Diagnosing Infertility

Like a lot of 20-somethings, school psychologist Kimberly Picinich was doing all the right things to try and have a baby with her husband. She had used oral contraception for many years, starting as a teen in order to regulate her frequent and lengthy menstrual periods.

When the time was right for the couple to start a family, she stopped taking birth control pills, knowing it may take some time for her body to begin ovulating again. She was healthy, young, and ready to be a mother.

Then, it seemed as though all of her efforts were futile. After stopping the pill, Kim had one regular cycle. Beyond that, her cycles were anywhere from 35 to 75 days in length. Without any other symptoms of health problems, the 29 year old just knew something was wrong.

Kim and her husband had been very proactive (Kim refers to herself as “such a planner”). They’d consulted with her OB/Gyn for pre-conception planning and then followed up again in six months. Her physician wanted to try regulating Kim’s periods by managing her insulin levels with glucophage, a drug that has been favored by fertility specialists for treatment of polycystic ovarian syndrome (PCOS). After a couple of months using glucophage with no effect on her ovulation, Kim became frustrated.

A Team Approach to Care

A friend who had been a patient of Dr. Stephen Greenhouse at Shady Grove Fertility suggested Kim call the Center. “I wasn’t even sure if I was someone they would see at that point,” recalls Kim, “but they said yes,  and an appointment was scheduled.” Before the consultation, Kim felt she needed to have a difficult and frank talk with her OB/Gyn, who had been her trusted primary care physician for several years. It was a big step for Kim, who felt like her request to see a specialist implied that she was second guessing her primary doctor.

“Oh, I think I actually cried in her office,” Kim admits. “But she was just so understanding and supportive.” Like a lot of new patients, Kim wasn’t aware that seeing a specialist did not mean that she had to discontinue being a patient of her primary care physician’s practice. In fact, Dr. Greenhouse and Kim’s gynecologist continued to work together for the patient’s benefit, collaborating on Kim’s treatment issues and needs once she was diagnosed at Shady Grove as having PCOS.

Kim didn’t have the classic visible symptoms of PCOS, like male pattern hair growth, but her hormone levels indicated to Dr. Greenhouse that indeed she had the syndrome. Her gynecologist had previously tested Kim, but had determined that her level of symptoms didn’t warrant a PCOS diagnosis. “I’m pretty asymptomatic, except for the menstrual disorder,” explains Kim.

Since treatment with glucophage had already been unsuccessful for Kim, Dr. Greenhouse prescribed a stimulated cycle with intrauterine insemination (IUI), using clomiphene citrate (an oral tablet, commonly known as Clomid) and injectables – Follistim, hCG, and progesterone. As is common in many women with PCOS, Kim became hyperstimulated, meaning that her body produced too many eggs to have a safe IUI outcome, so the first cycle was cancelled.

That’s when the additional diagnostic experience of a fertility specialist made a big difference for the young couple, who were going on a year of trying to conceive without success. A cyst was seen during ultrasound monitoring for her second IUI cycle. They tried a similar protocol without Follistim, but Kim didn’t conceive. Eventually, Dr. Greenhouse determined that the cyst, a type called dermoid, was too large to go untreated surgically.

Kim’s OB/Gyn performed laparoscopic surgery to remove the cyst, in addition to some previously undetected endometriosis. The two physicians communicated on behalf of their mutual patient, who took a month off from trying to conceive after surgery before trying another IUI at Shady Grove Fertility.

Being Proactive Pays Off

In Kim’s case, the third time was certainly the charm. As she says with a laugh, “I’ve been kicked out of Dr. Greenhouse’s care.” The reason: she is pregnant. Typically, fertility patients who succeed in conceiving move on to their obstetrician within the first trimester.

She and her husband hope to pursue subsequent pregnancies, but for now, they’re thoroughly enjoying this one, even with the nausea. “I think about whether we’ll go through fertility treatment for future pregnancies, and I’m not sure. I feel like I have a new body, without that cyst and the endometriosis. But I stay aware that ovulation may be a future issue for me and if that’s the case again, we won’t wait this time before going to Shady Grove.”

Kim’s story illustrates a common patient perspective. “I was afraid to seek out a specialist, and so many people kept saying ‘you’re young, it takes time’… but in a 12-month span, I’d only had four periods. Even though my doctor was very supportive and she’s a really positive person,

I don’t think she would’ve recommended my seeing a specialist if I hadn’t brought my concerns to her attention.”

Kim, who is now gratefully a few months pregnant, says “I really think that I would’ve never gotten pregnant without that help.”

“There were times when I thought maybe I just wasn’t meant to get pregnant,” the mother-to-be reflects. “I think a lot of people say wait the full year [before seeing a fertility specialist], but I tell everyone now if you don’t think things are right, see someone, don’t wait.”

