***** Abstracts

Endocrinol Metab Clin North Am 1994 Dec;23(4):783-793
Male infertility.
Baker HW
Department of Obstetrics and Gynaecology, University of Melbourne, Royal Women's Hospital, Australia.

Male infertility is a common problem but only about one quarter of patients have specific or defined conditions that make them either sterile or severely infertile. About half of these patients have untreatable primary seminiferous tubule failure, and donor insemination or adoption are the only possibilities of having a family. The other half have potentially treatable conditions, including genital tract obstruction, sperm autoimmunity, gonadotropin deficiency, coital disorders, or reversible toxin effects. The majority of men seen for infertility (75%) have reduced semen quality, which impairs fertility to a variable degree. Thus far no treatments have been shown unequivocally to increase semen quality and fertility in this group. Assisted reproductive technology has improved the outlook for pregnancy in couples with male infertility and the new technique of intracytoplasmic sperm injection promises to further improve results for those with severe sperm defects or previous failure of in vitro fertilization.

*****

Arch Androl 1997 Nov;39(3):197-210
Relationship between etiological factors and total motile sperm count in 350 infertile patients.
Martin-Du Pan RC, Bischof P, Campana A, Morabia A
Department of Obstetrics and Gynecology, University of Geneva, Switzerland.

The prevalence of different etiologic factors has been evaluated in 350 male patients consulting the same physician in an urban, ambulatory setting for primary or secondary infertility of more than 1 year. Environmental factors such as alcohol or drugs represented 12% of the etiologies, acquired diseases such as varicocele and prostatitis 40%, congenital diseases and primary testicular failure 16.2%, idiopathic cases 19.4%, and abnormality of sperm transport 7.4%. The severity of sperm alterations in the different etiologic categories was evaluated by the total motile sperm count per ejaculate (TMS) (normal > 16). The TMS was less than 5 in classical causes of male infertility such as testicular failure, endocrinopathy, cancer, or antisperm antibodies. It was more than 10 in controversial causes of infertility such as varicocele, prostatitis, chlamydial infections, and professional exposure to heat. After treatment, there was a nonsignificant increase of the TMS in the latter cases. In cases of azoospermia of pituitary origin, the TMS was normalized by a hormonal treatment. In some cases of azoospermia of possible obstructive origin, sperm appeared in the ejaculate after diclofenac treatment. The utility of andrological investigation and treatment is discussed.

Anovulation and excess weight

I need some advice and I will listen to what you tell me. I have been trying to get pregnant for 2 years, have had a HSG, all sorts of blood work and my husband had a sperm test. All results were within the norm, but I do not ovulate. I have not ovulated in 2 yrs of keeping a BBT chart. My periods are quite irregular also. My LH was 6.1, my prolactin was 17.5, and my FSH was 4.1. It says luteal phase 0.8-7.5 mIU/mL and postmenopausal 34.4-95.8 mIU/mL My glucose test was fine.

My question is this...I have many of the symptoms of PCO, most of these showing up in the last 10 yrs, so it's not something I've always had. The symptoms are these...obesity (324 and gaining w/o changing any eating habits) acne, excessive facial hair on chin, sideburns and jaw line, irregular cycles and unusually long cycles, brownish rough skin on the back of the neck, skin tags (many around my neck and armpits), infertility, painful periods and large clotting, anovulation, and androgen body type. My RE told me that I don't have PCO because my FSH levels are not high enough. He said most infertile women have these symptoms. I have not had a vaginal u/s and don't want to question the RE but I have heard that your levels can be normal while still having PCO. Could I still have it, and insist on a vag u/s, or is there no way I could have it since my blood work was okay.

