage and whether or not the tubes
may be surgically restored. One way to diagnose a tubal factor is with
a hysterosalpingogram, or HSG. Your doctor or referred radiologist
injects a liquid dye (which is visible on x-ray) into the portion of
the tube where it connects to the uterus and observes to see if the
fluid is able to freely spill through to the opposite end of the tube
(near the ovary). If not, a blockage of some kind is usually the
culprit and your doctor will determine whether or not it can or should
be removed. In some cases, the simple act of flushing dye through the
tubes during the HSG is enough to clear minor blockages and restore
fertility. Depending on the results of the HSG and/or your medical
history, your doctor may wish to perform a surgical evaluation of the
fallopian tubes and the other reproductive organs called a laparoscopy (see below).
Regardless
of the nature of the tubal damage or obstruction, the fact is that you
can still become pregnant with only one or even no functional
fallopian tubes. Women who have only one functional tube will only be
able to conceive when an egg ovulates from the ovary near the good
tube. Typically, ovaries often alternate the release of an egg from one
cycle to the next. One month the left ovary releases an egg, the next
month the right ovary releases an egg, and so on. Thus, if one tube is
damaged or obstructed, the chance of pregnancy exists but will be less
than a woman with two functional tubes because an egg is only made
available every other cycle. Ovulation
Induction is one means we have of forcing
each ovary to produce eggs every cycle, thereby increasing
the overall chance of conception.
Now it’s also very possible to become pregnant with no
functional tubes. In these cases, however, the only alternative is in
vitro fertilization, or IVF (see ART section for
details). With IVF, the basic premise is that the eggs are taken
directly from the ovaries, placed in a dish with the partner's sperm,
allowed to develop to embryos, then transferred back to the patient’s uterus
a few days later. In this way, the tubes are completely bypassed. They
can be damaged, blocked, or even completely absent and they will not
factor into the outcome of the procedure. IVF has a higher pregnancy
rate than any other available infertility treatment, but is also the
most expensive to perform on a per cycle basis.
Microtubal Reanastimosis
In cases of women with a prior tubal ligation, which renders the
fallopian tubes useless, microtubal reanastimosis is a procedure that
can be performed by your GYFT Clinic physician to surgically reattach
the tubes to make them functional again. The probability of regaining
completely serviceable tubes depends on the type of ligation that was
performed and the resulting quality of the tubes. Good candidates have
as high as a 75% chance of restoring tubal function. Poorer candidates
may have a 50/50 chance of success and may be better off concentrating
their efforts toward alternative treatments such as IVF. Of note,
patient’s undergoing a reanastimosis procedure are at higher risk for
ectopic pregnancies, as scarring can sometimes occur at the point of
surgical reattachment causing a blockage.
Uterine
Factors
Uterine factors describe any condition which causes the interior of the
uterus (or endometrial cavity) to be abnormally sized or shaped and/or
non-receptive to an implanting embryo. Malformations of the uterus are
problematic not so much in preventing conception, but in making it
difficult to maintain a pregnancy. An abnormal uterus may
restrict the growth and development of a fetus, increasing the
possibility of miscarriage or premature labor.
Some examples of congenital deformities of the uterus include the
bicornuate, septate, and T-shaped variety. An HSG is an excellent tool
for evaluating and diagnosing abnormalities of the uterine cavity with
many of these anomalies surgically correctable by your GYFT Clinic
physician.
Other uterine factors that may impact the size and shape of the
endometrial cavity and also interfere with conception involve the
presence of tumors such as polyps and fibroids, as well as scar tissue
that may be a result of infection or past surgery or trauma. These
growths are typically benign and more of a nuisance than anything else,
but can hinder a pregnancy because their presence lessens the available
implantation area for a developing embryo. Uterine tumors are usually
detected with the help of an ultrasound and can be removed quite
readily by your physician. Scar tissue can also be removed but cannot
be seen using an ultrasound and may require a laparoscopy to verify its
presence.