There are times when some people just know there could be a problem. Call it worry, intuition, or education — occasionally, fertility patients are people whose strong first suspicions are confirmed by physician diagnosis. For them, getting to the point of choosing fertility treatment can often provide a sense of relief.

Take, for example, Chris.

“We knew there was a problem… I knew there would be a problem. I just didn’t know to what extent,” the man in his mid-thirties says, describing the time before his own worries were confirmed at Shady Grove Fertility. After a few years had passed, Chris and his wife, Ronda, had done all the investigating and soul searching they needed in order for Chris to decide “Let’s just do this.”

The Problem

Chris was diagnosed with diabetes over 15 years ago. He admits that his response to the diagnosis was like that of many young men. “I wasn’t too on top of taking care of it.” In addition, Chris eventually learned that he needed treatment for hypertension.

Over time, diabetes and hypertension both take a toll on several of the body’s systems. According toDr. Frank Chang of Shady Grove Fertility, “Patients can have a higher risk of retrograde ejaculation, possibly as the result of the disease process itself or resulting from medications used to treat the disease.”

Retrograde ejaculation occurs when sperm cells enter the bladder rather than being propelled through the urethra during ejaculation. Other conditions that could lead to retrograde ejaculation are multiple sclerosis, spinal cord injury, back surgery, and the most common cause, surgery of the lower bladder or prostate. Chris was knowledgeable about the potential reproductive system damage from his diabetes. By the time he and Ronda wanted to start a family, he believed from the start that fertility treatment may be warranted.

The Cautious Approach

The couple, who have known each other for 17 years, had always wanted children after their first two years of marriage. As time passed, they found themselves surrounded by family and friends who were having their own children. Speaking together, the couple echo each other’s sentiments:
Chris: “We always wanted kids…”
Ronda: “… but we never put a time limit on it…
Chris: “Well, maybe, like, 35 [years] when you start doing the math. The big factor was everyone around us was having babies, so you start wondering ‘why not us?'”

About their first attempts to conceive naturally, Ronda remembers, “We realized something was going on here, and we needed to get it checked out.”

“I didn’t need a doctor to tell me that it was me,” recalls Chris.
They went to Shady Grove Fertility for an initial consultation. Then the couple stopped pursuing treatment for reasons that are only now vaguely clear to them. “We hadn’t known anyone back then who gone through fertility treatment. It sounded like the cost would be too much. It was all just too much information at once,” Ronda explains, “ It was overwhelming”.

Five years later, things fell in place. A family member had successfully achieved pregnancy with the help of fertility treatment. A friend who had recently been successful with fertility treatments recommended they try again. Ronda reflects on how timing isn’t always predictable. “It was a different time, things were better as far as the treatment options Shady Grove told us about… maybe we just hadn’t been ready up to that point.”

Chris feels like his health issues prompted a sense of mild urgency to have a child. He’s been in and out of the hospital more than once recently to combat his Stage 3 kidney disease, a consequence of diabetes. “My brother had a daughter, I’d always wanted a child. It was time,” he says assuredly.

The Decision

After a few rounds of blood work to get at the root of the couple’s infertility causes, the decision was made to pursue IVF using Chris’ sperm after trying to alkalize it. Dr. Chang explains the retrograde sperm recovery process. “Sperm cells can be retrieved from urine following ejaculation. Sometimes the result is cells that are too acidic so we administer an alkalizing agent.”

In Chris’ case, that would mean drinking a lot of Alka Seltzer. “I drank that stuff on two different occasions,” he describes. “I started to wonder if this was a waste of time. The second time, drinking it made me ill, so I said ‘no’ to their request for a third attempt.”

Though he spent his younger years mostly ignoring his diabetic condition, a more mature Chris followed up regularly with his primary care physician. He knew from those visits that he’d always had too much protein in his system. His sense of urgency combined with knowledge of his own medical conditions translated to decisiveness, which he communicated to his Shady Grove treatment team. “They were trying to deter me from surgery. I think their primary concern was the pain involved. I told them that the pain wasn’t a problem; we want a child. I said ‘let’s just do this’, and they heard me.”

The Resolution

While the couple’s cause of infertility was male factor, treatment required full participation of both partners. Any time IVF is the chosen therapy, much of the time and discomfort is placed on the woman’s shoulders because of preparatory drugs used and related monitoring appointments.

“All the shots I had to go through… it wasn’t too bad,” Ronda recalls as she and Chris both laugh.
“Well,” he jokes, “you know hindsight.”

But Chris went the extra mile, something Ronda says he does in lots of situations. “He was more involved in our wedding than any man I’ve known.”

“I don’t know about other guys,” Chris modestly reports, “but being involved in this whole thing makes you appreciate it so much more.”

He describes how he would sometimes be one of the few men in attendance at Shady Grove Fertility’s IVF education classes. “I could see from the information they were giving on the whole process — from the egg retrieval to embryo transfer — that it might seem there’s no reason for the men to be there. But there was at least one woman who was texting her husband back and forth during the class, and it became apparent how much Ronda needed me to be there.”

