Diagnosing Infertility

Medical contribution by Lauren Roth, M.D.

Lauren Roth, M.D., is the Medical Director of SGF, and board certified in obstetrics and gynecology and reproductive endocrinology and infertility. She has published research on a range of fertility topics including polycystic ovary syndrome (PCOS) and the impact of weight on reproductive hormones. Dr. Roth sees patients in SGF’s Rockville, Maryland office.

Overcoming male factor infertility is possible through the right diagnostic testing and appropriate treatment protocols. While the infertility conversation often revolves around the female partner, the male partner’s role is just as important. Infertility is often seen as a female problem, but surprisingly, 40 percent of cases are attributed to the male partner, with an additional 10 percent coming from a combination of the male and female partner.

The large occurrence of male factor infertility makes testing fundamental to obtaining an accurate diagnosis and designing an appropriate treatment protocol. The good news is that testing at a qualified laboratory that uses strict semen analysis parameters can provide patients with an accurate picture of the male partner’s fertility status.

If your physician diagnoses male factor infertility, there are many treatment options. Here are the three basic steps to diagnose, improve, and overcome male factor infertility.

Step 1: Does he have strong swimmers?

In normal reproduction, one sperm must be healthy enough to go the distance to fertilize the egg. This means the very first step in diagnosing male factor infertility is to assess the overall fertility potential of the male partner’s sperm. Fertility treatment should never be initiated without completion of this step. It is important to understand that the parameters laboratories use to judge the quality of sperm can drastically vary.

“Frequently, patients will come to us with a normal semen analysis and upon re-evaluation we find that the results are not accurate and male factor infertility is present after all,” explains Firoozeh Naeemi, andrology laboratory supervisor at Shady Grove Fertility. There are several factors that may impact test results when using an outside laboratory:

1. Wait time between collection and testing: Shady Grove Fertility analyzes soon after receipt of the sample, whereas other laboratories may take up to 24 hours. This delay can considerably compromise the integrity of the sample.
2. Computer-Assisted Semen Analysis (CASA) versus an andrologist: Some labs use computer technology instead of an andrologist to visualize and interpret the sample. Shady Grove Fertility has found the human eye is more accurate and objective when assessing the sperm sample, resulting in more reliable test results.
3. Training and experience: Shady Grove Fertility’s Andrology Team is dedicated solely to the analysis of sperm. Their experience, along with specialized training, makes them experts in the field and produces more accurate test results.

Shady Grove Fertility follows the World Health Organization’s (WHO) recommendation for analyzing sperm. One of our twenty specialty-trained andrologists visually evaluates each sample. He/she is looking for:

• Volume of the ejaculate
• Sperm count
• Motility (movement)
• Morphology (shape)

This disciplined approach to semen analysis testing provides each patient with accurate test results within 48 hours.

Step 2: Naturally improve the quality of your semen

Frequently, lifestyle factors can impact the condition of sperm. A man can make small changes immediately to naturally improve sperm quality and quantity. Our physicians suggest the following tips to help improve sperm quality:

1. Lose weight and exercise
2. Maintain a healthy diet with foods rich in antioxidants
3. Don’t smoke or use recreational drugs
4. Reduce your intake of alcohol to fewer than 5 drinks per week
5. Take a daily multivitamin

Semen is continuously being produced in the male body, and takes approximately 74 days to mature, meaning that positive lifestyle changes today can result in improvements in sperm quantity and/or quality in as little as 2 to 3 months time.

Further evaluation may be required based on the abnormality of the semen analysis.  We recommended patients receive further evaluation with our in-house fertility urologists, Paul Shin, M.D., Cori Tanrikut, M.D., Russell Hayden, M.D., and Jessica A. Marinaro, M.D., to determine if there are other underlying issues (hormonal imbalances, anatomic or genetic conditions) that may be contributing to the results.

Watch below as Maria and Areen share their story and how they overcame male factor infertility:

Step 3: Fertility options that work

A man can overcome male factor infertility with a variety of treatment options. A diagnosis of male factor infertility is categorized as mild, moderate, or severe. The goal with any treatment is to get the sperm as close to the egg as possible. The severity of the case, the fertility status of the female partner, and comfort level of the couple together dictate the planned course of treatment.

For milder cases, many patients find success with intrauterine insemination (IUI), a low-tech treatment option. Prior to the insemination, the man will collect the sperm and an andrologist will “wash” the sample. The washing process separates debris from the healthy sperm, creating a concentrated semen sample. Upon insemination, the physician will place the washed sperm into your uterus through a soft, thin catheter. This method places the sperm in very close proximity to one or two eggs that have been released through the natural process of ovulation.

