Taking Charge of Your Fertility

by Toni Weschler

  •low sperm count (including morphology and motility)

  •varicoceles

  •damaged sperm ducts

  •hormonal deficiency

  •testicular failure

  •sperm antibodies

  Low Sperm Count

  The most common cause of male subfertility is low sperm count, due to a variety of possible causes. Among these are hormonal deficiency, bacterial infections, and varicoceles, all of which may be treated by standard medical procedures, as discussed further below. Success rates vary depending on the cause. Unfortunately, low sperm counts often have no detectable source, though abnormal testicular maturation dating back to embryonic development is often suspected.

  Regardless, it’s possible that sperm production can be increased through the use of various fertility drugs such as Clomid, Pergonal, and HCG, all of which are more commonly associated with women’s fertility procedures. In addition, low sperm counts can be treated with a variety of high-tech procedures to take advantage of the sperm that exist, and indeed, even men with zero sperm count have some promising options, as discussed here.

  Varicoceles

  A type of varicose vein in the man’s scrotal sac, varicoceles is often cited as the most likely cause of diminished sperm counts. Around 30 to 40% of all infertile men have them, though it’s not clear how much impact, if any, they have on fertility. They almost always occur in the left testicle, since the spermatic vein enters the renal vein at a right angle on that side, allowing pressure to build. The most plausible reason why this would affect sperm is that the pooled venous blood overheats the sperm production centers of the testicles. And, as you know, heat can kill sperm.

  Either general or local anesthesia can be used to treat them. The effective sperm count improves in the majority of infertile men after surgery, but only half of these men typically go on to impregnate their partners. This would suggest that male infertility is often caused by a series of overlapping problems. Regardless, you shouldn’t forget the general principle that it takes about three months for sperm to mature, so the man would not experience any improvement in his sperm count for at least that period of time.

  Damaged Sperm Ducts

  Blocked sperm ducts may account for about 10 to 15% of all male infertility. Scarring in the vas deferens may prevent the sperm from reaching the cervical fluid as it flows through the urethra. This is often caused by an infection that is the result of an STI. The vas deferens may also be blocked by a varicocele that is pressing against it. Some of these cases can be corrected without surgery, but most would require a minor operation to eliminate the blockage or scarring. Microsurgery is generally very effective in restoring fertility to men whose only problem is obstruction of sperm outflow.

  Thankfully, it’s now possible to avoid the invasiveness of tubal surgery by removing sperm directly from the man’s epididymis. This is done through two procedures, called microsurgical epididymal sperm aspiration (MESA) and percutaneous epididymal sperm aspiration (PESA). In PESA, an ultrathin needle is used to retrieve the sperm. It’s also possible for sperm to be removed from the vas deferens in similar but somewhat less common procedures—microscopic vasal sperm aspiration (MVSA) and percutaneous vas deferens sperm aspiration (PVSA). All of these procedures are usually done in conjunction with IVF and ICSI.

  Hormonal Deficiency

  The next most common cause of male subfertility is hormonal deficiency. It’s usually due to an insufficient or erratic release of FSH and LH, the sex hormones necessary for sperm production (these hormones, discussed extensively throughout this book, are also present in the male reproductive system). If hormonal deficiency is causing a low sperm count, it may be possible to treat the problem with gonadotropins. Male hormonal problems are generally complex and difficult to cure, though the chances of success are much greater when the problem results in marginal sperm count, as opposed to the complete cessation of sperm production.

  Testicular Failure

  Another fairly common problem is testicular failure, in which the amount of reproductive hormones being released from the pituitary is sufficient, but the testes fail to respond appropriately and therefore do not produce sperm. The causes for this condition range from illnesses such as mumps and various STIs to physical traumas caused by surgery, tumors, and drugs. It may even be caused by a sports injury, in which a sudden blow to the testes can lead to reduction in the flow of oxygen to the spermatogenia, causing the cells to die. Unfortunately, there appears to be no effective treatment that will improve sperm production in cases where the man truly has no sperm.

  However, if there are some sperm, fertility drugs may be able to increase the numbers. And, as mentioned earlier, it’s now possible to retrieve sperm directly from the testicles even when the man’s count is deceptively zero! In two relatively new and remarkable procedures, called testicular sperm extraction (TESE) and testicular sperm aspiration (TESA), special high-powered needles and delicate microsurgical instruments take sperm directly from the testicles.

  There is also a new procedure used by some clinicians called testicular mapping, in which fine needle aspiration (FNA) is used to see what areas of the testes, if any, are producing sperm. This is a significant breakthrough, since many men may appear to have no sperm at all, but in fact have some which are hidden in certain testicular “pockets.” Testicular mapping currently takes about 45 minutes and is done under local anesthesia, but in the future, a less invasive technique called metabolic mapping may be able to ascertain the location of the sperm through MRI scanning.

  Finally, there are some men who truly have no mature sperm at all, but they may have tiny round sperm buds, called spermatids, which have not yet developed a head or tail. Remarkably though, clinicians have harvested and successfully matured them before using them with ICSI and IVF. Unfortunately, this technology is still experimental and the rates for a successful pregnancy are still very low.

