Fertility FILE

Fertility FILE 101: SEMEN ANALYSIS

A semen analysis is a test to evaluate the husband's sperm.  It is one of the least expensive, least invasive tests in the standard fertility evaluation. To perform the test, the husband is asked to abstain for at least two days, preferably three, and no more than seven days. He is then instructed to ejaculate into a sterile cup and bring the sample to the office within one hour.

Upon receipt of the sample, the first thing done in the laboratory is to look at it and describe anything unusual about its color or appearance. Next, the sample is measured for its volume. Finally, a drop of it is placed into a special counting chamber, such as the Makler chamber, which is what we use in our office.

By counting how many sperm fall into the squares of a precisely calibrated grid and by distinguishing the moving sperm from the non-moving sperm, a sperm count and motility are calculated.

The basic two features evaluated are the sperm count and the sperm motility. The count refers to how many sperm there and the motility refers to how many of them are moving.

There are also more detailed features that can be determined about the sperm, such as the morphology and the DNA integrity.

Fertility 2007. Our world is changing!

Prior to 1978, for many couples with infertility, the chance of cure was as bad as the chance of cure for many terminal illnesses such as some types of cancer, meaning there was almost nothing that could be done. These couples either successfully adopted or they proceeded to have a childless life.

The discovery and development of In-Vitro-Fertilization (IVF) changed that tremendously. There are three types of problems that contribute to infertility – problems with the wife’s eggs, problems with the husband’s sperm and problems with the “plumbing” (the anatomic pathway which allows the sperm and egg to come together and nourish a thriving baby). In medical terms, this refers to the woman’s fallopian tubes, uterus and cervix.

IVF involves taking the sperm and egg and bringing them together in a laboratory for a few days before being put back into the mother’s body as an intact embryo. The rest of the pregnancy journey takes place just as it always has in nature, inside the mother’s womb. Initially, IVF was thought of as just a way to solve the plumbing problems. Instead of relying on a sperm and an egg to come together inside the body under natural conditions, women with scarred or missing tubes could still have a baby by having the sperm and egg introduced to each other outside the body under ideal laboratory conditions. Over time, IVF has evolved to help couples with severe sperm problems and even couples with significant egg issues. Couples with extremely severe egg issues can not be helped through IVF, unless they are willing to enlist the help of an egg donor. While IVF is still not 100% in its usefulness to infertile couples, it has come a long way.

Rather than be some space-age oddity, IVF has become an everyday household word. As of 2006, over THREE MILLION IVF BABIES have been born. In fact, over 1% of the healthy babies born in the US today arrive as a result of IVF. In certain other countries, that ratio is higher than 3%. As with any new scientific advancement, there are questions as to long term consequences. The issue of future health in IVF babies has successfully breached new hurdles as each generation of IVF babies successfully finishes infancy, childhood and now, early adulthood without any major surprises. As time has passed, we have reached the moment when the first generation of IVF babies are starting to have their own normal babies and the majority of them appear to be doing so naturally, without the need for any infertility treatment.

Today, there are still some people who promote the extreme view that all scientifically advanced ways of assisting reproduction, including In-Vitro-Fertilization, should be banned. While it is true that as mankind discovers more advances that push the limits of nature, such as cloning and genetic selection, we need to constantly evaluate the differences between what we CAN do vs. what we SHOULD do. However, to argue for elimination of IVF would unfairly deprive many infertile couples of the option of having a baby. IVF is now a proven effective way to help most couples exercise their privilege (or their RIGHT) to be happy parents.

Blueprints for Making Your Baby

As you seek to learn ways to help you have a baby, you will run into a lot of scientific details. Knowing the general concept of how a healthy baby is brought to life will help you better understand these details.

Advanced organisms, including us human beings, reproduce by SEXUAL REPRODUCTION. In contrast, simpler organisms, such as bacteria and amoebae reproduce by ASEXUAL REPRODUCTION. Imagine if we reproduced asexually, just like an amoeba. Then, when it came time to make a baby, a piece of ourselves would pinch off and become another organism identical to ourselves. However, that is not the case. We reproduce sexually, meaning it requires two separate organisms (father and mother) to each contribute half of their genetic influence. These come together to make a new person who has a 50/50 combination of the genetics of the two parents. One marvelous advantage of our reproducing this way is the ability to generate nearly infinite diversity. It's the reason that all of us (except for identical twins) are genetically unique.