A fertility specialist can successfully treat moderate cases of male factor with IUI but, if unsuccessful, in vitro fertilization (IVF) is very effective. The benefit of IVF is that sperm have more available eggs to fertilize. Once the physician retrieves the eggs from the woman, an embryologist places them in a Petri dish in the laboratory. He/she will place a concentrated amount of sperm directly onto the eggs and monitor closely for fertilization.

Moderate and severe cases may also use IVF treatment with the addition of intracytoplasmic sperm injection (ICSI). Instead of positioning the sperm close to the eggs in the Petri dish, the embryologist actually selects a single sperm and injects it directly into the center of an egg. An embryologist then monitors each egg for signs of fertilization and embryo development. ICSI is an extremely effective technique for overcoming male infertility.

Between 40 to 50 percent of infertile couples experience a form of male factor infertility. Luckily, this form of infertility is easily overcome with the right diagnosis, lifestyle choices, and treatment.
Learn more about Male Factor Infertility with our On-Demand Webinar.

To schedule a virtual consultation with an SGF physician, please call our New Patient Center at 1-888-761-1967 or click below.

Editors Note: This post was originally published in April 2013 and has been updated for accuracy and comprehensiveness as of June 2021.

Medical contribution by Joseph E. Osheroff, M.D.

Joseph E. Osheroff, M.D., is board certified in obstetrics and gynecology and reproductive endocrinology and infertility. He is member of the American Society for Reproductive Medicine, the Society for Reproductive Endocrinology and Infertility and the American College of Obstetricians and Gynecologists. Dr. Osheroff sees patients at SGF’s Columbia, Maryland office. 

AMH is an early and reliable predictor of ovarian reserve and a decrease in AMH levels may indicate that there is an egg issue before FSH levels begin to rise (another test for ovarian reserve).  Since AMH adds valuable information as a predictor of ovarian reserve, the testing is now part of our standard fertility evaluation for all patients at Shady Grove Fertility. When our physicians review AMH levels in conjunction with FSH, estradiol, and an antral follicle count, we are able to gain a more comprehensive evaluation of the quantity of a woman’s remaining eggs.

If you’re still under the care of your OB/GYN for fertility issues and an AMH level was not ordered as part of the initial fertility evaluation, you can request that your physician order the test or see a fertility specialist for this insightful information.

In addition to using AMH for a fertility evaluation, we also use it to determine how a patient may respond to stimulation medication when undergoing treatment, which treatments are appropriate for her specific situation, and if she is a good candidate for egg freezing.

FAQs about AMH and a woman’s fertility

How is AMH measured?
We measure AMH with a simple blood test. AMH levels are fairly constant throughout a woman’s menstrual cycle; therefore, one advantage of AMH is that a woman can undergo testing at any time during her cycle. In addition, unlike the follicle-stimulating hormone (FSH), AMH levels are fairly consistent from month to month.

Can I test my AMH if I am on a contraceptive?
In a recent study, researchers revealed that women using continuous contraceptives, regardless of type (oral contraceptive pills, skin patches, or vaginal), had significantly lower AMH levels. Based on this new study, if a patient’s AMH levels are low and she is on a contraceptive, we recommend retesting the AMH after stopping the hormones for a month.

What does my AMH level tell me about my fertility?
AMH blood levels are thought to reflect the size of the remaining egg supply; therefore, AMH is an early and reliable predictor of ovarian reserve that your reproductive endocrinologist—also known as a fertility specialist—will use to help predict how you will respond to fertility treatments and stimulation medications. As a result, your physician can recommend medical treatment that will be effective and safe.

How do the results of my AMH level impact treatment?
Your physician will use your AMH test result to gauge your anticipated response to medication. AMH is a better predictor of ovarian response than a woman’s age, body mass index (BMI), or FSH level alone. This insight has transformed the ability to individualize medication dosing and treatment plans for patients at a level that wasn’t possible before.

What medical conditions affect the level of AMH in my body?
Women with polycystic ovary syndrome (PCOS) generally have a higher number of early antral follicles resulting in higher baseline AMH level. AMH levels may be correlated to PCOS severity and have been found to be higher in women with insulin resistant PCOS. Women who are older, or who have undergone medical treatments that are toxic to the ovaries (such as chemotherapy or radiation therapy) may have a lower number of eggs remaining and therefore a lower baseline AMH level. While AMH levels do correspond to a woman’s ovarian reserve, it does not predict fertility.

Where can I have my AMH level tested?
Your primary care physician, OB/GYN, or reproductive endocrinologist can order an AMH test along with the other day 3 bloodwork for you. Due to AMH’s ability to identify a diminished ovarian reserve — better than FSH — test results can give providers information earlier regarding a potential fertility problem.