Ronda concurs, “There’s so much information to absorb, it was incredibly helpful for him to be there, hearing it from the staff just as I was so we could compare notes later.”

The couple gives high marks for instructive and empathetic support to both Dr. Chang and their IVF nurse, Kavitha Fernando RN. As for the doctors’ concerns about painful sperm retrieval surgery, Chris says it was a breeze. He was under intravenous sedation, during which time sperm cells were aspirated directly from his testes with a special needle, and the entire procedure took around 15 minutes. “I may have psyched myself out or something,” Chris offers as an explanation for why he had no pain at all, before, during, or after the procedure. “Or it may be because they only had to go in with the needle one time.” Meanwhile, Ronda was undergoing egg retrieval at the same time.

“The whole process, for both of us, took only 45 minutes,” she reports. The physicians retrieved 18 eggs, and lab technicians fertilized 15 of them. The couple conferred with their treatment team and, because of Ronda’s petite size and related concerns about potential multiples, the choice was made to transfer only one embryo of very high quality.

The result: Ronda is due with the couple’s first child in December.

The Future

“We don’t care if it’s a boy or a girl,” Ronda and Chris agree. “We’re just happy to be having a baby.” If they choose to try a subsequent pregnancy with their remaining three frozen embryos, it will be soon. Chris’ kidney disease is manageable right now, controlled with nutrition and medication. Still, he’s a realist.”Age-wise, I want to be fair to my children,” says the newly expectant father. “I want to be young enough to really enjoy them.”

While he admits, like so many of us, that if he knew then what he knows now, “I would’ve done things differently and taken care of myself more.” That slight regret, though, recedes further into the background as the time for his child’s arrival approaches, thanks to technological advances in fertility treatment and to his own clarity of decision.

For more information or to schedule an appointment with one of our physicians, please speak with one of our friendly New Patient Liaisons by calling 888-761-1967.

Things are progressing. You’ve had your new patient consultation, and met with your doctor and your nurse. You’ve had a chance to discuss insurance, benefits and/or payment issues with your financial counselor. Any needed pre-testing (bloodwork, HSG or semen analysis) has been obtained and reviewed by your clinical team. Your doctor has recommended a treatment plan, and you are almost ready to start a new phase of your fertility journey!

Before you proceed with your treatment cycle, you will need some final education. Your nurse or clinical assistant will share and review a written ‘protocol’ of your proposed treatment. This written protocol sheet serves as a combination of calendar and instructions for your upcoming treatment cycle. It provides instructions on when to call the SG office, when to come into the office for ‘baseline testing’ (bloodwork and/or sonogram to confirm your ovaries and uterus are at a ‘baseline’ stance), and when to take any recommended medications.

You will make sure that if you are taking any injectable medicine, that you have signed up and completed an injection class. Your nurse or clinical assistant will remind you to read and return your signed treatment consent forms.

When it is time to start a ‘treatment cycle,’ usually you are instructed to place two phone calls. One call is to your office front desk, who will make your appointment to come in the first few days of your menstrual cycle. Additionally, you will be asked to contact your primary nurse, who will verify your cycle start instructions, as well as make sure your orders are in the computer. This will insure your care is streamlined when you arrive at the office.

Monitoring: What is it?

‘Monitoring’ is a general name for the morning activities of ultrasound and bloodwork testing, to evaluate how a woman is responding to her treatment. The results of the ultrasound and/or bloodwork are reviewed each day by the physician, and further instructions for continued treatment are shared by the patient’s nurse.

Whether you are having a ‘natural cycle’ (no medication) with timed intercourse, an IUI (Intrauterine Insemination) cycle, IVF (in vitro-fertilization) or donor egg treatment, monitoring is a part of each woman’s treatment plan.

• IUI: Either oral or injectable medication may be introduced to encourage follicle growth. With monitoring, ovulation timing is determined, and an office IUI is scheduled.
• IVF: Injectable medications are given, and monitoring appointments are necessary to observe the number and size of a woman’s follicles. Medication dosing is then adjusted, based on the monitoring results.
• Donor Egg: Donor patients are given injectable medication, to induce follicle growth, like the IVF patients. Recipient patients are given injectable medication to encourage uterine lining growth, for placement of an embryo at the appropriate time.

The Monitoring Team: Who You’ll Meet

Your morning monitoring team is a well-orchestrated group of professionals whose daily focus is to insure you have a safe, efficient and caring appointment. It begins at the front desk, where the PSR (Patient Services Rep) will check you in for your appointment.

The monitoring MAs (Medical Assistants) will draw any needed bloodwork, and take you to the ultrasound area. There, one of our registered sonographers and/or a Shady Grove physician will perform the ultrasound examination and provide feedback. Additionally, one of our SGF nurses is typically available to answer questions, offer clarity, provide additional prescriptions prescribed by the doctor, or other services as needed.

