Is infertility exclusively a female problem?
No. The incidence of infertility in men and women is almost identical. Infertility is exclusively a female problem in 30-40% of the cases and exclusively a male problem in 10-30% of the cases. Problems common to both partners are diagnosed in 15-30% of infertile couples. After thorough medical investigations, the causes of the fertility problem remain unexplained in only a minority of infertile couples (5-10%).
What treatment options do infertile couples have?
Several options are offered to couples depending on the type of infertility that has been diagnosed. The vast majority of female patients are successfully treated with the administration of drugs such as clomiphene citrate, bromocriptine or gonadotropins. Surgery can also be a means to repair damage to the reproductive organs, such as those caused by endometriosis and infectious diseases. Treatment options for male infertility also include the administration of drugs, surgery and assisted reproductive technologies, such as intracytoplasmic sperm injection (ICSI). Drug therapy and surgery have proved very successful for specific types of male infertility. However, in a great number of cases, the reason why men have fertility problems remains unexplained and the treatment methods applied are empirical. Some patients nevertheless require more complex medical intervention. Assisted reproductive technologies (ART) refer to several different methods designed to overcome barriers to natural fertilization such as anatomical problems (e.g. blocked fallopian tubes). One of these techniques, in-vitro fertilization (IVF), has now been practiced for more than 15 years. Overall, the estimated number of infertile patients currently treated by ART is around 40%.
I’ve seen ads for a fertility clinic that guarantees success in helping women have babies. Consider me skeptical. Can this or any other clinic really back up such a claim?
It should be the goal of every clinic to succeed in helping every couple that hopes to conceive. In reality, though, this can not be guaranteed. In our practice, we work with couples to explore the causes of their infertility and to outline all possible treatment options. By empowering couples to explore these options and participate as a partner in the decision-making process, we believe each and every couple is helped. What these ads refer to is a financial agreement offered by some clinics to couples whose history suggests that they’re likely to be successful in conceiving a child through reproductive technologies. If the couple is accepted into the clinic, they pay in advance for a specified course of treatment. If the couple successfully conceives and the woman carries the pregnancy beyond the first trimester, the clinic keeps the money. If the couple is not successful, their money is returned. In general, patients pay much more for these “guaranteed” treatments than they would for a single cycle of in vitro fertilization therapy. These programs remind me of the ancient Chinese practice that required patients to pay their physicians for staying well and not for treating illnesses.
My wife and I have been trying to conceive for two years without any luck. I had two sperm counts taken (16 million after three days of abstaining and 28 million after seven days). I have read that any count under 20 million is “functionally sterile” and the likelihood of conceiving is remote. Is a count under 20 million a great cause for concern? If I abstain from sex for longer periods of time (more than seven days) will my count increase?
The issues about sperm count are more complicated than you might realize. To begin with, there are a number of measurements involved in the semen analysis. First, we look at the concentration — how many sperm there are per milliliter of semen (the fluid). Next, I need to know how many mL of semen are present. So a count of 40 million sperm per mL with only 1cc of fluid may not be as good as a count with 16 million and 4mL. I like to see more than 20 million sperm per mL and 2-5cc of semen. Another measurement to consider is what percentage of the sperm are moving forward progressively; 50 percent motility is considered normal. The next factor is sperm morphology — that is, what percent of sperm look normal. When you assess the fertilizing potential of a given specimen, you must consider all these factors. Thus, a slight abnormality in sperm count may be compensated for by better motility or an increase in volume. So you can see this is a bit more complicated than just one number. We find that delaying ejaculation may increase the total concentration of sperm and perhaps the volume of semen. However, the percentage of normal sperm and the percentage of motile sperm decreases with infrequent ejaculation. Overall, it appears that ejaculation three to four times per week will ensure the optimum number of “nice-looking” motile sperm. If your sample shows a sufficient number of motile sperm, you may be rewarded by a treatment protocol that includes ovulation induction and intrauterine insemination.
