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Subject: Infertility FAQ (part 2/4)

This article was archived around: Mon, 03 Apr 2006 12:42:47 -0400

All FAQs in Directory: medicine/infertility-faq
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Archive-name: medicine/infertility-faq/part2 Posting-frequency: weekly Last Modified: May 14, 2001 URL: http://www.fertilityplus.org/faq/infertility.html
This FAQ is maintained and updated by Rebecca Smith Waddell. Copyright (c) 1997, 1998, 1999, 2000 by Rebecca Smith Waddell, Meg Fiegenschue, Lynn Diana Gazis-Sax, William F. Panak, Rachel Browne, Jennifer Clabaugh, Kate MacKenzie, and Ian Scott Speirs. All rights reserved. Information in this FAQ may be distributed as long as full copyright information is attached, including URL, and use is strictly not for profit. ______________________________________________________________________ ______________________________________________________________________ SECTION 7 - INFERTILITY TESTS Information and brief description of the more common tests used to diagnose infertility. ------------------------------------------------------------------------ 7.1 - EVALUATION PROCESS FOR MEN Discussion of medical and surgical history. This includes a history of systemic diseases, such as viral infections (particularly postpubertal mumps and venereal disease), fevers, and diabetes mellitus, previous surgery, especially in the genitourinary area, duration of infertility, previous pregnancies, and sexual history. Many men had a hernia repair as babies and this occasionally causes a blockage of the vas due to scar tissue or to just bad surgical practices. Physical exam: This includes an examination of testicle position in the scrotum (if the testicles haven't descended properly, the sperm will not be cool enough), an examination of the scrotum for varicoceles (varicose veins of the testicles), and an examination of the prostate and prostatic fluid for signs of infection. Also, fat and hair distribution is examined, for signs of hormone imbalance. Urinalysis: Looks for signs of a urinary tract infection, presence of sperm in the urine (which, in conjunction with a low sperm count, may indicate retrograde ejaculation), and signs of systemic disorders such as kidney problems or diabetes mellitus. Semen analysis: This is done at least three times, since sperm count varies, and a 2-3 day abstinence is required before each analysis. Normal values follow: ejaculatory volume: 1.5-5.0 cc sperm density: > 20 million/ml motility: > 60% forward progression: > 2, on a scale of 1-4 morphology: > 60% normal forms (should have oval head and long tail) 1) no significant microscopic sperm clumping, 2) no significant white or red blood cells, 3) no increased thickening of the seminal fluid (hyperviscosity). For more information check http://matweb.hcuge.ch/matweb/endo/PGC_network/Semen_analysis_rrumbullaku.htm. Endocrine tests: Blood tests to check levels of testosterone, FSH (follicle stimulating hormone), LH (luteinizing hormone), prolactin, estradiol, and the thyroid hormones T-4 and T-3. Usually FSH levels are measured first for men with low sperm counts, and others are measured as indicated. Some patterns of hormone abnormalities are more amenable to treatment than others. An elevated FSH is an indicator of testicular failure or the beginnings of testicular failure. If this is the case, there is little that can make a large difference in the count. Low normal or low levels of testosterone often indicate testicular atrophy (usually due to varicoceles). There is also little that can be done to change the sperm count if the levels of testosterone are low. Thyroid is an often overlooked or forgotten cause of sperm problems and is easy to check and easy to remedy. A link to general thyroid disease info is http://thyroid.miningco.com/. Postcoital: Checks cervical mucus for presence of sperm after coitus. If a sperm count is low, generally it is just as easy to move on to intra-uterine insemination (IUI)rather than waste a cycle or more trying to do a postcoital. The sperm of men with low counts are more delicate and have more trouble surviving in mucus than do normal men's sperm. Sperm Penetration Assay (SPA), or Hamster test (HEPA): This tests the ability of the sperm to penetrate a specially prepared hamster egg. This test is controversial and there is no clear evidence that the results are worthwhile. (FWIW, a little hamster has to die to donate the egg.) Testicular biopsy: Takes a small piece of testicular tissue, and checks sperm-producing tubules and cells between the tubules. Possible patterns include: Normal (the tubules and the sperm in them are normal, so the problem is likely a blockage elsewhere), maturation arrest patterns, hypospermatogenesis (elements are there, but sperm isn't), and germinal cell aplasia (there just isn't any sperm there, and the only options for parenthood are donor insemination or adoption). This test is usually done as a last resort. It is often done in conjunction with an IVF cycle where donor sperm are ready as a backup in case there are no sperm in the biopsy. Ultrasound of seminal vesicles to show their size, development, and whether they are emptying and storing sperm properly. Vasogram: An x-ray using a dye to outline the ducts and look for obstructions. ------------------------------------------------------------------------ 7.2 - EVALUATION PROCESS FOR WOMEN Hormone tests: These are simple blood tests to check if there is a hormonal imbalance. These tests may include any or all of the following: Hormones: luteinizing hormone (LH) follicle stimulating hormone (FSH) estradiol (E2) progesterone prolactin thyroid stimulating hormone (TSH) free T3 free thyroxine total testosterone DHEAS androstenedione sex-hormone binding globulin<BR> 17-Hydroxyprogesterone A chart of hormone levels is posted at http://www.fertilityplus.org/faq/hormonelevels.html. Insulin resistance (IR) testing: Insulin resistance is precursor to diabetes that can cause weight gain and is often seen in those with PCOS. Testing should be done on overweight infertility patients and anyone suspected of having PCOS, What happens is that the body starts producing excess insulin (hyperinsulinemia) in order to keep glucose levels normal. Testing glucose levels alone won't indicate insulin resistance until