  So, let’s see . . . MESA, PESA, MVSA, PVSA, IVF, ICSI, TESE, TESA, FNA . . . OK, study up—test on Friday!

  Sperm Antibodies

  In some men, the problem is caused by production of antibodies to their own sperm, so that the immune system effectively destroys the sperm as soon as they are produced. This occurs in about 10% of infertile men, though the numbers may be higher among those who underwent a vasectomy and then reversed it. If a man has developed such antibodies, he may be prescribed steroids, which are potent drugs that suppress the immune system (clearly such treatment has its risks). There is also some evidence that adrenal hormones may restore fertility in certain cases.

  Another option is to have the sperm washed, as discussed earlier. Basically, the semen is mixed with culture media in a test tube and then rapidly spun. Although it doesn’t dislodge antibodies, it permits separation of the best swimmers, allowing for intrauterine insemination (IUI) high in the woman’s reproductive tract. If IUI is unsuccessful, however, the couple can try IVF combined with ICSI, which is, in fact, the most common way of solving the antibody problem.

  Finally, it’s also possible that the woman may develop antibodies against her partner’s sperm. If this problem is identified, there is a good chance that the clinician will recommend ICSI with IVF, since this is considered the most effective option in such cases.

  The Bottom Line on Male Infertility

  Many of the conditions discussed above as well as some less common fertility-related problems can now clearly be treated. And as the revolution in reproductive medicine continues, it now looks like there is even hope for those men who produce no sperm at all. Of course, these new technologies can be expensive and are not guaranteed to work for all men, but even in those cases where they don’t, couples can still use a sperm donor for artificial insemination.

  THE LIMITATIONS OF CLINIC SUCCESS RATES

  Although the advances in assisted reproductive technologies are real and promising, you still need to be wary of the success rates that clinics report, since they are notoriously inc
onsistent and often misleading. It’s nearly impossible to compare their success rates in using ART, because there are so many confounding variables, such as the cause of infertility and numerous variations within the procedures themselves. In addition, many clinics have a lower age cutoff for women so that they may appear more successful than those that accept older women.

  Finally, a straight pregnancy rate is often reported (whether a miscarriage results or not), even though it is the “take home baby rate” that is obviously more relevant for intelligently analyzing your options. Having said all that, for the most reliable comparison of clinics and technology success rates, you might want to explore either of the websites listed below:

  •Society for Reproductive Technologies sart.org

  •Centers for Disease Control and Prevention cdc.gov/art/ARTReports.htm

  A FINAL WORD ON FAM, INFERTILITY, AND HIGH-TECH OPTIONS

  Assisted reproductive technologies continue to make headline-capturing advances. While I believe that a low-tech option such as FAM is the preferred solution to infertility problems whenever possible, you should be aware of its limits. If you have not been able to get pregnant within about 4 to 6 cycles by timing intercourse perfectly with FAM, you should consider seeing a fertility doctor. Regardless, even if you can’t have a baby through completely natural means, charting can certainly help you identify the problem and utilize the various solutions that modern medicine increasingly offers.

  CHAPTER 16

  Dealing with Miscarriages

  Alas, most of the high-tech procedures discussed in the las, most of the high-tech procedures discussed in the previous chapter will probably not help if you are experiencing repeat miscarriages. For unlike any other infertility issue, this is not a problem of achieving pregnancy, but of keeping the embryo viable after conception has occurred. And as women age into their late 30s, miscarriages become among the most prevalent causes of infertility, with undetected ones probably composing the majority of fetal loss.

  Fortunately, though, promising medical advances are being made even for those women who’ve already had several miscarriages in the past. Of course, before you can begin to seek treatment, you must first be aware that you are even having them. As you’ve already learned, charting can play a crucial role in this area. FAM can identify abnormally short luteal phases of less than 10 days that would make a successful implantation improbable. It can also warn of or detect miscarriages as they occur (as seen by at least 18 temps followed by dropping temps and bleeding).

  Most women who discover they are getting pregnant but losing the embryo should be able to start trying to conceive again within a cycle or two. But keep in mind that each woman and situation is unique, so the length of time you may want to wait will depend on numerous factors, including how early in the pregnancy the miscarriage occurred, what actually caused it, what possible treatments your clinician will recommend for your situation (discussed later in this chapter) and, of course, whether you are emotionally prepared to try again.

  Aside from the obvious steps you should take to make sure you are in the healthiest condition possible, I urge you to consult a qualified fertility specialist if you have had two or more miscarriages. Better yet, you should bring the doctor your Fertility Awareness charts. By doing so, you will not only feel more in control, but you may very well be expediting the process that leads to a healthy baby.

  Deborah and Burt used FAM to get pregnant, but the pregnancy sadly ended in a miscarriage due to a blighted ovum (a situation in which a sac develops, but an embryo never does). Because they had no problem initially getting pregnant, they decided not to resume charting when they were ready to try again.