I’m interested in elective egg freezing, should I test my AMH level?

Absolutely. AMH provides valuable insight into your ovarian reserve, however other tests are important when evaluating if egg freezing is a good choice for you. In addition to the AMH level, we measure other reproductive hormone levels as well as measure your antral follicle count through a vaginal ultrasound. When combined with your age and medical history, these test results provide the most accurate insight into ovarian reserve as and ultimately your potential success with egg freezing.

We have found that the best predictor of your egg supply is through the Ovarian Assessment Report provided by ReproSource. Your egg supply score–or how many eggs you have and if that number is high or low based on your age–helps you and your Shady Grove Fertility physician determine if egg freezing now is in your best interest. The cost of your evaluation, which includes the physician consultation, is generally covered by insurance.

If you are interested in learning about your anti-Müllerian hormone levels or are currently trying to conceive, schedule an appointment or call our new patient center 877-971-7755. 

Medical contribution by Jason G. Bromer, M.D.

Jason G. Bromer, M.D., is board certified in obstetrics and gynecology and reproductive endocrinology and infertility. He has been involved in cutting-edge research in fertility preservation for cancer patients, pregnancy implantation, and methods of embryo selection for in vitro fertilization. 

Many women who have had a tubal ligation, commonly referred to as “having your tubes tied,” find themselves wanting another child due to life changes. But can a woman get pregnant if she’s had a procedure that is considered a permanent form of birth control? Yes, and talking to a reproductive endocrinologist is the first step in determining all of the options.

Dr. Jason Bromer, of SGF’s Frederick and Hagerstown, MD offices, says, “Women with tubal ligations are some of our most successful patients because we know that they have been fertile before. There are two ways pregnancy can be achieved after tubal ligation. Traditionally, the only option for patients was through a surgery called a tubal reversal. However, there is now another option for women with in vitro fertilization, or IVF.”

In almost every case, IVF is the better option because it gives patients the highest chance of pregnancy in the shortest amount of time and avoids a significant surgical procedure.

Tubal reversal surgery

Tubal ligation can be performed in a number of different ways, but the result is always the same – an interruption of the Fallopian tubes that prevents pregnancy. “The most common method of tubal ligation is the surgical removal of the middle section of the tubes,” says Dr. Bromer. “So, the goal in a tubal reversal surgery is to reconnect the tubes to make them open all the way through.”

The latest methods for performing a tubal reversal surgery require only 1 day for the procedure and 7 days of light bed rest following it. About 3 months after the surgery, patients have a hysterosalpingogram (HSG) to check the status of the tubes. An HSG is a diagnostic test using x-ray technology to show the flow of dye through the uterus and Fallopian tubes into the uterine cavity. It shows if there are any blockages remaining in the tubes that might prevent pregnancy.

Tubal reversal success and increased risks

Whether or not tubal reversal surgery can be successfully performed depends on two factors. “Is there enough healthy tissue on each end of the tube to be reconnected,” explains Dr. Bromer, “and is the reconnected tube long enough to function properly? Unfortunately, not all patients have tubes that can be reconnected.”

“Sometimes even when reattaching the tubes is successful, there can be scarring of the tissue that interrupts the flow of the tube,” says Dr. Bromer. “This happens in about 20 percent of the cases.” If, however, the HSG confirms that the tubes are open, then the patient can begin trying to get pregnant on her next cycle.

There is also an increased risk for ectopic pregnancy after tubal reversal surgery. “One risk with tubal reversals is that there is a 10 to 20 percent chance of having an ectopic pregnancy after tubal reversal surgery,” says Dr. Bromer. Ectopic pregnancy occurs when a fertilized egg gets stuck in the Fallopian tubes and implants there. Ectopic pregnancies must be terminated with medications or surgery to avoid a rupture of the Fallopian tube, which can be life threatening.

Since the tubes cannot always be reconnected, the success rate for achieving pregnancy after a tubal reversal is around 40 percent for women under 37.

IVF and success rates

Another popular option for women trying to get pregnant after a tubal ligation is in vitro fertilization or IVF. IVF is a process by which an egg is fertilized in the lab and then transferred to a woman’s uterus. This allows for pregnancy to occur by completely bypassing the Fallopian tubes.

Any woman who has a good ovarian reserve or has previously attempted a tubal reversal unsuccessfully would be a good candidate for IVF treatment. Dr. Bromer adds, “Even couples with fertility challenges other than the tubal ligation, such as advanced age or male factor infertility, can be helped by IVF.”