Until about two months ago my husband was a very heavy drinker. He has had no booze in more than two months. The doctor says my husband’s sperm count was that of a 20-year-old’s, but there was little to no motility. Is there something that can be done about the motility? Could the alcohol have any effect on this problem? If so, how long will the effects last, and what can we do to correct it?
Alcohol may result in abnormal liver function and a rise in estrogen levels, which may interfere with sperm development and hormone levels. Alcohol is also a toxin that can kill off the sperm-generating cells in the testicle. As sperm take at least three months to develop, I would check his semen again after a three- to four-month period of abstinence. If no motile sperm are seen, a testicular biopsy may be necessary. If this reveals any live sperm, you may consider in vitro fertilization with sperm injection (ICSI) to introduce the sperm into the egg.
My wife and I have been trying to conceive for six years. I have been told that my body temperature is too high, particularly in my testicles, and this is the cause of my low sperm count. Is there any solution for us? I once used a device to cool the scrotum area with the slow release of water. Is this effective?
While body temperature – about 98.6 degrees F. – may be detrimental to sperm, the scrotum is designed to keep the testicles from overheating. In fact, the supportive muscles of the testicle are temperature sensitive. In a cold environment, the testicles pull closer to the body. When the body temperature rises, the muscle relaxes, allowing the scrotum to descend and keep the testicles at a more favorable temperature. A few years ago a device called the testicular hypothermia device (THD) was available. Essentially it was a water-cooled jockstrap; evaporating water kept the jockstrap a bit cooler than the surrounding environs. This was believed to benefit men with varicoceles (dilated testicular veins). Unfortunately, the role of high temperature regulation as a means to restore fertility for men with varicocele has never been convincingly proven. In fact, more recent studies suggest that varicocele surgery may be of limited value for all but large varicoceles. Rarely are any therapeutic efforts aimed at improving sperm count or function effective. After six years of infertility, I would suggest that if other fertility factors have reliably been ruled out by a trained fertility physician, you may wish to consider either ovulation induction and intrauterine insemination or in vitro fertilization for male factor infertility.
I have no problem with erection, but no semen comes out from either masturbation or even intercourse. A doctor has checked for prostate problems and it is negative. I used to be able to produce semen. I am diabetic?
You probably have a common condition called retrograde ejaculation, which is frequently seen in people with diabetes. The semen enters the penis via the ejaculatory ducts, which pass through the prostate. At the time of ejaculation, a muscle at the opening to the bladder squeezes shut. With each muscle contraction, the semen is propelled down the urethra and out the opening of the penis. However, if there is nerve damage due to diabetes, the muscle at the opening to the bladder will not close off properly, and the semen enters the bladder instead of shooting out the end of the penis. Your urologist can diagnose this condition easily by checking your urine for semen after ejaculation. If this is the problem, you may try medication to strengthen the function of the muscle that closes the bladder. Or you may have sperm collected from the bladder to use for insemination or for in vitro fertilization.
My husband was just started on a series of testosterone injections for a low testosterone level (198). His semen analyses were very variable — 17.1, 5.1, 50.5 and 21.5 million with good motility and morphology, but with low volume (1.5-3mL per specimen). Do you think these injections will help?
Low testosterone may result from two different types of abnormality. The first, a failing testicle, is identified by the blood FSH level (too high a level means the testicle is failing) or small, very firm testicles, which may indicate previous infection or damage. The second condition occurs when the testicle is not receiving appropriate hormonal stimulation from the pituitary gland, which releases the hormones LH and FSH. LH stimulates the testicle to produce testosterone, while FSH stimulates sperm production. In this case, examination of the testicle may demonstrate normal to small testicular size with a softer-than-normal consistency. Testosterone supplementation would not usually be the first treatment considered for infertility associated with low testosterone. In my experience, the use of testosterone injections may actually depress sperm production further. After a thorough medical history and examination and a blood test to confirm normal liver function, I would consider the use of clomiphene, 1/2 tablet every other day. After three months a beneficial effect may be seen on semen analysis. In your husband’s case, it would appear that all but one of the specimens for semen analysis ( 5.1 million sperm/mL) were normal. I would suggest consideration of clomiphene therapy followed by a repeat semen analysis after three months. If infertility persists, ovulation induction combined with intrauterine insemination would be the treatment of choice.