The office financial counselor is usually available in the mornings for any financial questions. And at checkout, our PSR can help make any additional appointments.

The First Step: Baseline or Premed Testing

A blood pregnancy test and an ultrasound are done in the early days of a woman’s menstrual cycle (typically days 2, 3, or 4). The purpose of this ‘baseline’ is to assure that the patient is not currently pregnant, her blood estrogen is low, and her uterine lining thin. This accompanies an ultrasound assessment to assure there are no significant ovarian cysts, and measure the resting antral follicle count (AFC). These measurement parameters signal the best time to begin a treatment cycle.

Once your physician has reviewed the results of your blood work and ultrasound, you will receive a phone call from your nurse, typically in the afternoon, to begin your medication protocol and to make an appointment for your first monitoring appointment.

Monitoring Begins

No matter what treatment type you are embarking on (excluding donor recipients), monitoring will include two factors: blood estrogen level testing and ultrasound to view follicle growth and uterine lining.

Monitoring Blood Hormone Levels
The estradiol (blood estrogen) or ‘E2’ level is produced inside the developing follicle. The blood estrogen level helps correlate appropriate growth of the egg follicle and can alert the SG doctors and nurses to an increasing risk for hyperstimulation. We are not looking for a specific estrogen level, but rather a progressive growth.

The blood LH level indicates when a woman is about to ovulate. This helps with the timing of ‘timed intercourse’ and IUI treatment cycles. This LH level is drawn in some of our IUI patients’ cycles.

Monitoring Egg (Follicular) Growth
Either simply time or medication may be used in a treatment cycle to help promote egg (follicle) growth. ‘Ideal’ follicular development is based on treatment type. If a woman is not ovulating at all on her own, doctors may try to mimic Mother Nature and attempt to get a single egg to grow.

During monitoring, the clinical team will be looking for the normal, progressive growth of a single follicle. If a patient is being monitored for an IUI cycle, the focus will be on a low number of follicles (egg sacs) exhibiting normal growth progression. In an IUI situation, we try to limit the number of follicles so that a multiple pregnancy is avoided. The exact number is dependant on the woman’s age, the egg quality and diagnosis. For example, a younger woman might be looking at 1-2 follicles, whereas in a 38-year old patient, the ideal number may be 3-4 eggs.

Egg (follicular) growth ‘monitoring’ is obtained through the use of a transvaginal sonogram. This relatively painless office procedure is performed by one of our registered ultrasound technicians and/or one of the SG physicians. This view provides immediate visualization of how the ovaries are responding to time and/or medication.

Uterine Lining Growth: Important for Embryo Implantation
Around days 6 or 8 of a cycle, the uterine lining (endometrium) begins to ‘thicken up.’ This is visualized as an increased area seen on the patient’s ultrasound. Lining growth is dependant on the estrogen levels, and how advanced the follicle growth is occurring. This is an important parameter that is watched during monitoring, to insure an optimal environment for embryo implantation.

It is not uncommon to have slower development of this uterine lining. This simply means a patient’s treatment cycle may take a bit longer. Again, this is not uncommon in women who have had historically longer cycles, those patients with PCOS, or those with hypothalamic amenorrhea.

Sometimes our patients respond to medications in differing ways. Occassionally we find that a woman’s uterine lining is too ‘thin.’ That may be related to medication. For example, while Clomid is a medication that assists ovulation, it also has some anti-estrogenic effects, making the endometrium thinner. This issue may be overcome with an estrogen replacement medication.

Physician Results Review and Cycle Instructions

The patient’s monitoring results from ultrasound and bloodwork are reported in the computer, where they are available for your primary doctor to see. Each day, Shady Grove Fertility has a results review, where the ‘Results Doctor’ and your primary doctor review your results and make dosing decisions.

You can expect to receive a call with your instructions between 4:00 – 6:00 pm. In addition to your primary doctor, you may have several other specialist physicians reviewing your cycle progress. This is a wonderful value of having a larger fertility practice: more expert eyes are involved in each case.

Convenient Monitoring Locations for Patients

Electronic medical records (EMRs) make it very easy for our patients to be followed by your primary clinical team, no matter where you decide to do your cycle monitoring. Our patients may schedule their monitoring appointments starting at 7:00 am in any of our 13 full-service locations Monday-Fridays, and on the weekends there are four locations open for monitoring (Annandale, Annapolis,Baltimore and Rockville). We know that your time is valuable, so our staff makes every effort to make sure your monitoring appointment goes smoothly and efficiently.

Triggering Ovulation

The decision to ‘trigger’ or induce ovulation is based on a combination of factors-the length of stimulation, the number of mature follicles, the blood estrogen levels, the type of treatment, and the patient’s personal history, among others. Follicles are considered ‘mature’ when they measure between 18-20mm.