An IVF cycle takes about 2 months to complete. After the evaluation and hormone suppression phase of the cycle, patients are prescribed injectable hormones that stimulate egg maturation. During this 10 to 12-day stimulation period, the patient is seen frequently for ultrasound and bloodwork to monitor the growth of egg containing follicles and the levels of hormones.

At the end of this period, an egg retrieval procedure is performed. The eggs are fertilized with the partner or a donor’s sperm and grown to 3- or 5-day embryos. Then, one or more embryos are transferred to the woman’s uterus. Two weeks later, a blood pregnancy test reveals the results.

The success rate for achieving pregnancy with IVF frequently exceeds that of a tubal ligation. At SGF, IVF has a 50 to 60 percent success rate for women under 38, even when only one embryo is transferred.

View Shady Grove Fertility’s IVF Success Rates

Four things to consider:

1. Time to pregnancy 

It takes about 3 months after a tubal reversal surgery to confirm that the surgery was a success. Once the tubes are shown to be clear by the HSG test, the average time to pregnancy, from start to finish, is 2 years.

“The fact that it can take up to 2 years to become pregnant after tubal reversal surgery is really off-putting to a lot of my patients,” says Dr. Bromer. “Most of them are anxious to get pregnant sooner, often because they are older when they start the process.”

“One of the best things about IVF is that the time to pregnancy is so much shorter,” says Dr. Bromer. A cycle of IVF takes only about 2 months to complete. Some women require multiple rounds of IVF to achieve pregnancy, but even with difficult cases, treatment is usually completed within 1 year.

2. Age

Age is a key factor in the decision between IVF and tubal reversal surgery. As a woman ages, the number and quality of her eggs decline, making it harder to get pregnant. As early as 30 years old, a woman’s chances of getting pregnant each month start to go down.

Since many women who want to get pregnant after tubal ligation are in their 30s, there is a chance that even with a successful tubal reversal surgery, they won’t become pregnant, as the 2-year time to achieve pregnancy becomes even more significant. In this case, it is likely that IVF would be recommended. To avoid having to do surgery and IVF, it is recommended that these women choose IVF as the first line of treatment.

“For women over 37, I would almost never recommend tubal reversal surgery,” says Dr. Bromer. “In this age group, where declining fertility is coupled with a higher risk of ectopic pregnancy, IVF is clearly a safer option with better chances of success.”

3. Cost

Tubal reversal surgery and one cycle of IVF cost about the same amount, ranging between $10,000 to $15,000. Tubal reversal surgery is almost never covered by insurance.

SGF has several innovative financial programs that reduce the cost and financial risk associated with treatment. These include the Shared Risk 100% Refund Program, Multi-Cycle Discount Program, Shared Help Discount Program and options for grants and loans for fertility treatment.

The most popular is SGF’s Shared Risk 100% Refund Program. This plan offers patients up to six IVF cycles with unlimited frozen embryo transfers. If the patient does not bring home a baby, 100% of the fee is refunded.

“With the Shared Risk program and the success rates being so high at SGF,” says Dr. Bromer, “IVF is almost always the more cost-effective option.”

4. Male partner’s fertility

One more factor that can tip the scales is the male side of the equation. Having a sperm analysis completed for the male partner is a critical step in making the decision about whether to use IVF or tubal reversal surgery. “If the male partner of the couple has a low sperm count for example,” explains Dr. Bromer, “then even a successful tubal reversal surgery is not likely to result in pregnancy.”

IVF, however, can be performed with special techniques that work around the male factor issues. Intracytoplasmic sperm injection (ICSI), for example, is a process in which a single healthy sperm is injected into the center of each egg resulting in normal rates of fertilization even in men with severely abnormal sperm counts.

The prognosis is good

Dr. Bromer says the key to this decision is a thorough evaluation and a discussion of the patient’s goals. “I suggest that couples come in and bring all the paperwork about their tubal ligation surgery,” he says. “We will do some basic fertility testing on both partners and go from there – but the first step is making an appointment.”

For some women, the answer will be tubal reversal surgery. “The ideal candidate for tubal reversal surgery is a woman under 35, who wants multiple additional children and who had a well-performed tubal ligation,” Dr. Bromer says.

“The majority of my patients, however, have had multiple children, but now have a new partner, and want to have only one more child with their new partner. For these women, IVF is nearly always a much better option.”

“Either way, the prognosis is good. With a little expert guidance, women with tubal ligations can be back to changing diapers in no time,” adds Bromer.

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To schedule a virtual consultation with an SGF physician, please call our New Patient Center at 1-888-761-1967 or submit this brief form.