Irreparable uterine factors may prevent a woman from conceiving or
carrying a pregnancy to term, but does not preclude a woman from having
her own genetic offspring. The use of IVF with a gestational host
allows embryos to be created from the eggs of the woman with the
uterine problem and the sperm of her partner, and introduced into a
woman with a healthy uterus who can likely carry the baby to term. We
use the term "gestational host" to describe the woman carrying another
couple’s child rather than "surrogate" since the term "surrogate"
implies that the woman is providing the service in exchange for money.
At GYFT, "gestational hosts" are always a relative or close friend
providing the service out of love, not money.
Pelvic
Factors
Pelvic factors are less specific in terms of their
location, and generally refer to any condition in the pelvic area which
may be affecting the reproductive organs. These may include the
presence of scar tissue or pelvic adhesions from prior surgery or
infection, pelvic endometriosis, or pelvic tumors or cysts, all of
which may interfere with the normal function of the ovaries or
fallopian tubes.
We’ve discussed the impact of and ability to remove scar tissue and
tumors from the uterus and they are basically dealt with in the same
way in the pelvis. Endometriosis, however, is a disease particular to
the pelvis and can cause a number of infertility problems related to
the reproductive organs. Endometriosis is a condition in which tissue
more or less perfectly resembling endometrium (or uterine lining)
occurs in various locations in the pelvic cavity, including growing in
and on the fallopian tubes and ovaries, sometimes debilitating them.
The cause of endometriosis is not clearly known but may involve the
expulsion of endometrial tissue during menstruation upward through the
fallopian tubes and into the pelvic cavity where it is able to implant
and grow on the ovaries and elsewhere. It may also involve a hormonal
change or other event that triggers undifferentiated tissue in the
pelvis to transform into endometrial tissue. Regardless of the cause,
if left unchecked could lead to complete infertility and even cancer.
Endometriosis
usually requires a pelvic laparoscopy (see below) to verify its
presence and, during the same procedure, can be removed by burning away
the tissue with a laser or by cutting the tissue out directly (our
physicians prefer the use of a laser as it is believed to cause less
pelvic scarring). Depending on the severity of the growth, this can be
a painstaking process.
Cervical Factors
Initiating a
pregnancy requires that the egg and sperm meet so that fertilization
can occur. This "meeting" normally occurs in the fallopian tube. Thus,
their meeting necessitates the sperm swimming from the vagina, through
the cervix, past the uterus and into the tube. Clearly then, conditions
which impede or block the ability of the sperm to reach the egg will
prevent a pregnancy from occurring. Infection in the vagina or cervix,
anti-sperm antibodies in the cervical mucus that can immobilize sperm,
and poor quality cervical mucus which can prevent the passage of sperm
into the uterus are some examples of cervical factors that can cause
infertility.
Thus,
it doesn’t seem too much of a stretch that we would want to examine the
quality of the cervical mucus to determine if a cervical factor exists.
The most common way we do this is by performing a Huhner or post-coital
test (PCT). This test is accomplished by
having the couple to be tested engage in intercourse as close as
possible to (but before) the time of ovulation. This timing is
necessary because the cervical mucus changes composition after
ovulation such that it actually prevents sperm from entering. Then, at
some specified number of hours after intercourse, an exam is performed
where a small amount of mucus is extracted from the woman’s cervix. The
mucus is examined for evidence of
infection, proper clarity and "stretchiness"(called Spinbarkeit), and
for the presence of sperm. Sperm are evaluated regarding the number
present, percent swimming, quality of movement, and physical appearance. A normal post-coital exam suggests a good
vaginal and cervical environment and also usually predicts a normal seminal fluid analysis.
Laparoscopy
The laparoscopy is the most complete way of evaluating the pelvic
anatomy and the reproductive organs for the presence of the variety of
abnormalities mentioned above. It is a minor surgical procedure which
lets the physician actually look inside the pelvic cavity and
physically exam the uterus, ovaries, fallopian tubes, and pelvic region
for irregularities.