All babies, including ourselves way back at one time, start out as an embryo. What makes each embryo different is the special genetic information within the DNA. The unique information encoded in our DNA is what regulates our physical features such as eye color, potential height or vulnerability to diabetes.

When a husband and wife set out to create a baby, they each contribute half of their genetic information to create a new person. Each time they do this, they send out a random combination comprising half of the billion bits of genetic information in their DNA. This is the reason that a man and woman can produce a different child each time, rather than having children who are exact replicas of each other.

What are gametes? A human being is composed of many cells. Estimates range from 10 trillion (10 million million) to 100 trillion cells per person. Each of the cells in our bodies contains the same full set of DNA with the exception of sperm cells and egg cells. These are collectively known as gametes and are special in that they only contain half the DNA of other regular cells. The reason they contain half is so that one sperm and one egg can add together to make a fertilized embryo that has a normal full set (half plus half) of genes.

As you and your spouse try to conceive, it may help your understanding to remind yourselves that you are essentially attempting to combine your genetic information by way of your sperm and your eggs. Anything short of one perfect sperm uniting with one perfect egg will fail to produce a healthy baby.

In future posts, we'll learn the important differences between how sperm and eggs function to affect your odds of getting pregnant.

Not Wasting Your Fertile Years

Judging from the questions I'm getting, the greatest fear still for many of you is that month after month is being wasted waiting for pregnancy when in reality, it's just not going to happen naturally for some reason. Most average couples can expect a normal 20% chance each month to get pregnant. If you are in this group, it is smart for you to just be patient, because pregnancy will happen without any special action on your part, usually within six months. Even if you are subfertile and only have a 10% chance each month, you still can expect to eventually conceive on your own. It just might take a year or so. But if you only have a 0-1% each month, then all you're doing by putting off getting help is just wasting time as your reproductive potential is gradually depleted.

The moment you make your decision that you would like to get pregnant, there are three questions to ask yourselves right away.
1. Am I not releasing an egg each month?
2. Is there adequate sperm?
3. Is there any physical barrier to the sperm and egg meeting properly?

The answer to the first question is one you can easily figure out yourself in many cases. If you are not getting your period at least ten times per year (no less frequent than every 35 days), then you are not ovulating as often as you should and therefore, time is being wasted during your reproductive years. It's wise to get help sooner rather than later.

The second question can only be answered by doing a semen analysis. There is no way to know the truth about a man's sperm just by looking at him nor by analyzing his general health. Granted, if he has fathered several pregnancies in the past, and nothing drastic has happened to his health since then, most likely, he does not have any severe sperm problem. A semen analysis can be done fairly easily for under $150 and is a very basic test to start with.

The third question can best be answered with a test called a HysteroSalpingoGram or HSG. This is a test where a special liquid is gently introduced into the uterus and images are taken to see where the liquid flows. This can detect if you have a polyp or fibroid tumor in the uterus that is blocking your implantation. It can also show if your Fallopian tubes are blocked or not. You should be suspicious that you might have these problems if you have had previous gynecological surgery, previous pelvic infections, very painful periods or especially heavy ones. Compared with a semen analysis, this test is more costly and more inconvenient to do, but can be obtained usually for under $800.

So how do you avoid wasting time?

Here is one good approach:
1. Begin by understanding the stages that couples go through in their desire to have a baby and figure out where you are.
2. Stop all contraception and maintain a patter of having sex every 1-3 days (preferably every 1-2).
3. If you have regular periods and are under 40 years old and do not suspect a physical barrier to pregnancy, then set yourself a deadline of 4 months, 8 months or 12 months depending on your age and personal sense of urgency.
4. If your deadline arrives and you're still not pregnant, make a decision regarding which you would rather do: semen analysis, HSG or consult a fertility specialist. At the very least, do a semen analysis. It's cheap and fairly convenient (the sample can be produced at home and does NOT have to be produced in the lab or doctor's office). If the testing is normal, set a new shorter deadline of 4 more months.
5. If still not pregnant by then, choose another action that you did not choose before. Most people would choose the semen analysis the first time and then the HSG the second time. Both these tests can be ordered by your primary care physician or by your OB/Gyn.
6. If both these tests are normal, but you are still not getting pregnant another four months later, it's time to see a reproductive endocrinologist.

By following these simple steps, you can avoid unnecessarily wasting time. Best of luck!