When the timing is right, the patient will be instructed to take a trigger shot to mimic the LH surge in the natural cycle. Luteinizing hormone (LH) prepares the eggs for the final stage of maturation and ovulation. Patients doing timed intercourse or intrauterine insemination cycles will be instructed to take an injection of HCG. Our IVF patients will be instructed to give themselves an injection of HCG or Lupron. Lupron is given when monitoring has indicated patients are at a higher risk of hyperstimulation.

Sometimes Things Change – Being Flexible

While we try to share plans and expectations in a timely manner, there are times when situations change. It may come in the guise of needing additional medication, a different appointment time, or responding to the protocol in unexpected ways.

Please know all the SGF staff is here to assist you on your treatment course. Your flexibility will be a useful tool if you need to navigate the roads of unplanned medications, differing appointment times, or unexpected treatment response.

Some of our patients may require additional medications than originally planned, to obtain an optimal treatment response. This may cause distress in not only obtaining the medication, but also with costs. We wish your cycle to proceed optimally, and we have your best interest at heart. We will work with you to address any such changes in your treatment protocol.

Support for the Journey

Monitoring is something that nearly every patient experiences. To help you navigate the journey, Shady Grove Fertility offers many support services to assist our patients including:

• Psychological Support Services, including groups and focused discussions
• Our SGF Facebook page is an online community of active patient support
• Complementary and alternative medicine provides services as acupuncture and massage
• Blogs and our SGF website

Depending on the patient and her treatment regime, ‘morning monitoring’ may be 2, 3, 5, or 6 morning appointments to assess your status. This is an important time in evaluating your response to prescribed treatment, and making adjustments along the way. SG’s goal is to optimize your response to make this the most successful treatment for you.

For more information or to schedule an appointment with one of our physicians, please speak with one of our friendly New Patient Liaisons by calling 888-761-1967.

Male infertility is a reproductive problem which may affect a man’s ability to father a child. Some of the problems associated with male infertility include: poor quality or quantity of sperm production, hormone disorders, genetic disorders, trauma to the reproductive organs, obstructions within the reproductive organs and impotence or erectile dysfunction.

How common is male infertility?

Related Stories   Male Factor Impedes Conception   Multiple Factor Infertility

About 50% of all infertility cases are due to the male factor being abnormal or subnormal. Over the past 20 years, data has shown that approximately 30% of cases are due to just the man alone while another 20% of cases show that both the man and women are abnormal.

What are some factors that could affect male infertility?

There are many risk factors that affect a male’s fertility include smoking; excessive consumption of alcohol; recreations drugs such as anabolic steroids, cocaine, or heroine; sexually transmitted diseases; hot baths, saunas and spas; being underweight or overweight; and exposure to toxins such as heavy metals, industrial chemicals and radioactivity. These factors can affect the quality of semen, decrease sperm counts and have an overall negative effect on the reproductive system.

Does masturbation affect fertility?

No. Masturbation does not affect a man’s sperm count nor does it cause infertility.

Does a man’s age play into his fertility?

A man’s fertility does decline as he ages. While it is not as dramatic of a decline as in women, it has been estimated that the amount of semen ejaculated and sperm motility begins to slowly decrease from the age of 37.

How is male infertility diagnosed?

If male infertility is suspected in a couple, then the man will undergo a testing protocol that includes a physical examination and a semen analysis. A blood test may be ordered as well to check hormone levels.

What is a semen analysis?

Semen analysis is a test that examines Sperm Count (concentration); Volume; pH; Motility (percentage of moving sperm); Progression (motion and forward progression); Viscosity (consistency); Morphology (percent of normal forms); and the presence or absence of white, red blood cells, or immature sperm.

Why would I be asked to repeat a semen analysis?

Often times, sperm counts may fluctuate from one specimen to the next, so a doctor may want to evaluate a several different samples over several weeks or months.

How do I know I am getting accurate results on my semen analysis?

Shady Grove Fertility’s andrology center is the largest male infertility testing laboratory in the US, and has one of the most reliable semen analysis testing protocols in the country. In 2008 alone, our team of 12 specially trained and experienced andrologists performed 4,800 comprehensive semen analyses for Shady Grove Fertility patients and patients who have been sent to the Center by more than 750 referring physicians. Samples brought to Shady Grove Fertility’s andrology center are processed and evaluated within two hours of a fresh specimen being collected, and results are usually available to the patient and their physician 3-to-5 week days following their appointment.

What are treatment options for male infertility?