In polycystic ovarian syndrome, usually the LH/FSH ratio is greater than 3 but not always. It's not the absolute levels that are key. Your values may or may not represent PCOS. The ultrasound may help but there can be follicles present in ANY anovulatory state. If there were more (or equal to) 10 follicles in one or both ovaries, that would be evidence toward PCOS. See our news article about Diagnosis of Polycystic Ovarian Syndrome

The rough skin makes me think of hypothyroidism. I assume you had that checked; its pretty routine for anovulation. The excess hair growth can represent androgen excess from the ovary (testosterone) or from the adrenal gland (DHEA). Have both of those hormones been checked?

Also at your weight, a check for diabetes or abnormal glucose tolerance should be done. Any abnormal glucose findings would go along with PCOS. The weight itself is a problem for anovulation as I'm sure you know. Weight watchers or Overeaters Anonymous may be helpful for this at your weight. I don't mean to be unkind, but I know its affect on health.

At this point, I would ask your RE (not quarrelously but firmly) to do any additional studies such as the above. There is a tendency on the part of many physicians to skip tests in the interest of reducing costs if there is not going to be a difference in the treatment. In your case, there may not be any difference in how you are going to be treated unless the thyroid test (TSH) or the adrenal test (DHEA) is abnormal. It may also be that your RE is just judgmental about "large" women and may be jumping to the conclusion that the weight is the only problem.

Are you currently on any medication?

Have you had any treatment for the anovulation or are you just in the diagnostic process now?

I read your reply, you asked if I am currently on meds. I am not. My RE told me that Gonal F would be my next step, and as we cannot afford this, and our insurance doesn't cover treatment, this isn't an option. I was on 6 cycles of Clomid® last yr, starting at 50 mg and ending at 150 mg. With HCG on day 14 of my last cycle of Clomid®. I failed to ovulate on these (according to BBT) I was not monitored. I had a glucose tolerance and the GYN has written to the side of the numbers, "normal". This is why my 2nd GYN concluded that I didn't have PCO and referred me to an RE. I have my records in front of me, and do not see the tests for testosterone, DHEA or TSH anywhere, unless they are written out in some other way. I had a thyroid test done in March of this yr. The TSH from that test results say 4.26, this test was done by a diet doctor, not my GYN or RE. If these are all important tests, why weren't they done on me? Wouldn't a testosterone test be a given? I don't want to sound argumentive but I would think they would perform every test possible before I had to give up with the Gonal F? None of my Dr's have mentioned my weight and I have even asked them if it was affecting my fertility, they all said no. Each said losing might help with labor and delivery, but might not cure my infertility. The diet doctor said with my low BBTs I wouldn't be able to get pregnant. I haven't heard any other Dr mention this. They average 96.7 to 97.3 upon awakening. Thank you very much for your help, and if you have any other ideas, PLEASE reply. Do you think I should switch REs? He is dead set on my beginning Gonal F. His reasoning for this was my FSH was 4.1 and my E2 was 105.

I don't think you need to change REs, but just ask him to check out the excess hair growth by looking at the ovarian and adrenal androgens (testosterone and DHEA).

You probably will still need something like the Gonal F (pituitary gonadotropin releasing hormone) because you failed to ovulate with Clomid®. Moderate weight loss is well known to help many women resume ovulation whether or not PCOS or adrenal hyperplasia is a problem. The low basal body temperatures just reflect the lack of ovulation. They don't CAUSE anything.

Initial infertility consultation

I am going to my OB-GYN for infertility for the first time. She refers to this appointment. as a consultation. Do you have any information on what she might do? Will she just talk to me or will she go ahead and do tests? If so, what types of tests would she start with, and what problems will she be searching for? I am in good health, normal periods, no apparent problems, except unable to get pregnant after a year. Thanks for any insight you can provide.

(Another woman responds) I would think twice before going to an OB-GYN for infertility. I did that and wasted $$$ as well as time. Unfortunately my experience is not an isolated incident. If you truly have a problem you want to see someone who knows the most about the problem. You should ask to be referred to a Reproductive Endocrinologist.

Usually the initial visit is just to get a thorough history and do a physical and pelvic exam and then on that basis, formulate a plan as to how to go ahead and diagnose and treat your infertility.

Will she just talk to me or will she go ahead and do tests?