You are welcome to email me with comments or questions.

UCLA In-Vitro Fertilization Conference

I just returned from the 20th Annual UCLA In-Vitro Fertilization review course held in Santa Barbara each year, where dozens of reproductive endocrinologists from around the world convene to review the latest on IVF.

During the drive there, I was rewarded with a soothing view of the Pacific Ocean on my left, as I looked forward to spending time at the Four Seasons Biltmore. I like these meetings for reasons besides getting to improve my knowledge about topics ranging from the optimal ovarian stimulation protocols, embryo transfer techiniques and patient management strategies. I like them for the chance to catch up with old friends and colleagues in the field from around the world. There's a lot to be learned, not only from the lectures, but also from trading tips and stories at night around the dinner table. I first attended this particular meeting when I was a UCLA Reproductive Endocrinology fellow, but find there's always plenty of new things to learn each year. It's helpful to see what other people are doing in their practices to help their patients get pregnant, meanwhile being respectful that there are many ways to accomplish the same goals.

Also present at these meetings are reps from the major companies that manufacture IVF equipment, embryo culture media and the medications that we use in our work.

The highlight for me this year came when I found myself in the auditorium watching a slide on the large screen showing a family with mom, dad and two lovely daughters in their late teens / early 20's. About 20 years ago at UCLA, one of the earlier IVF cases involved an egg retrieval done by ultrasound guidance through the bladder. One of the embryos that was created became the older daughter and another embryo was frozen and then transferred a few years later to give birth to the second daughter. The speaker at the lectern was Dr. David Meldrum, the physician who performed those procedures. He had just got done giving an excellent talk about the history of IVF. Afterwards, to the delight of the audience, one of the two daughters in the slide came on stage and gave him a plaque and a warm thank-you for helping bring her into this world. It was a touching reminder how all our work with sperm, eggs and catheters gives rise to very real babies and families!

This year, as always, I came back with a few new ideas to incorporate into my practice. I didn't bring my camera this time, but I hope to take pictures when I go to the next big conference, the annual meeting of the American Society for Reproductive Medicine, which will be in Washington DC this October.

Q & A : July 13, 2007

HOW DO I KNOW IF I'M INFERTILE?

This question is one of the most commonly asked by women who have yet to have a baby. If you are looking for just a rigid definition, by one commonly accepted set of criteria, if you have been wanting to have a baby (not practicing contraception) for over a year, but still are not pregnant, then you can be considered infertile. However, a more useful way of thinking is, rather than focus solely on labels and getting caught up in rigid definitions, to instead step back and look at the big picture and ask ourselves some more practical questions.

Question 1. Is it reasonably possible that I will be able to get pregnant and give birth to a live healthy baby?

Question 2. If so, what is/are the next step(s) that I need to take in order to make it more likely to happen?

Just as for any goal in life, it is sometimes best to think it terms of actions and decisions. Keep this in mind if you find yourself in the situation of wondering if you're infertile. The correct questions to ask are whether or not you are reasonably able to have a baby, and if so, what should you do next?

Anyway, in order to specifically answer these questions, it is necessary to know more information about you and your partner. The three items of specific information that would be especially important would be the likely condition of your eggs (as based on age and other factors), the condition of your uterus and Fallopian tubes and the status of your partner's sperm.

You are welcome to email me with your questions or comments.

Fertility FILE 101: The UTERUS

The uterus is the female organ which serves as the baby's home during a pregnancy. It begins as a muscular organ about the size of an orange and slowly grows during pregnancy to be large enough to accommodate a full term baby. 

The lowest part of the uterus is the door by which the baby eventually exits. This is know as the cervix. There are also two openings at the top of the uterus that lead to the right and left Fallopian tubes. After a sperm fertilizes an egg, an embryo is formed which travels from the tubes into the uterus.


Every month, there is growth of an inner lining of the uterus. This is known as the endometrial lining. If a healthy embryo enters the uterus from the fallopian tubes, then the lining remains in place for the duration of the pregnancy and serves to nourish the baby. If no healthy embryos shows up that month, then the lining is shed as a menstrual period.

One of the most common ways in which uterine abnormalities contribute to infertility occurs when there are fibroid tumors inside the uterus. The fibroid can act the same way that an IUD contraceptive device works in preventing successful implantation. Fibroids that are inside the cavity of the uterus should be removed in infertile patients before proceeding with other types of treatment.