Male
Infertility
Believe
it or not, infertility is far from just a female problem. In fact,
male-related factors contribute to infertility problems in almost half
of the couples having trouble conceiving. There are a number of factors
that can cause infertility in men, most of which, not surprisingly,
impact the sperm. The major male infertility factors involve problems
with sperm production, blockage of the sperm delivery system,
antibodies against sperm, injury to the testicle, or possibly the
presence of a varicose vein around the testicle (called a varicocele) –
all of which may affect sperm quantity and quality. Less understood,
but believed to impact sperm quality, are the effects of stress,
chemical exposure, strenuous exercise and the like. Although often
temporary, illnesses, infections and medications can also cause
infertility in men. Interestingly, problems associated with sexual
dysfunction, ejaculatory dysfunction, hormone imbalance, testicular
cancer, structural defects and the like are really quite rare,
accounting for less than 3% of male infertility diagnoses. In our
experience, low sperm counts, poor motility and/or abnormal sperm
morphology (often from unknown origins) make up the bulk of male factor
infertility problems. Fortunately, there are very effective treatments
available to circumvent the problems they cause.
Well, first
we’ll need to determine if there is a male factor problem. So one of
the first tests your GYFT physician will request is a seminal fluid
analysis (SFA). See Reproductive Assays Lab for specifics on collecting semen specimens, how the
test is performed, and what is considered "normal." The results of this
test will go a long way in determining the fertility potential of the
male patient and may also indicate the need for more detailed testing
or treatment. Keep in mind that the SFA is not an absolute test for
fertility because it does not actually test sperm function, such as
whether the sperm in question are actually capable of penetrating an
egg; but it is useful in determining obvious male factor infertility
such as oligospermia, azoospermia, asthenospermia, severe
agglutination, or teratospermia.
Following are some of the actions typically taken as a
result of a semen analysis outcome:
Azoospermia: Refers to a complete absence of sperm in
an ejaculate. If unexpected, a fructose test is performed to rule out
congenital absence of the vas deferens and/or the seminal vesicles (see
Male
Reproductive Process) since
fructose is a normal component of semen produced by the seminal
vesicles. If there is no fructose in the ejaculate, then there is
something either missing or blocking that may be preventing the exit of
sperm from the spermatic cord. If fructose is present in an azoospermic
ejaculate, then we can be pretty sure that there are no anatomical
defects of the sperm delivery system and that the cause of the
azoospermia lies elsewhere. Men with unknown azoospermia are often
referred to a urologist for further studies which may include hormone
testing and/or testicular biopsy. Use of anonymous donor sperm is a
commonly recommended treatment for men with azoospermia (see Sperm Donors
under Intrauterine Insemination for more information on the use of
donor sperm).
Oligospermia:
Describes an ejaculate with an abnormally low number of sperm present.
There is often no clear explanation as to why some patients have
oligospermia, but factors may include hormone imbalance, past
testicular disease or surgery, or any one of the theorized
possibilities mentioned at the beginning of this section. Because there
are no clinically proven methods to increase one’s sperm count
substantially, oligospermic men have little hope of impregnating their
partner through conventional means. Your doctor may recommend an SPA,
or Sperm Penetration Assay, to test the function of the sperm. The
results of these tests may determine the treatment options available.
Depending on the severity of the oligospermia, IUI and/or freezing
multiple specimens for eventual thaw and "pooling" may be viable
options for the less severe cases, while IVF with or without ICSI may
be appropriate for the more severe cases.
Asthenospermia:
Describes sperm that show poor movement, i.e. speed and forward
progression. Again, there is usually no clear explanation for this
abnormality, either, assuming the specimen was collected properly and
was not exposed to any harmful environmental conditions. Asthenospermic
men also have little hope of conceiving naturally, as the sperm are
unlikely to reach their ultimate destination moving at such a sluggish
pace. Again, tests for sperm function may be ordered by your doctor as
a result. There are some chemicals (pentoxyfylline and deoxyadenosine)
which have been shown to improve sperm movement when added to
IUI-prepared specimens, but have yet to become routinely accepted.