Usually just talk but sometimes will start a schedule for tests if you and she agree to go ahead.

If so, what types of tests would she start with, and what problems will she be searching for?

Tests depend on your history. She is searching for ovulatory factors(ovary egg release), tubal factors, cervical factors, and systemic diseases on you part and sperm/semen adequacy on your husband's part.

To some extent, our other responder is correct about seeing reproductive endocrine person. Infertility is their full time job. On the other hand, general gynecologists across the country treat many infertility patients and then they refer the ones who did not get pregnant to the reproductive endocrine/infertility specialist. If you are one of the people who ends up being referred, then you feel you have wasted time and money. It's important when you see your doctor that you both agree when to go on to further "advanced reproductive technologies" that the infertility specialist does.

Missed abortion after Clomid® therapy

I'm looking for information and any kind of doctor referral. I'm 37, been married 2 1/2 years, and am trying to get pregnant and carry a baby to term. In '93, I had half of a multinodular goiter removed. It was diagnosed as benign and levels were "normal." Annual checkups are consistent and no overt symptoms have come up. I have had a history of endometriosis and had a laparoscopy in 2/97. In 7/97, I had one cycle of Clomid® and got pregnant right away. My OB/GYN said that I had a missed abortion sometime in my 9th week even though I had few symptoms. Could my TSH level be too high? (2.96)

2.96 is completely normal in our lab. Was that a normal value in your doctor's lab?

Could I have thyroid antibodies and not know it?

Possible but if the TSH is normal, the antibodies (if they existed) aren't enough to affect the thyroid function.

My endocrinologist is very conservative and has dismissed my hunches before. He's very expensive and I'd rather ask someone else. We don't feel comfortable pursuing IVF and fertility drugs. What kind of doctor could I see? What would you recommend?

Most general gynecologists can prescribe Clomid® if that is needed. They can also order thyroid studies. What are your specific goals?

I'm interested in finding out what kind of doctor to see to explore a possible connection between my thyroid levels and my recent miscarriage.

Your thyroid levels appear normal so the next step is to get pregnant again, probably using Clomid®. The most likely explanation for the missed miscarriage is either unknown or due to age. Chances are still 2 out of 3 that if you get pregnant, you will not miscarry.

I have been charting BBT for 2 months and notice my luteal phase is only 9 days. I do see a temperature drop and then a rise so I assume I am ovulating. I have used OPK the past 2 months and it did not detect a surge but by my charts I did . Any suggestions?

Where are you starting the count for your luteal phase, from the drop to the 1st day of your menses? What does OPK stand for? What is total length of cycle?

I have used OPK ovulation prediction kit and never detected the surge. My cycle is 26 days. I count from the temp rise and did not include until my menses because the temp rise was only 9 days and then a drop of temps for 3 days and the my menstruation came on. Any suggestions?

Count from the temp drop to the start of menses to get luteal phase. See past messages on luteal phase. Luteal phases don't have to be short to be inadequate.

You should be detecting an LH surge with the kit. Double check to see that you are following the directions correctly. You may need to call your physician to see if you are doing it correctly. Make sure the kit isn't outdated.

Ovulation prediction with a kit

I have been charting BTT and observing for cervical mucus. My temps and cervical mucus do coincide to detect that I am ovulating. However I also tried Ovulation Prediction Kit and it doesn't detect the surge. Do you have any idea why this occurs? I am reading the directions and doing the kit right.

I can't tell why it didn't work. Sometimes they just seem so miss the short LH surge. How many days after your temperature drop (before the rise) did your menstrual period start? Were you testing at that time of the drop? For how many days on each side?

I started charting BBT. Last month I ovulated on the 14th day of my cycle. Is it normal if I ovulate on a different day this month? Or should it also be on the l4th day of my cycle? Thanks for your help.

If your cycles are fairly regular, it will probably be on the same day but it can vary up to two days normally. If your cycles are more variable, ovulation will be just as variable.