How long should one wait after a varicocelectomy to see results? I have heard three to nine months. My husband had a varicocelectomy three months ago and the summary says there has been no significant results. Is this likely to improve with time? Exactly how is the surgery supposed to help, and why might it take a while for results to show?
A varicocele is a dilation (enlargement) of the veins of the scrotum. This pooling of blood in the testicle causes an increase in temperature, which may interfere with the testicle’s production of sperm. Up to 60 percent of men with varicocele will note an improvement in their sperm production after surgical repair. Repair consists of tying or clipping the veins. This is performed through a small incision in the groin. Improvement can be seen in as little as three months, and further improvement may be seen for up to two years. If you see no improvement at all by six months, you should consider alternative therapies.
We have been married for four years, and my husband has a very low sperm count (10,000) with very little motility, dead sperm and deformed ones. The doctor said we should do intrauterine insemination. Is this painful for the woman? Does it work in a situation like ours? Can we use my husband’s sperm?
Intrauterine insemination (IUI) should not be painful. If the semen specimen is properly prepared before insemination and the procedure is performed by a skilled physician, your discomfort should be limited to mild cramping. In your case, IUI will work only if you choose to use donor sperm. Pregnancy is unlikely using your husband’s sperm for insemination. With sperm counts that low, the only successful approach is to perform in vitro fertilization with intracytoplasmic sperm injection (ICSI). With that procedure, results depend in large part on your age and not his sperm count, as long as a few hundred motile sperm are available. If his urologist has ruled out obstruction as the cause of the abnormal semen analysis, you may wish to consider genetic testing. In about 10 percent of cases, a genetic abnormality or an abnormality in a small section of his DNA (called a microdeletion) may be responsible for the problem. If this is the case, you will need to be aware that the particular defect could be inherited by a male offspring, who may subsequently have fertility problems.
My husband had a sperm count done and it showed not even one sperm. He then had an LH and an FSH drawn. Both were somewhat elevated. His urologist told him that he shouldn’t bother to do any further testing. Is this true? Or are there any other tests or procedures that can be done to see if he is able to produce sperm?
What you were told is NOT true. There are many conditions that might result in an absence of sperm in the ejaculate. We divide these conditions into three main classifications. The first possibility is failure to stimulate sperm production by the testicles. Sperm production depends on appropriate release of the hormones FSH and LH from the pituitary gland – no LH/FSH, no sperm production. In your husband’s case, the FSH and LH are slightly elevated, so let’s cross this problem off our list. The next possible culprit is “outflow obstruction.” The sperm are produced in the testicles and mature in a nearby structure called the epididymis. Then the sperm pass through the vas deferens and ejaculatory ducts, through the prostate and penis and out of the body. If any of these passages are absent or blocked, sperm cannot reach the ejaculate. Clues can be obtained by noting the volume of ejaculate. If ejaculate volume and hormone levels are all normal, the problem might be a blockage close to the testicle, which might be caused by infection. If volume is low, there may be a neurological abnormality that allows the sperm to be diverted into the bladder, rather than taking the correct path down the urethra to escape the male genital tract. Or there may be a blockage in the prostate gland that can keep the sperm volume low. If this is suspected, the urologist will check the bladder for sperm after ejaculation or perform a prostate ultrasound. While obstruction may be repaired with microsurgery, the most cost-effective option is to surgically retrieve and cryopreserve (freeze) sperm for later use in IVF and ICSI, procedures in which eggs are retrieved and a single sperm is injected into each egg. The final possible culprit is the testicle. Is it doing its job? The physical exam may provide clues. Is one of the testicles small & firm? Is there a dilation of veins (varicocele) surrounding the testicle? These findings may suggest testicular failure. Other tests may indicate that the testicle does a great job when it comes to making the male hormone testosterone, but fails to make sperm. The elevated FSH is a clue to this condition. This diagnosis is made by taking a small biopsy from the testicle, a simple outpatient procedure. If no sperm-producing cells are seen, a condition called Sertoli-cell-only syndrome is diagnosed. But the results can be misleading. It is best to do this in a fertility laboratory, because often live sperm cells can be missed after processing. If an embryologist is present at the time of biopsy, any live sperm can be cryopreserved for later use in an IVF cycle. If the initial specimen is inadequate, additional biopsies or a biopsy from the other side may provide adequate sperm for cryopreservation.
