Male Factor Infertility (MFI)

Getting the news that your facing MFI can be devestating for both partners.

The great news is with advances in MFI many couples will conceive a child with some help from their RE's and MFI Urologists.

If you receive a diagnosis like 0 sperm in the sample or your husband is missing the Vas Deferens, it is very important that you find a reputable Urologist that specializes in MFI. Link and more info below.


Normal numbers of a semen analysis (SA) are:

Volume	2.0 to 5.0 mL or more
Sperm number	20 million/mL or more
Motility	50 percent or more
Forward Progression	at least 2+ forward progression
Morphology	WHO> 30 percent; or Kruger, at least 4%

And

No significant sperm clumping or agglutination No significant white blood cells or red blood cells No hyperviscosity (increased thickening of the seminal fluid)

Infertility effects one in every six couples who are trying to conceive. In at least half of all cases of infertility a male factor is a major or contributing cause. This means that about 10% of all men in the United States who are attempting to conceive suffer from infertility.

The most common identifiable cause of infertility in men is varicocele. This is a condition of enlarged veins in the scrotum that causes abnormalities in the temperature regulation of the testis. Enzymes that are responsible for both sperm and hormone (testosterone) production have an optimal temperature at which they operate most effectively. If this temperature is elevated by even one degree, sperm and testosterone production are adversely effected.

The second major cause of infertility in men is blockages or obstructions of the male reproductive tract. This is particularly true for men with zero sperm count, a condition called "azoospermia." Men with zero sperm count can be divided into two broad groups:

1. men who have an obstruction problem or blockage, meaning they are making sperm, but the sperm can't get out, or
2. men who have a production problem, meaning they are not making sperm, a condition called "non-obstructive " azoospermia."

We can easily determine which group an infertile male is in by doing a testicular biopsy, also using a microscope to minimize discomfort and complications.

Blockage can also be caused by a urinary tract infection or by the sexually transmitted diseases chlamydia and gonorrhea. Bacteria can infect the tiny duct called the "epididymis," which is essentially a swimming school for sperm before they are able to swim to fertilize an egg. Infection of the epididymis can cause scarring and blockage, inhibiting the sperm from leaving the duct to fertilize an egg. With the use of microscopes employing 30-power magnification, blockage repair success rates are extremely high.

One of the most common causes of blockage is vasectomy. Approximately 500,000 to a million men undergo vasectomy each year in this country for permanent birth control.

Approximately 1% of all infertile men are born with the congenital absence of the vas deferens, the "equivalent" of a vasectomy. Unfortunately, there are no artificial tubes strong enough to replace the vas deferens. However, we are now able to help such men conceive using an operating microscope to retrieve sperm from the tiny ducts of the epididymis, freeze them and use them later for in- vitro fertilization (IVF) with the injection of the single sperm directly into an egg.

Another cause of MFI is Andropause, or what is sometimes referred to as, male menopause. For most men, testosterone levels drop as the age but for some it happens much earlier and this causes lower and lower sperm counts. Sometimes testosterone replacement therapy can help increase counts.

Helpful links and information about MFI, general and specific diagnosis:

General Information

Male Reproductive System

Male Work-up

Additional Info on MFI Testing

Causes

The emotions
additional info

Varicocele

Microsurgical Varicocelectomy (graphic photos)

ICSI

Azoospermia

Non-Obstuctive Azoospermia

Andropause

Vas Deferens (CBAVD)

TESE

Lifestyle, Dietary and Vitamins to improve MFI

Alternative Treatment

Source website - more information
more info

TW

Polycystic Ovarian Syndrom (PCOS)

PCOS stands for Polycystic Ovarian Syndrome. PCOS is a serious condition which can affect a woman in a number of areas, including her hormones, fertility, heart, blood pressure, insulin production, blood vessels and appearance. Women who have PCOS have high levels of androgens. They have an irregular menstrual cycle or no menstrual cycle. They typically have fluid-filled sacs, called cysts, on their ovaries. PCOS is the most common hormonal reproductive problem in women of childbearing age. Somewhere between 5 and 10% of women of childbearing age have PCOS.

There is no single test to diagnose PCOS. Your doctor will take a medical history and perform a physical exam. This exam may include an ultrasound, checking your hormone levels, and measure glucose levels in the blood. At the physical exam the doctor will want to evaluate the areas of increased hair growth, so try to allow the natural hair growth for a few days before the visit. During a pelvic exam, the ovaries may be enlarged or swollen by the increased number of small cysts. This can be seen more easily by vaginal ultrasound, or screening, to examine the ovaries for cysts and the endometrium. The endometrium is the lining of the uterus. The uterine lining may become thicker if there has not been a regular period.