Sometimes the simple process of removing the sperm from the semen to a
biological medium as done in standard IUI preparation is enough to
improve sperm speed and progression. In many cases, however,
asthenospermia indicates the need for IVF/ICSI.
Teratozoospermia: Describes specimens containing a high percentage of
abnormally shaped sperm, also called poor morphology. Although it is
common to have 50-60% of sperm with some type of head or tail defect,
teratozoospermic men have significantly more. And sperm with abnormal
morphology are more likely to be dysfunctional when it comes to
fertilizing an egg. Thus, again, your doctor may wish to test the
functional nature of the sperm using the SPAtest, results of which may
indicate the need for IUI or IVF/ICSI.
Severe Agglutination: Describes sperm which, although thrashing about,
are clumped together with little or no forward progression.
Agglutination is sometimes the result of the presence of anti-sperm
antibodies that are particularly common in men who have had
vasectomy-reversals. Thus, your doctor will likely order an anti-sperm
antibody screen in response to a high level of agglutination in the SFA
(see Reproductive Assays Laboratory for information on how this test is
performed). Anti-sperm antibodies are created when there is contact
between sperm and immunocompetent lymphocytes in the blood. Sperm can
enter the blood stream as a result of trauma, surgery, or infection.
And just like with any foreign cell in the blood stream, these
lymphocyctes attack the sperm by creating antibodies against it. These
antibodies remain in the blood stream and are able to freely pass the
blood-sperm barrier in the testis and attack the sperm waiting there.
Once attached to the sperm, these antibodies appear to interfere with
penetration through cervical mucus and with penetration of the egg.
Women may also develop antibodies to sperm. IVF/ICSI is indicated in
cases of high levels of agglutination and/or anti-sperm antibodies.
Varicoceles
As
mentioned above, a varicocele is an enlargement of
the veins of the testicle particularly in and around the spermatic
cord. Varicoceles are usually located in the upper part of the scrotum
and have historically been reported to occur in 24 to 41% of infertile
men, although this is a controversial statistic in many circles today.
The mechanism by which a varicocele produces infertility is not well
known nor even well proven, but is generally believed to be related to
an increase in the temperature of the sperm production centers due to
the increased bloodflow in the enlarged veins. This contention is hotly
debated, however, with many specialists believing that varicoceles play
a negligible role in male infertility. In our experience at GYFT,
varicoceles are, in fact, quite uncommon in explaining a
man’s infertility. Varicoceles are usually diagnosed by physical
examination and ultrasound performed by a urologist and can be
surgically repaired by a high ligation of the spermatic vein.
You’ve probably noticed a few similarities in the treatments available
for the variety of sperm factors discussed above. IVF/ICSI is pretty
much the only viable option with the highest probability for success
when dealing with male factor infertility, regardless of the specific
nature of the problem. In fact, before the advent of ICSI in the last
several years, men with the disorders mentioned had very little hope of
becoming fathers of their own genetic children.
Congratulations on reaching the end of this section! You’re probably
the kind of person who hangs around at the end of a movie to watch the
credits in the hopes of seeing something everyone else missed. We like
that. So, perhaps we can make it worth your while by succinctly
summarizing the "work-up" process. We realize we’ve discussed the
diagnosis process in great detail and the elements of the "basic"
infertility work-up may have gotten lost in all of the information.
Here are the tests you should expect your doctor to want results for,
all of which can be performed here at GYFT. We’ve also provided links
to relevant discussions of each in case you need to be refreshed as to
why the test is important in diagnosing infertility problems.
Female: Any of the following blood tests:
Estradiol,
FSH, Progesterone, Prolactin, Testosterone, DHEA-SO4, Thyroids
Physical Exam:
Ultrasound, Post-Coital Testing, HSG
Male:
Seminal
Fluid Analysis