If a man is diagnosed with infertility there are many treatment options he and his partner may undergo to try and achieve pregnancy:

• Intrauterine Insemination (or IUI) is when the sperm is washed to separate it from white blood cells and prostaglandins in the semen and then inseminated into the uterus around the time of ovulation.
• In Vitro Fertilization (IVF) is when a woman’s eggs are retrieved and then fertilized in a lab with the man’s sperm. This fertilization may be accomplished with Intracytoplasmic sperm injection (or ICSI). This is when one sperm is injected directly into the egg using a tiny glass needle. The embryos are then incubated and transferred to the uterus.
• If a man has a low sperm count or has problems ejaculating, techniques such as PESA or TESE may be utilized. Percutaneous epididymal sperm aspiration (or PESA) is when a doctor penetrates the scrotum with a needle and draws sperm into a syringe. Testicular sperm extraction (or TESE) is the use of gathering sperm by removing of a small amount of testicular tissue. Both PESA and TESE can be performed either under local anesthesia or with IV anesthesia and the procedures usually last only about 30 minutes.

If you have additional quesions about male infertility, please schedule an appointment with a Shady Grove Fertility physician by calling 888.761.1967

Medical Contribution By Dr. Melissa Esposito and Michael Tucker,

Thirty percent of couples experience infertility related to a male factor, either alone or in combination with a coexisting female factor. For the affected couple, discovering that they need to seek assistance to get pregnant is often emotionally challenging. Men often react differently than women to the news because of society’s cultural measurements of virility and manhood. The good news is that treatment for male factor infertility is usually successful, often with minor intervention.

Fatherhood, From the Start

A crucial element of successful fertility treatment is that both partners are equally involved in the diagnostic and treatment processes. Proceeding toward treatment without first taking a diagnostic look at both partners’ fertility status will likely result in wasted time, energy, and money.

Though men don’t often want to hear it, the fact is that the semen analysis is one of the first tasks to accomplish in diagnosing the cause of infertility (along with the preliminary testing of the female). It may not be a pleasant test to consider, and it truly is not what any individual has in mind when thinking about making babies, but the semen analysis is the best test in its ability to rapidly and inexpensively detect problems with male infertility.

The often heard phrase “sperm count” is actually only one important component of male fertility. It refers to the concentration of sperm per milliliter (ml). This aspect of a man’s results can impact the type of treatment recommended but, as Shady Grove Fertility’s Dr. Melissa Esposito explains, “There’s no definite count where we’ll say you must use IVF or IUI. It’s really a combination of the multiple semen analysis parameters that we measure.”

The other important parameters besides the number of sperm cells are their shape (morphology) and movement (motility). In fact, even men with zero sperm count (called azoospermia) can often have conception success through various sperm extraction techniques and in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI- a procedure where a sperm can be injected into an egg to try and achieve fertilization), if indeed healthy sperm cells can be found.

As with other health conditions, the definition of “average” plays a part in diagnosis and treatment. The World Health Organization long ago established reference standards for “normal” semen analysis parameters that are widely respected. Dr. Esposito and her colleagues occasionally review the lab results brought in by patients who had their semen analysis done elsewhere. The numbers can be misleading, especially for people without medical training. “Not all labs use WHO criteria and parameters. Some may not even test for morphology, for example. So we encourage patients to use Shady Grove’s andrology lab if at all possible.”

Dr. Esposito discusses the importance of taking all criteria into account. “We look at all of the parameters in relationship with each other — count, motility, morphology, and also, volume. For example, some men can produce four to five milliliters of ejaculate, which is considered more than average (2 mls is the norm). Let’s say they have a count of 10 million sperm per ml. If they have good overall parameters, and would be left with more than 5 million total motile sperm after the sperm wash (the procedure done for IUI), then they may benefit from IUI despite the initial low count. But if they have a good count, but less than 1 ml ejaculate and low motility and morphology, then they may have a low total motile sperm count after the sperm wash and need something more in the way of treatment.”

Some important points to understand about semen analysis:

• Because the normally functioning male body is constantly producing new sperm cells, a single “negative” test may not be the most reliable indicator of a man’s true fertility status. As with all other health systems, the reproductive system is impacted by lifestyle issues such as stress, nutrition, sleep, and illness.
• A test that is poorly run — subject to human and lab errors — can render inaccurate findings. Examples of test problems include: too much time passing between the patient procuring the sample and the lab running the test; and labs using more general, non-fertility focused parameters for results.
• For the above reasons, many patients are asked to undergo subsequent semen analyses for accuracy.

In many cases, the semen sample for analysis or, later, for prescribed fertility treatment can be obtained in privacy at the patient’s home, so long as it can then be transported in relatively warm conditions and within about an hour’s time to the lab. Regarding the use of semen for treatment, cases warranting special attention — such as for men whose jobs require travel that conflicts with scheduled treatment dates — can even make use of previously frozen samples.

Urological Approach to Better Family Health

For some men, finding the answers to their infertility leads serendipitously to better overall health. When the situation warrants it, Shady Grove Fertility’s reproductive specialists refer patients to a team of urologists who specialize in male infertility. An example would be a couple with severe male factor for unknown reasons. Some couples, Dr. Esposito says, simply don’t want to pursue aggressive therapy like IVF and may have a male factor issue that can be corrected by a urologist.

