Basic Infertility Evaluation – What you should know
This is what I tell everyone who comes to see me for their first infertility evaluation, “It takes three things to get pregnant: 1. Sperm 2. Tubes that are open (this includes a normal uterus) and 3. Ovaries that are working.” If you remember those three things and look into possible problems with the three areas I just listed – you will know (most of the time) why things just aren’t working.
So the question is: How do you know if there is a problem?
1. Let’s talk about sperm. The magic number for sperm is a total motile count of 40 million. If you have a total motile count that is less than 40 million, your chances to conceive are going to be reduced. There’s more to sperm than just the count and the motility and a lot of people miss this very important point. So not only are we looking for a total motile count of 40 million – take the % normal morphology (this is the percentage of sperm that are normally shaped) and multiply it by the total motile count – if it is > 40 million – you may not need my help. If it less than 40 million, you may need my help.
Sperm are funny looking. No offense to all you sperm out there but you are! The majority of sperm when ejaculated are usually not normally shaped. Something else that everyone needs to know – there is more than one way to look at sperm. There is a criteria used called the WHO criteria and there’s another criteria called the Strict Kruger criteria. Based on the criteria you use to look at the shape of the sperm – you will get a different result and your result will mean different things. If you are having infertility problems – make sure your semen analysis is being done using the Strict Kruger Criteria. You want the sperm to be at 15% normal or better. Between 10-15% normally shaped sperm is the grey area – fertility may or may not be impaired.
This is what I tell my patients:
<10% normal morphology or normal shaped sperm = Impaired fertility
6-10%= you may be able to get pregnant with inseminations
<6%= you may need more help to get pregnant. What does more help mean? It means having an embryologist take a sperm and inject it into the egg. That way, we don’t have to rely on the sperm to do the work – we do the work for it.
Why? What is it about funny looking sperm that affects fertility? This is what you should know – funny looking sperm aren’t able to penetrate the outside of the egg and ultimately fertilize the egg.
It does not mean that your baby is going to be funny looking. Once the sperm is in the egg – the egg does not care how it got in there or if it was funny looking. For the most part – an abnormally shaped sperm isn’t going to be able to fertilize an egg.
Patients ask me all the time, “If my sperm is not normally shaped – does that mean that there is going to be something wrong with my baby? Ie abnormally shaped?” The answer is – no.
Another thing you should know – never define sperm based on 1 semen analysis. Repeat it. Like everyone else – sperm can just have a bad day. Maybe you were in the hot tub for 12 hours before your semen analysis (bad when trying to get pregnant). Maybe you have been attached to your laptop (on your lap) for the last 3 months (also bad). Maybe you had a really high fever and were really sick (bad for sperm) right before your semen analysis. So check again – because it may not be the same the second time around. If it is the same – it’s time to ask why.
I am always asking why and you should too. What causes the sperm to become abnormally shaped?
A couple reasons: I mentioned some of the reversible reasons above. But some things I always look for:
- Low testosterone: Sperm need a normal testosterone level to fully mature and become normally shaped. So I always check this. Even if you don’t have erectile dysfunction or problems with your libido – your testosterone may be low. There are things that you can do (not taking testosterone) that will help. Ask me what and I will tell you.
- Varicocoele: this is a dilated vein around the testicle. The testicles don’t like to be hot. They just don’t – that’s why men carry their testicles outside their body. A dilated vein may increase the temperature of the testicle just enough to affect the shape of the sperm. A urologist will be able to detect if you have a varicocoele. My recommendation is this: Ask your infertility doctor if it’s worth your while to have it fixed. If your wife is older – you may not want to wait the 6 months it takes to see a result. And know this – you don’t always see improvement even after a varicocele repair (also known as a varicocoelectomy).
I’m not mentioning everything here but there are things you can do now:
- Take high dose antioxidants. Make it easy on yourself – just buy a supplement. I recommend one through Coast Reproductive.
- No hot tub use, laptop use on the lap, no bike riding, no car seat warmers…..Just think, “coooooool.”
There’s a lot more to sperm than what I’m mentioning above but this is just for starters.
2. So let’s go back to the 3 things that we want to evaluate…..We talked about sperm…..going up the reproductive tract next is the uterine cavity and the fallopian tubes.
How do you know your tubes are open or not? Well there are 3 ways to find out:
A. Laparoscopy: this is where we put a camera in your belly, inject blue dye through your uterus and hopefully watch it spill out of your tubes. You need surgery to do this. In the “old days” we used to do this for every infertile couple that walked in the door thinking we could pick up other problems such as endometriosis and cure them.
B. Hysterosalpingogram: You hear this being called the “dye” test. It is very common to hear people talk about this test as, “the most painful thing they’ve ever been through in their entire life.” In a nut-shell, a radiologist or your infertility doctor places a catheter (after placing a speculum) through your cervix (the opening of the uterus) and injects a really sticky dye through your uterus and watches it come out your tubes through a machine that exposes you to a very minimal amount of radiation. You can usually get the results as the test is being done.
C. I prefer doing a saline infusion sonogram: With a brand new ultrasound machine you will actually be able to watch water (a little more complicated than how I’m describing it) come out your tubes…..and this is without exposing you to radiation. Not all infertility docs do this test. But it’s the same idea as a hysterosalpingogram but it uses ultrasound so no radiation exposure.
What would put you at risk for tubal blockage? Have you ever been exposed to any sexually transmitted infections? This puts you at risk. Have you had abdominal surgery? Does your doctor think you may have endometriosis…..all of these things can lead to scar tissue formation which can lead to blocked tubes.
3. Let’s talk about the ovaries now. How do you know if your ovaries are working or not?
Women were born with all the eggs we’ll ever have. There will come a day when we will be able to re-generate eggs from other cells (germ cells) – but not any day soon. Men are always making new sperm cells – not women.
Every month – we ovulate one egg. Did you know that we all have the potential to ovulate more than one? Some women have the potential to ovulate 30, some women have the potential to ovulate 10.
Hope you can follow me through this scenario……Let’s say a woman has the potential to ovulate 10 eggs. She ovulates 1 egg every month and the other 9 die – she can never use them again. When we do infertility treatment we try to save some of the eggs that would have died to give patients a better chance of pregnancy. We don’t make women run out of eggs (common myth).
The potential number of egg varies from woman to woman and decreases as we age. This number is genetically determined (for the most part). We call this the antral follicle count. Follicles are fluid-filled sacs that sit in the ovary. Each follicle or fluid-filled sac contains 1 egg. Eggs are microscopic – can’t see them until you remove them from the body and look at them using a high powered microscope.
Eggs go through a maturation process during a menstrual cycle so that when an egg is ovulated it is mature. Mature = sperm ready. Sperm can only fertilize sperm ready or mature eggs.
How do we know how well ovaries are working? Know your FSH level. I will talk more about what FSH levels mean another day. Find out your antral follicle count. If it is less than 10, you may need higher tech therapy to get pregnant. Ask your mom when she went into menopause. If it was within 5 years of your current age and you are trying to get pregnant – you will have to work very hard and very fast….so don’t delay seeing an infertility doc.
What other things can affect ovaries negatively ? Smoking, diabetes, diet, stress, thyroid disorders, high prolactin levels.
This is a very quick summary of what you need to know to get pregnant. If you’re having problems: get the following evaluated: sperm, tubes and ovaries and ask your doc for a plan that’s right for you. Don’t ever go high-tech until you’re ready to do so because miracles happen when you least expect them to.