I am 37 and have no children. I have been diagnosed as having a thin endometrium (3-5mm). Since July 1997 I have had two miscarriages (one blighted ovum and one lost between 8-12 weeks after a heartbeat was detected at eight weeks). I had spotting and bleeding in both cases and D&Cs with both. I am now on a second round of a hormone treatment with Progynova & Provera after an ultrasound checkup showed a first round produced no visible improvement. This time an estrogen patch will be used & Sildenafil(Penegra) will be advocated for use vaginally. Are there any additional ways to improve the endometrium thickness — say, diet, homeopathic remedies, acupuncture, etc.? Can you suggest any other sources of information on this topic?
Thin endometrium at the time of ovulation can be a concern and may be a factor in poor placental development and miscarriage. Normally, in response to estrogen, the uterine lining or endometrium grows about 1-2mm every other day. By the time of ovulation, I like to see the endometrium at least 8mm thick. The endometrium also has a very specific ultrasound appearance marked by three bright lines. This is often called a grade-C or triple layer pattern, and it is a good sign. Failure to develop a normal uterine lining may reflect any of several factors such as infection, scarring from D&Cs, low estrogen levels, poor uterine blood supply or maybe endometrial antibodies. Clomiphene (Clomid) is an anti-estrogen and as such can block the stimulatory effect that estrogen has on the endometrium and cause thin endometrium. If clomiphene is the problem, other ovulation induction medications may be chosen. Uterine leiomyomas or a condition called adenomyosis may also predispose to thin endometrium. While adenomysosis may be successfully addressed with a GnRH-agonist such as Zoladex, success has been limited. The use of antibiotics or antioxidants such as vitamin C has been proposed, but these too are rarely successful and little supportive data exist. “Thin endometrium” is a finding — not a condition or disease or syndrome. As such there are few, if any, research papers addressing this problem specifically. I suggest that your physician try to determine the cause in your case; then you can seek information about that particular condition. Unfortunately, for most women with this finding, no discernible cause is identified and treatment is rarely successful.
Does Viagra have any effect on sperm in a man trying to have a child? Does it affect the sperm count, mobility, etc.?
Viagra has no known effects on sperm production, morphology (shape), motility (movement) or count. If a man has organic impotence — meaning the problem is due to a medical rather than psychological condition — then Viagra may improve the chances for achieving conception simply by restoring potency. Remember, though, that while Viagra can improve rigidity, it does not necessarily bring about ejaculation. Many men with impotence may have diabetes or other conditions that affect the penis. In this situation, the muscular sphincter that constricts to help ejaculate the sperm may not close properly. In such a case, retrograde ejaculation occurs: The sperm are shot into the bladder rather than out through the penis to begin their journey to find an egg. If your partner is concerned about his fertility, I would suggest that he consider a semen analysis, regardless of whether Viagra helps his performance. If he has psychological impotence, counseling may be very helpful to ensure that pregnancy is advisable.
After years of trying, my husband and I finally had a baby girl through in vitro fertilization. I don’t want her to suffer with fertility problems as an adult. Is it possible that infertility is hereditary?