Symptoms of PCOS may include:

- infertility due to not ovulating
- acne, oily skin or dandruff
- type 2 diabetes
- pelvic pain
- excessive snoring and breathing stops while sleeping
- sleep apnea
- high blood pressure
- infrequent or no periods
- irregular bleeding
- increased growth of hair, including hair on the face, chest, stomach, back, thumbs, or toes
- weight gain or obesity, usually carrying extra weight around the waist
- high cholesterol
- male-pattern baldness or thinning hair
- patches of thickened and dark brown or black skin on the neck, arms, breasts, or thighs
- skin tags, or tiny excess flaps of skin in the armpits or neck area

Helpful sites:

Soul Cysters

PCOSupport

Infertility Physicion Explanation of PCOS - This is one of the best explanations of PCOS that I have ever found. Polycystic Ovary Syndrome (PCOS) FAQ - A thourough FAQ for PCOS. Polycystic Ovarian Syndrome (PCOS) - Frequently Asked Questions Polycystic Ovarian Syndrome - PCOS Research and its Findings SoulCysters Online Community - The largest online community of women with Polycystic Ovarian Syndrome (PCOS). Polycystic Ovarian Syndrome Association - Women with PCOS helping others. WebMD's explanation of PCOS - A thorough explanation of PCOS and what steps need to be taken. Polycystic Ovary Syndrome - Harvard's Medical School's Explanation of PCOS. Disease Profile of PCOS - Distinguishing the different types of PCOS PCOS Diagnostic Lab Tests - Lab tests that should be done for pcos diagnosis. Hormone Levels & Fertility Bloodwork Chart - Information Written by Patients, for Patients. Information about PCOS and its effects on your health - A site with lots of information on healing and reversing the effects of Insulin Resistance. Insulin Resistance Syndrome - Insulin Resistance Information. Thin-PCOS Information - Article about Metformin and Clomid for thin "cysters". Treating PCOS - Current Trends Project PCOS - Awareness, Information, and Support for PCOS TTC with PCOS - Personal web page to help understand and treat PCOS Metformin: A Beginner's Guide - Understanding the Benefits of Metformin Metformin (Glucophage) - Benefits & Side Effects - Great Explanation of the Benefits and Side Effects of Metformin & Glucophage for PCOS. The Power of Cinnamon - A research article stating the correlation in cinnamon consumption and reducing insulin resistance. Clomid vs. Femera - Comparing the two medications for the use of infertility WebMD's Progesterone Test - Great Explanation of the Benefits and Side Effects of Progesterone for PCOS. About Progesterone - Progesterone Effects on the Female Body. Androgen Deficiency in Women - Review of the Subject PCOS: Increased Risk of Cancer - The relationship of endometrial cancer and PCOS Letter to Doctors and Patients - Phytotherapy (Herbal Therapy) for polycystic ovarian syndrome PCOS Coach - Understanding and Treating PCOS PCOS - Dealing Day-to-Day Breastfeeding and Polycystic Ovarian Syndrome (PCOS) - Articles concerning the effects of PCOS on breastfeeding. PCOS and Breastfeeding - A Chat with a researcher concerning her findings on the effects of PCOS on breastfeeding. Breastfeeding and PCOS - Living and Feeding With Low Milk Supply. Breastfeeding and PCOS - Learning How to Breastfeed with PCOS. The Way We Live Now - A PCOS Diagnosis

Book Recommendations:

• A Patient's Guide to PCOS - Walter Futterweit
• PCOS and Your Fertility - Colette Harris
• The Savvy Woman's Guide to PCOS - Elizabeth Lee Vliet
• PCOS: Polycystic Ovarian Syndrome - The Hidden Epidemic - Samuel Thatcher
• What to Do When the Doctor Says It's PCOS - Milton Hammerly
• Polycystic Ovary Syndrome: Fighting Back! - Angela Kay Dotson
• PCOS: A Woman's Guide to Dealing with Polycystic Ovary Syndrome - Colette Harris
• Living with PCOS - Richard S. Legro
• New Glucose Revolution Guide to Living Well with PCOS - Dr. Jennie Brand-Miller
• The Insulin-Resistance Diet - Cheryle R. Hart M.D.
• The Low GI Diet Revolution - Dr. Jennie Brand-Miller
• The PCOS Diet Book - Colette Harris

Hypothyroidism and hyperthyroidism

Thyroidism is caused by either underproduction or over production of the thyroid gland. The production levels can be detected by a CD3 blood test. Please keep in mind that many fertility experts believe that the recommended amount of TSH should be lower in TTC/Pregnant woman then in the general public. That recommended amount is 0.24 - 2.99. When getting your blood drawn it is recommended you ask for your levels, if it is higher then the above recommended amount, please be proactive and ask questions! Some doctors still are not on the same page about what is the correct level, it is important to seek advice from a Endrocrynologist (thyroid specialist).