Dr. Esposito details how seeing a urologist can result in more than just assistance with fertility issues. “Virtually any patient with azoospermia or severe male factor infertility will be referred to the urology team. The urology exam can determine, for example in an azoospermic patient, if there’s an absence of the vas deferens (part of the male reproductive tube system), so then we know that we need to test for the cystic fibrosis gene to see if there are any mutations.” Men with congenital absence of vas deferens (CBAVD) often also carry the risk of transmitting cystic fibrosis genetically to their offspring if their wives also carry the gene mutation.

Even prior to urology referral, though, Shady Grove’s doctors will test all men with azoospermia and some cases of oligospermia (very low sperm count) for genetic conditions that can not only stand in the way of fertility but can also impact the health of their children.

High-Tech Conception Help

Depending on the diagnosis, there are a variety of techniques to treat male factor infertility. Problem areas can be roughly grouped thus:

• barriers to sperm cell transport and delivery
• barriers to sperm production

Treatment can either focus on the individual problematic condition, such as repairing a varicocele to promote higher quality of future sperm cells produced, or treatment can be used to bypass the condition, which is essentially the effect of ICSI with IVF. Patients will likely hear their condition referred to as either obstructive or non-obstructive or, in fewer cases, neurogenic. Neurogenic reasons for infertility would be related to nerve damage, such as for men with spinal cord injury or complications of diabetes.

In addition to ICSI with IVF, other treatment options that may be considered are:

• Vasectomy reversal
• Varicocele ligation
• Microsurgical repair of obstructions
• Electroejaculation
• Several methods of sperm retrieval, both surgical and needle-aspiration
• Intrauterine insemination (IUI)

Male reproductive surgery can be used to clear the path, which is made up of several different sections of tiny tubing, for sperm cells. In cases of severe oligospermia (low sperm count) or azoospermia (no sperm in ejaculate), cells can be retrieved through a variety of sperm aspiration techniques.

Medical treatment is sometimes recommended for less severe cases of sperm quantity and quality issues. Therapeutic level hormones and antioxidants may be prescribed, or antibiotics if infection is found to be a factor.

Cellular Level Experts

The laboratory is an important component in the treatment of male factor infertility, particularly since treatment has successfully been narrowed down to the cellular level.

Michael Tucker, PhD, Director of Shady Grove Fertility’s IVF and Embryology Laboratory, pioneered ICSI over fifteen years ago. The cell-by-cell conception technique remains the predominant successful treatment for male factor infertility resulting from myriad causes.

“ICSI is the standard for enabling us to take a small number of sperm and be able to fertilize however many eggs the patient has available,” says Tucker, “but there’s been a change in thinking about it as we’ve learned more about male infertility. Early on, we thought all we needed was one sperm, just any one cell, to make ICSI work. You can, in fact, have pregnancy success with technically dead sperm cells in mice, but no one’s ventured to attempt it in humans routinely. So now, we know more about how much sperm quality really counts.”

The result is that Shady Grove’s lab staff and clinicians work together more to try and find those healthy sperm cells. Sometimes that means going to the point of cell production — the testicle. Sperm removed directly from the testes are often healthier than those that have traveled all the way through the male reproductive tubing and urethra.

Highly sophisticated equipment now allows increased magnification and a better perspective of individual cells by lab scientists. “More than just whether or not a sperm is moving,” Tucker details, “we can really focus now on apparent qualities of them. Defects in the head morphology, in particular, can indicate potential problems. For example, very generally, smaller sperm heads are often lacking DNA, whereas unusually large ones are often diploid and have too many chromosomes. We also assume that misshapen heads may be a manifestation of underlying poor quality.”

A key area that is now being analyzed beyond what lab staff can see with their state-of-the-art optical equipment is actually measuring the DNA integrity. “That’s a sort of catch-all term for the amount of fragmentation of the DNA in cells,” Tucker explains. “For example, if a man is taking chemo-toxic or recreational drugs, or is a frequent user of hot tubs, we’re finding a deleterious effect on the production of sperm itself. That often registers in terms of the health of the sperm’s DNA.”

Semen samples can be tested for DNA integrity at specific laboratories, and Tucker believes there may even be home-testing for the fertility indicator in the future.

Today’s high tech fertility labs might resemble a computer gamer’s dream. The Lab Director describes the equipment of his profession. “We use joysticks, micro-manipulators, tiny glass micro-tools, hollow needles.”

“We’re talking about holding an egg that’s only about 120 microns across. The tool that holds it measures about 100 microns across, about a tenth of a millimeter. The sperm head is about 3 to 3.5 microns across, the length of the head is about five microns, while the tail is a good 20 to 30 microns long. The tool used to pick up the sperm and push it into the egg cell is about seven to eight microns across.”