Genetics sometimes plays a role in both female and male infertility. If you suffer from endometriosis, your daughter is at increased risk for the same condition. Endometriosis, which affects about 10 percent of all women, can cause tubal infertility. Another condition that could be hereditary is polycystic ovarian syndrome – a source of ovulation problems. There also seems to be a genetic component to certain aspects of male factor infertility. A small percentage of men have microscopic abnormalities in the DNA of the Y chromosome that leads to their infertility problems. With the advent of in vitro fertilization and ICSI (taking a single sperm and injecting it into the egg) many of these men pass this genetic defect to their offspring. But DNA isn’t necessarily destiny. And even if your daughter does suffer from infertility, it’s unlikely that her struggle will be comparable to yours. When we compare our present understanding of infertility and its treatment with that of 20 years ago, we realize that we have made remarkable progress. Our ability to identify the cause of infertility and develop cost-effective treatments continues to improve. I suspect that when your daughter comes of age, the diagnostic and treatment options that will be available to her will certainly be different and will likely make the process of infertility treatment much less of an ordeal.
How successful is infertility treatment?
When talking of success rates for any type of infertility treatment, one should bear in mind that the average chance to conceive for a normally fertile couple having regular unprotected intercourse is around 25% during each menstrual cycle. It is estimated that 10% of normally fertile couples fail to conceive within their first year of attempt and 5% after two years. Comparable to normal fertility rates, effective treatments can be expected to have, on average, up to a 25% success rate per cycle of treatment, and may therefore need to be repeated several times before a pregnancy is achieved. Simple ovulation induction to compensate for hormonal imbalances has a very high success rate; more than 80% of women suffering from such disorders are likely to conceive after several cycles of treatment with drugs such as clomiphene citrate or gonadotropins.
Are there particular factors influencing the success of a treatment?
In any type of infertility treatment, important factors need to be taken into account when referring to success rates. The age of the woman and the duration of the couple’s infertility are likely to influence the success of treatment. In women, fecundity decreases as age increases, particularly after 40 years of age. When the woman is being treated, her chances of conceiving can be lessened if her partner also has infertility problems (e.g. poor quality sperm).
After having sex, most of the semen leaks out of my vagina. How can we prevent this? Should we change our sexual technique? Could this be a reason for our infertility?
Loss of seminal fluid after intercourse is perfectly normal, and most women notice some discharge immediately after sex. Many infertile couples imagine that this is the cause of their problem. If your husband ejaculates inside you, then you can be sure that no matter how much semen leaks out afterwards, enough sperm will reach the cervical mucus. This leakage of semen ( which is called effluvium seminis) is not a cause of infertility. In fact, this leakage is a good sign – it means your husband is depositing his semen normally in your vagina ! Of course, you cannot see what goes in – you can only see what leaks out – but the fact that some is leaking out means enough is going in!
What about success rates of IVF?
Overall, success rates for IVF have steadily improved over the last ten years. Birth rates for IVF vary according to the expertise of the centers practicing this technique. However, centers in Europe have reported pregnancy rates after one cycle of IVF equal or superior to 25%. In 1993, the French IVF registry (FIVNAT) reported a pregnancy rate of 25.4% per embryo transfer on a total of 23,025 oocytes retrieved. Based on such results, after three to four cycles of IVF, a woman under 40 whose partner does not have any fertility problems could reasonably expect to give birth. Again, in general, success rates may vary from one center to another, since they are influenced not only by the level of expertise of the medical team but also by the characteristics of the patients treated. A clinic treating a large number of women over 40 is likely to report lower success rates than a clinic having a majority of patients under 35.
Are there particular health risks for women undergoing infertility treatment?
Along with their intended benefits, drugs used to treat infertility may on occasion cause side effects. In ovulation induction, close monitoring of follicular growth is crucial to ensuring successful treatment. Monitoring techniques (such as ultrasound scan and blood tests) and adequate use of treatment protocols help the physician to avoid ovarian hyperstimulation syndrome (OHSS) and minimize the risk of multiple pregnancy. Current treatment protocols have been designed to reduce the risk of multiple births and OHSS.
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