Hypothyroidism is when your TSH levels are above the recommended amount. Thyroid disease is interrelated with women's hormones, and can have an impact on menstrual cycles, fertility, estrogen/progesterone levels, successful pregnancy and/or miscarriage, the ability to breastfeed and menopause.

For more information please read the following links:

WebMD

About.com

Hypothyroidism Diet

Thyroidism and pregnancy


Hyperthyroidism is when your TSH level fall below what the recommended amount is.

For more information about hyperthyroidism please read the following links:

The Mayo Clinic

Web MD medications

About.com - general information

Testing

• In about 20 percent of cases, infertility is due to a cause involving only the male partner.
• In about 30 to 40 percent of cases, infertility is due to causes involving both the male and female.
• In the remaining 40 to 50 percent of cases, infertility is due entirely to a cause involving the female.

There are several basic tests that everyone should have before beginning treatment:

Cycle Day 3 (CD3) blood work. This is blood drawn on the 3rd day after you get your period. This blood draw will check different hormone levels. You can check a complete list of hormone levels here

Hysterosalpingogram (HSG) - This is a test where dye is inserted using a catheter into your cervix to watch the flow from your tubes to your uterus. This will tell you if you have anything blocking your tubes. Here is more information about the HSG

Semen Analysis (SA) - This is your husbands/partners part in the testing. What it will check for is amount, motility and morphology of his sperm. Keep in mind that even if you have a diagnosed issue, you should not rule out issues with your husband, in fact, 30% of cases the cause is attributed to both male and female factors, meaning there is an issue with both of you. For a chart of normal and abnormal results click here

Additional testing:

Besides the above tests that everyone should have, there a a couple of other tests that you should consider, especially if your doctor feels it is needed or after all other tests are done you feel you need more answers.

Laproscopy - Check here for more information

Sonohysterogram (SIS or SHG) - Check here for more information

7 day past ovulation (7dpo) bloodwork - This will check if you have ovulated and if your progesterone levels are considered high enough. If you have a short luteal phase you should ask about this.

Diagnostic Hysterscopy - Check here for more information

What now: Where to begin and insurance

If you have a known issue or suspect that you have an issue, do not hesitate to talk to a health provider as soon as you are considering trying to conceive. This can include any previous condition or concern with the reproductive organs of either partner, or irregular or infrequent periods for the female. At the least, they can guide you through a basic preconception workup and give you guidelines when to ask for help in the future.

If you are approaching the year mark if you're under 35, or the 6 month mark if you're over 35 and are not sure where to begin, first, check your insurance. Not every insurance is the same, even if it is through the same insurance company so call them to find out exactly what is and is not covered. This really is the best and only way to know for sure. Call more than one time, as one representative may not be as thorough as the next.

There are 15 states in the United States that mandate insurers and companies offer infertility coverage. Each mandate within each different state is different so be sure to check what your state requires. There are also loopholes to these mandates, so never assume you are covered.

For information on mandated states:
RESOLVE: state mandates and coverage

For questions to ask your employer and insurer:
important questions to consider (Attain Fertility)
benefit checklist (San Diego Fertility Center)

For more information:
INCIID: PAGE 1, PAGE 2, PAGE 3
RESOLVE on insurance
ASRM on insurance

Unfortunately there are many people who do not have any insurance coverage. Resolve offers some information and strategies to look into. Not one plan is right for everyone.

Who should you see for treatment? 
A board certified Reproductive Endocrinologist (RE) is an Obstetrician-Gynecologist with advanced education (a mandatory three year fellowship) and research in Reproductive Endocrinology. These highly trained and qualified physicians treat Reproductive Disorders that affect children, women, men, and the mature woman. They are certified with the American Board of Obstetrics and Gynecology in the Sub-Specialty of Reproductive Endocrinology and Infertility. It is important to find a doctor who responsive and well matched to your needs and diagnosis. Most importantly, a reproductive endocrinologist specializes in treating infertility, and is far more likely to have the experience necessary to identify and treat your problem than an OB/GYN who treats only a few infertility cases each year. It is ideal to have a clinic that is open 7 days a week, for optimal procedure timing.