Tucker says that his technical field that demands the highest level of skill has done nothing but improve over the years. “Not only our fertilization rate, which has crept up, but the overall level of damage [to cells manipulated in the lab] seen annually has dropped off.” He believes that one factor in the improved quality of embryo quality resulting from ICSI-fertilized eggs is testament to the increase in skill. “We’ve honed the process over the past decade, not unlike any surgeon whose skills get better with time and experience.”

The diagnosis and treatment of male fertility problems has improved significantly over the past couple of decades, to the point that pregnancy success is the most usual result. The scientific and technological advances have interacted in tandem to develop a wide array of answers to the perplexing questions of what stands in the way of reproduction for many men.

Uncovering the specific cause of infertility is the first step toward designing a successful fertility treatment. The Hysterosalpingogram (HSG) is one of the initial tests patients undergo in the diagnostic process to determine the health of the uterus and fallopian tubes. Though the name sounds intimidating and stories circulate on the internet about how painful this test can be, we want to reassure you that the test itself is quick, painless, and, even better, patients are able to get their results immediately.

Shady Grove Fertility’s physicians and physician’s assistant (PA) personally perform and read over 2,500 HSG’s annually. “This is the kind of exam where clinical technique and experience really makes a measurable difference in the patient’s overall experience,” states Stephen J. Greenhouse, MD of Shady Grove Fertility’s Fair Oaks, VA office.

Shady Grove Fertility currently has two HSG testing locations open Monday through Friday in the Rockville and Towson locations. It’s important for patients to know that nearly all insurance companies will pay for the test to be performed at Shady Grove Fertility’s facility. “There are some HMO-type plans that might limit where a patient can have the test,” says Dr. Greenhouse, “but I’d say 90% will cover it at Shady Grove Fertility.”

Why Does Everyone Need An HSG?

Most new patients at Shady Grove Fertility will need to have an HSG test before initiating treatment. Sometimes couples with a known male factor infertility, like a low sperm count, wonder why the test is even necessary. Dr. Greenhouse explains, “We often see couples where both partners have a fertility issue, so it’s important to check both partners completely. Otherwise, we might spend precious time trying treatments that won’t work because we didn’t know of a problem in the uterus or fallopian tubes.” The HSG test can detect several kinds of issues, such as polyps, fibroids or scarring in the lining of the uterus, and blockages in the fallopian tubes.”

Likewise, patients who are planning to undergo In Vitro Fertilization (IVF) might wonder why a test to look at the fallopian tubes would be necessary, since the IVF process is designed to bypass the fallopian tubes. Dr. Greenhouse says, “Not only is it important to make sure there are no issues in the uterus that could prevent the implantation of an embryo, but there are actually some tubal diseases that have been shown to reduce pregnancy rates when using IVF.”

The HSG Procedure – What to Expect

An HSG is usually scheduled between days 5 and 12 of a woman’s menstrual cycle.

One of the common concerns patients have about undergoing an HSG is whether the test will be painful. “For the vast majority of patients at Shady Grove Fertility, the HSG is not painful,” says Dr. Greenhouse. “If a patient feels discomfort or cramping, it’s usually at about the same level as menstrual cramps.”

Shady Grove Fertility’s expertise in facilitating accurate results and a pain free experience for the patient comes from the fact that the physicians and physician assistant (PA) conduct HSGs day in and day out. Patients may not have the same experience at an outside facility where the methods used could cause the patient unnecessary discomfort.

Dr. Greenhouse explains, “Some radiology centers perform HSG by inserting a balloon catheter into the uterus so they can inject the dye quickly. This can cause the uterus to expand rapidly and result in tubal spasms that may be uncomfortable.” He continues, “The reality is that the test is much more reliable and effective when the dye is injected slowly, and it’s more comfortable for the patient.”

Results on the Spot

Another benefit to having the HSG performed at SGFC is that patients receive immediate results.

“There are so many unknowns with infertility that cause patients anxiety, so we don’t want to add to that by delaying the results of the test,” says Dr. Greenhouse. “The specialist performing the test will let you know whether the test is normal or abnormal right away.” He continues, “For most patients, the results are normal, so it’s a weight off their shoulders to know that before they leave the office.

The results will be reviewed in more detail with the patient during a follow up conversation with her physician. Dr. Greenhouse explains that even when the results are abnormal, a patient’s treatment can usually be tailored to overcome the problem.

Dr. Greenhouse concludes, “Patients don’t need to fear this test. Despite what they may have heard or read online, it can be painless and quick. They can also be reassured by the fact that each step in our process is designed to get them one step closer to their goal of becoming pregnant.”

For more information or to schedule an appointment with one of our physicians, please speak with one of our friendly New Patient Liaisons by calling 888-761-1967.