Gratitude extended to Dr. Davide Brunelli for his unique digitally-rendered images of the uterus.

The Four Red Alerts for Seeking Infertility Help

When it comes to having difficulty getting pregnant, you have a choice. You can get help or keep trying to do it on your own. Most of the time, it's easy. In fact, over 80% of couples are able to get pregnant on their own within six months to one year. If you are in the other 20% and have gone over a year without success, it's time to make a decision. Here are FOUR warning signs that you need to seek professional help.

1. AGE: If you are over 35, you are at increased risk for miscarriage, pregnancy complications, birth defects and the possibility of never having a child. Getting help sooner than later is strongly advised. As a rule of thumb, if you are over 35 and nothing has happened after one year, get help. If you are over 38 and nothing has happened after six months, get help. Couples over 41 who haven't even started trying might benefit from a single pre-conception consultation visit to help plan their fertility strategy. Note that these guidelines refer to the age of the wife.

2. DURATION: If it's been over two years without birth control and you're still not pregnant, it's time to get help, because most likely something is wrong. Exceptions include situations where there is a clear excuse such as job assignments or military assignments so that husband and wife are geographically separated the majority of the time. Please note that the two-year limit mentioned is a "red-alert" level for taking action. You are well-advised to seek help even if it's only been one year.

3. OBVIOUS SUSPICION OF A PROBLEM: Some people already anticipate trouble conceiving even before they start trying. These would include couples in which the wife fails to have periods every month, couples where at least one partner has significant medical problems or situations where the wife has had serious gynecological problems in the past. It makes sense to get help quickly in these situations, even if hasn't been a full year yet.

4. URGENCY AND PRIORITY: On one extreme, if you are very willing to accept never having children at all, then you can certainly continue trying on your own without any time limit. If you DO get pregnant on your own, it will be a great blessing. If you don't, then you are able to accept it. On the other extreme, if the thought of having a baby is the #1 priority consuming your every waking moment and is seriously hindering you from enjoying life, then you owe it to yourself to at least discuss things with a professional immediately.

REMEMBER: Always have a plan! Even if that plan consists of trying on your own for 12 months, at least you have a safety net for when you will be triggered to move to the next step and seek treatment. If you are not pregnant yet and want to be, make sure to set yourself a deadline so that if you're still not pregnant by that time, you will take action and do something! This is the only way to reassure that you don't let time pass by before it's too late.

The Four Stages of Wanting a Baby

You would like to have a baby and would like to know where to begin. Before we discuss what to do, let's review the big picture of the stages couples go through with regards to having a baby.

The earliest stage that couples pass through is the "DON'T WANT BABY YET" stage. Often, this is during the first months of marriage when the priorities of getting adjusted to married life, setting career goals or traveling take precedence over any desire of starting a family yet. This is a time when the couple is fairly meticulous about contraception, either with birth-control pills or condoms or even just deliberately timing to avoid the fertile periods. All these actions are taken because the couple strongly prefer not to get pregnant yet.

Next comes the "IF IT HAPPENS, IT HAPPENS" stage. By this time, husband and wife feel ready for a baby if they should be so blessed, but still are in no hurry. So unlike in the previous stage, all effective forms of birth control are cast away and the couple enter a very carefree period where they are happy if they get pregnant and happy if they don't. It is in this very time that over 80% of couples WILL get pregnant naturally within a year, many of them within six months.

Next is the "GETTING JUST A LITTLE WORRIED" stage. As month after month passes by, there is a rise in anxiety as pregnancy fails to arrive. There is still no drive to do anything active, but this is a time characterized by casual surfing of the internet for information or possibly consulting some books. The topic eventually comes up during conversation between husband and wife, with the two of them agreeing to just give it a little more time. Many couples will dabble with meditation, acupuncture, fertility good-luck-charms, nutritional supplements, changing from briefs to boxers, lying upside-down after sex, using ovulation kits to time things and various other actions without necessarily asking for help from a physician. Fortunately, for many couples, the stork will finally arrive during this time and they might even credit their success to the various interventions they did and share this advice with their infertile friends, when in reality, it was just a matter of patience and time.

Finally, about 15% of American couples will reach the "DON'T WANT TO WAIT ANY MORE" stage and they will seek professional help. In future posts, we'll discuss two important questions.

"When is it time to make the move to get professional help?"
"What should we consider when choosing where to get that help?"

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