Again, check with your insurance to see if you need a referral to see a Reproductive Endocrinologist (RE), some insurance do require referrals either through your primary care physician (PCP) or a gynecologist (GYN), if that is the case make an appointment with them to get a referral. Some plans also require a pre-authorization prior to a consultation, or prior to any diagnostics and treatment. The only way to know for sure is to call and check what your plan covers.

Call the RE you are interested in seeing and confirm that they take your insurance. If they are part of a larger group of REs, see if the entire group is covered. Sometimes REs not listed under your plan are actually within your network, and vice versa.

Dr Geoffrey Scher article: How do I choose the right RE and IVF program?
Which includes how to interpret those CDC and SART outcome statistics.

If you have no coverage at all you need to make a difficult decision because RE's can be more costly then GYNs and GYN appointments can squeak through the cracks and be covered before diagnosis of infertility. If that is the case, please be proactive and choose your GYN very carefully for the reasons mentioned above. You don't want to regret your choice, and think, "I wish I hadn't spent all that time and money with my OB/GYN." It can be a tremendous waste of time, and money that you could put toward treatment with a specialist who can get to the root of your problem.

Some indications that your GYN is not giving you the same care that an RE would be:  If you are starting treatments and neither you or your partner have had a comprehensive workup (please see TESTING), you should closely scrutinize your choice to proceed. Same with undergoing a treatment cycle and having minimal or no monitoring. Frequent monitoring (blood work and ultrasound at the start of your cycle, repeating every other or every day from cd7 or so until ovulation) on any fertility medication is important to your health as well as to the success of your cycle. Fertility drugs are not miracle drugs that will fix all issues of infertility. Being thoroughly tested and going through properly controlled treatment cycles will save you both time and money in the long run.

It is helpful to have all your previous medical records forwarded to your RE; some REs only need you to bring them the day of the appointment, others want them in advance, so call and confirm when this needs to be done. It is wise to have all records sent to you, and to make copies to give to your RE's office. This way you avoid costly handling fees, plus you have your records on hand should you ever need to reference them, or give them to another doctor, since doctors cannot forward records previously given to them by another doctor or by the patient.

Your first appointment will involve a lot of discussion about your background, your family history, your partner's background and his history. It is not required that your partner attend this meeting, but it is highly beneficial for everyone involved to be present. You may have an internal ultrasound at this visit, and diagnostic testing may be scheduled or performed. Please see the THIS post for more information.

+++
EMD 03.19.11

General information: Am I infertile?

The definition of infertility recognized by both doctors and insurance companies:
Couples who are under the age of 35 who have tried unsuccessfully for over 1 year, if over 35 tried unsuccessfully for 6 months, unless otherwise diagnosed with an issue.

For those of you who are not at the year mark (I will use the 1 year, if you are over 35 self edit to say 6 months) there are some things that can help you be sure that you are ovulating and that you are timing sex correctly.

Not all bodies are created equal, many websites suggest that ovulation occurs 14 days before your period. This is inaccurate for a lot of woman, not everyone does have a 14 day luteal phase (the time after ovulation until your period). Because of that fact you should use other methods to determine when you are ovulating. A couple of methods are ovulation predictor kits (OPK) where you pee on a stick and if the line is as dark or darker then the control line you will ovulate within 12-48 hours after your first positive. Another method is charting, where you take your basil body temperature each morning and your temperature will show an increase after ovulation.

Charting is somewhat involved and there are websites as well as books that can help. www.fertilityfriend.com is a great site that will walk you through the ins and outs of charting. Taking Charge of Your Fertility is a must read for anyone trying to conceive, and they have their own charting website and software as well.

If it shows that after a few months of charting you are not ovulating, now would be the time to talk to your doctor. If you are ovulating, it can take the average couple 6 months to a year to conceive. Keep trying! Yes, no one wants it to take 7 months, especially when you see a lot of people that it works right away for, but it does not mean at this time that there is a problem, your BFP could be right around the corner.

Further reading:
INCIID glossary of medical terms
INCIID general infertility FAQ
RESOLVE general infertility information
FERTILITY PLUS Hormone Levels and Fertility Bloodwork

+++
EMD 3.19.11