Diagnosing Infertility Infertility is defined as the inability of a couple to achieve a pregnancy after a year of unprotected intercourse or the inability to carry a pregnancy to a live birth. There are two general types of infertility. Primary infertility is used to describe a couple having difficulty conceiving who has never had a baby before, while secondary infertility describes a couple unable to become pregnant again after already having a baby together.   Infertility is probably more common than you think. It is estimated that as many as 8% of couples have difficulty conceiving. Most couples take having children as a given, simply waiting for the right time in life to stop using birth control and then have babies immediately thereafter. For many, this is how it happens. Others are confronted with the realization that having a baby may not be so simple after all. Because there are quite a few physiological steps critical to successful conception (with a disturbance of any one of them capable of causing some degree of infertility) it may be helpful to first learn about the reproductive process so you can decide for yourself when and if it’s time to seek physician assistance to correct any potential problems. If you determine from the information that you may have a problem, your infertility specialist (a GYFT doctor, no doubt) has a variety of treatments available to accurately diagnose and remedy the situation to provide you the best possible opportunity to conceive.   Let’s ease into the whole infertility thing by running through the typical process of how reproductive disturbances are identified by your GYFT Clinic physician, and once found, how many of these problems are most effectively treated. And rather than start throwing a bunch of medical terms and definitions out at you, we thought, at least at first, that it would be valuable to describe the events that take place during a routine infertility consultation (and don’t worry, you’ll have plenty of medical terminology to grapple with elsewhere in this site). In doing so, our hope is that you will get a feel for the process of exchanging information with our clinical staff, what sort of tests are initially recommended and why, and more importantly remove the element of surprise from your first visit if you choose to come see us. If you know what to expect, we believe you’re more inclined to have a comfortable, hope-filled consultation as opposed to a nervous, when-are-they-going-to-stick-me-with-a-needle, I-hope-they-don’t-expect-me-to-give-them-a-sperm-sample-today kind of appointment. Don’t get us wrong, there will be needles to stick and sperm to collect at some point during your treatment, but at least by reading on, you’ll know when to expect it.   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). Both 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