Be sure to use the kit before you think you will ovulate. By the time the cervical mucus changes and you get an ovulatory temp rise, the LH surge has already passed.

Short luteal phase

I had a tubal reversal on 4 months ago and have been charting ever since. I noticed that my luteal phase is only 10 days long. I have been told by others trying to conceive that this is too short. Is it and if so what treatment would be the right course of action?

Normal luteal phases are 11-17 days measured from after the LH surge, usually by an ovulation predictor kit. Ten days is considered short. About 5% of all menstrual cycles have a short luteal phase. This is one form of luteal phase defect that many (but not all) infertility specialists think may affect fertility. The classic form of luteal phase defect, however, is a normal length luteal phase but evidence by endometrial biopsy that the histologic appearance of the endometrium is at least 2 days behind what is considered normal. These happen in about 30% of cycles. Because of the frequent occurrence of these "defects", the specialists say that you need to diagnose at least two of these (usually in a row) in order to consider treatment.

Since we are a Diagnostic Cyber, I think its appropriate to focus first on whether you really have a luteal phase defect and then, if so, the treatment. Luteal phase defect, either a short phase or an inadequate hormonal phase, is usually not diagnosed by BBT. You may suspect it from the BBT but they are not that accurate. I assume you are counting the days of elevated temperature. Many normal BBT charts have only 10-12 days of good temperature elevation. What is the total cycle length? I assume you've done ?2 cycles since your surgery?

The diagnosis is made one of two ways:

Biopsy on day 24-26 that is read by an experienced pathologist and lags by two or more days from what it should be.
Serum progesterone on day 7 after ovulation that is greater than 10ng/mL (some use 12 and others use 14ng/mL as the cutoff).

Almost all the scientific studies used the 1st criteria. Keep in mind that many experts interpret those studies as not really confirming that luteal phase defect has any effect on fertility.

Treatment is either progesterone suppositories or progesterone vaginal cream for defects that are normal length but with histology out of phase, or ovulation induction with Clomid® for short phases or normal length, out-of-phase luteal phases. The reason for this is that the luteal defect is thought to be due to poor follicular development.

Have you asked your doctor about this yet?

No I haven't spoken with my doctor yet. I wanted to get at least three cycles charted before calling.

The two cycles that I charted were 36 days in length. with ovulation occurring on day 26 as indicated by an LH surge on day 23 followed by a temp drop on day 25 and then a rise on day 26. Second cycle was 29 days in length with ovulation occurring on 20. LH surge was on day 18, temp drop on day 19 and rise on day 20. Should I count my luteal phase as starting on the day the LH surge took place? Do these cycles seem normal to you? I appreciate all of your help. I'm new at trying to conceive and any advice is a real help and comfort.

Since you are monitoring the LH surge, count from there. When there is only a basal body temperature curve (BBT) we usually count from the low temp rather than the rise. From what you describe, the first cycle (36 length) had a 12-13 day luteal phase. The second (29 length) had a 10-11 day luteal length. These are probably o.k. but I'm glad you are doing a third cycle. When your doctor looks at all of those, the decision as to whether you need a serum progesterone level or endometrial biopsy will be clearer. Sometimes it takes a few cycles after surgery for ovulation to get back in correct synchronization.

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FAQs About Infertility

I am concerned about the hormonal implications of having additional ovaries. Wouldn't my "normal" hormone levels be different if I had four ovaries instead of two?

Wouldn't I need a second pap smear?

The list goes on. I know you can't answer all of my questions, but could you at least tell me whether I could be pregnant even though the tests keep coming out negative?

How common is it for men to be sterile?

My husband is going in for semen analysis in a couple weeks and is quite nervous that HE is the reason we haven't become pregnant in the past year. Are there any stats I can give him for the different fertility problems in men?

I am aware of only a couple problems such as low motility, varicose veins, low sperm count. What are the treatments, if any, for the various problems?

If my question is too time-consuming to answer, maybe you could direct me to a web site that could answer.