  Deborah had one normal cycle following her miscarriage, but the cycle after that was extremely long and confusing to them. When she had spotting on Day 54, she didn’t know whether it was ovulatory spotting, implantation bleeding due to pregnancy, or the signs of a possible miscarriage. She only realized then how frustrating it was to not have charted that cycle, because it left her completely in the dark. She got a pregnancy test, which came back negative. Of course, she still wasn’t sure if the test was accurate, because she might have ovulated so late that the test could have indicated a false negative if her body had not yet had a chance to produce enough HCG to be detected.

  As it turned out, Deborah was not pregnant. Either she didn’t ovulate that cycle, or had an extremely delayed ovulation. She wanted me to mention their story because their confusion could have been eliminated had they simply charted. Needless to say, they learned from this experience how valuable charting is, even for those who seemingly have no problem getting pregnant. After waiting a few cycles, they tried again. This time they charted and were thrilled to discover they were pregnant through temps that remained above the coverline beyond 18 days.

  SYMPTOMS AND POSSIBLE MEDICAL RESPONSES

  Before discussing the most common causes and treatments of recurrent miscarriages, you should be familiar with various potential warning signs that you are actually having a miscarriage, beyond just the drop in your temps after Day 18. Vaginal bleeding is of course the most obvious sign, though not all bleeding is a sign of a miscarriage. (In fact, about 20% of women have such bleeding during their first trimester, though less than half of them will miscarry.) However, if your bleeding fills more than one sanity pad an hour, you should contact a clinician as soon as possible, especially if it’s accompanied by serious cramping or abdominal pain. In addition, the box below includes a more comprehensive list of potential symptoms.

  WARNING SIGNS OF A POSSIBLE MISCARRIAGE

  •temps continuously falling after at least 18 days above the coverline

  •red bleeding of any intensity

  •cramping

  •abdominal or pelvic pain

  •sudden loss of pregnancy symptoms

  •dizziness

  •headache

  •joint swelling

  •excessive nausea or vomiting

  •fever

  •extreme or sudden fatigue

  •fainting

  •severe or sudden backache

  Quite often, clinicians will perform an ultrasound to establish a firm diagnosis, and more specifically, to see if the pregnancy is still considered capable of progressing to term. Often what appear to be symptoms of a miscarriage are not. Unfortunately, though, there is usually no way to stop most miscarriages once they’ve started.

  As soon as you’ve had a miscarriage or are in the process of miscarrying, there is little medical treatment required in most cases. This is especially true if you’re still in the first trimester and your doctor verifies that you have stable vital signs such as blood pressure and pulse, and you have no signs of an infection. However, in some cases, certain medications may be given orally or vaginally over several days in order to stimulate the passing of remaining embryonic tissue.

  In addition, there are certain cases where doctors will recommend a surgical procedure called dilation and curettage (D&C), in which the cervix is dilated in order to use suction or a gentle scraping motion to remove the contents of the uterus. This procedure is often recommended when there is heavy bleeding or an infection, but if you don’t have those symptoms, you should discuss your options with the clinician before agreeing to a D&C. This can be important because occasionally women feel that in retrospect, they would’ve preferred to wait for the spontaneous passage of their pregnancy at home.

  Finally, women who’ve had a miscarriage should be prepared for a range of often difficult emotions that can last for several weeks or longer, and they should not hesitate to seek professional counseling if necessary. But most women will hopefully be able to take comfort in knowing that most of those who’ve suffered a miscarriage or even recurrent miscarriages are eventually able carry a pregnancy to term.

  Of course, if you’ve had two or more, you should try to seek a diagnosis from a doctor experienced with treating recurring miscarriages. Your charts will likely be he
lpful for whichever clinician you work with, and in reviewing the most common causes and treatments below, you’ll be able to better understand the possible issues you’ll face and options you’ll have as you try again for a healthy pregnancy.

  COMMON CAUSES AND POTENTIAL PREVENTIVE TREATMENTS

  Chromosomal Defects and the Promise of Preimplantation Genetic Diagnosis

  Researchers have recently discovered that the majority of miscarriages are caused by chromosomal and genetic errors in the embryo. Most of these abnormalities increase as women age into their late 30s and 40s. In a process known as aneoploidy, the actual number and position of the chromosomes within the egg becomes defective, and the end result is an embryo that cannot be sustained through a healthy pregnancy.

  Fortunately, and as mentioned in the last chapter, there is a continually improving process called Preimplantation Genetic Diagnosis (PGD) that enables clinicians to choose those embryos that are most likely to thrive throughout the pregnancy. Of course, PGD can be used only in conjunction with IVF, since the idea is to choose the healthiest embryos from perhaps a group of a dozen or more.

  For those couples who’ve suffered several miscarriages, PGD can be a powerful tool by which to shift the odds back in their favor. However, it should not be performed without serious consultation with an experienced clinician. Aside from the expense, which can add several thousand dollars to the cost of an IVF procedure, the state of PGD technology is still such that not all chromosomal errors can be detected. In addition, there’s a small chance that normal embryos might be mistakenly identified as defective. Nevertheless, the technology continues to advance and for many couples, the benefits clearly outweigh the costs and risks. The bottom line is that if you have suffered through two or more miscarriages, you should seriously weigh the pros and cons of PGD testing.