it is fairly advanced -- what's needed is fasting glucose and insulin levels, or a glucose tolerance test (preferrably also checking insulin). More info is at http://www.inciid.org/faq/pcos.html. Pelvic exam: A physical exam to check for signs of infection as well as obvious physical abnormalities. Pretty much the standard feet-in-stirrups event. Abdominal ultrasound: A transducer is passed over the bare skin of the abdomen in order to view the uterus and ovaries. Cysts, fibroids and uterine abnormalities may be visible. Trans-vaginal ultrasound: A transducer wand is inserted into the vagina to view the cervix, uterus and ovaries. Provides greater detail than abdominal ultrasound. Post-coital test (PCT): A sample of cervical fluid is obtained by gently scraping the cervix within a few hours of intercourse. The fluid is checked under a microscope to see if motile sperm are present. Must be done with fertile mucus at ovulation time. Endometrial biopsy (EMB): Used to "date" the lining in relation to ovulation and to test for infection or pre-cancerous cells. To date the lining, the test is generally performed a few days prior to expected menses. A thin catheter is inserted through the cervix and a small sample of the uterine lining is removed. Hysterosalpingogram (HSG): People often call this the dye test. A catheter is inserted through the cervix and a small amount of dye is pushed into the uterus while x-rays are being taken (usually continuous motion as well as a few stills). The shape of the uterus is observed, as well as how the dye flows through the fallopian tubes. Laparoscopy: This surgery is usually done under general anesthesia to look for structural abnormalities, endometriosis and adhesions as well as possibly repair any problems found. The abdomen is inflated with carbon dioxide and a scope is inserted through a small incision below the navel. A second incision just above or below the pubic hairline is used to insert a tool to help manipulate the organs for better viewing with the scope. Patients may be able to get a videotape of the surgery. Hysteroscopy: The cervix is dilated just enough to insert a small scope used for viewing the inside of the uterus. Minor abnormalities can be fixed during this procedure, which can be done under local or general anesthesia. Often done in conjunction with a laparoscopy. Personal experiences with EMBs, HSGs, laparoscopies and hysteroscopies are posted in the Invasive Infertility Tests FAQ at http://www.fertilityplus.org/faq/itests.html. Infectious disease testing: Some physicians will test for a variety of sexually transmitted and other infectious diseases including ureaplasma, mycoplasma, gonorrhea, chlamydia, syphilis, toxoplasmosis, rubella (German measles), cytomegalovirus virus, Hepatitis b&c and HIV I & II. Immune testing: Some of the tests mentioned below are still controversial, but more and more doctors are seeing the benefits of checking into and treating immune disorders which affect fertility. Lupus (SLE) tests (includes commonly tested for lupus anti-coagulant): Activated Partial Thromboplastin Time (APTT) Kaolin clotting time Platelet Neutralization Assay Dilute Russel viper venom time Anti-phospholipid antibodies (APA) tests (includes IgM, IgG and IgA markers): Anticardiolipin antibodies (ACA) Phosphoethanolamine Phosphoinositol Phosphatidic acid Phosphoglycerol Phosphoserine Phosphocholine Anti-nuclear antibodies (ANA) tests: ssDNA dsDNA Sm RNP SSA SSB Histone Scl-70 Anti-thyroid antibodies (ATA): Thyroglobulin Thyroid microsomal (thyroid peroxidase) autoantibodies Anti-sperm antibodies (ASA): These can be either autoimmune or alloimmune. They are a blood test, usually indicated by a specimen at IUI-time behaving abnormally. If it's autoimmune (the male has them) then the sperm are healthy looking, but they clump together and make knots that don't make satisfactory progression in great looking mucus. If it is alloimmune (the woman has them) then they are usually healthy looking but mostly dead on arrival or all of the live ones are incredibly slow. It's at IUI time that most of us get sent for the full range of tests, but many of us are treated without testing (testing cost is high, treatment cost is low). Treatment is usually prednisone for the party doing the antibodies. Dose is dependent on severity. Prednisone is very inexpensive -- about $5.00/month each. Alloimmune tests: Leukocyte Antibody Detection (LAD or HLA sharing) Natural Killer Cells (CD56+) Full Reproductive Immunophenotype (include NK cells) Embryo Toxicity Factor (ETF) The full Immunophenotype costs around $500 each and several may be necessary to gauge success of treatment. It is similar to testing that cancer, AIDS and transplant patients have. It measures all kinds of things about our immune systems in general and then our Reproductive Immunologists make some interpretations to apply our results to reproductive problems. More information on immune testing can be found on the ICIID (pronounced inside) web site, http://www.inciid.org/immune.html, and on Dr. Beer's web site at http://repro-med.net/index.html. MRI or CT scan: One of these might be done if elevated prolactin is found. This is to look for a pituitary tumor. ________________________________________________________________________ ________________________________________________________________________ SECTION 8 - COMMON CAUSES OF INFERTILITY Unexplained: One of the most common forms of infertility is unexplained. This is when no physical, hormonal or immunological cause for infertility is found in either partner. Recent studies indicate that some unexplained infertility may be related to the use of non-steroidal anti-inflammatory drugs (NSAIDs), which impede ovulation. Check http://www.fertilityplus.org/faq/nsaids.html for more information. ------------------------------------------------------------------------ 8.1 - CAUSES OF INFERTILITY IN MEN Cancer treatment: Chemotherapy and radiation can cause abnormal sperm or sterility. DES (diethylstilbestrol) exposure: Synthetic estrogen used in the 50s and 60s used by women to prevent miscarriage. Can cause low sperm counts, decreased sperm motility, and abnormal sperm forms, small penises, undescended testicles (risk factor for testicular cancer), abnormal testicles. Hormonal imbalances: Hormone problems affecting sperm count include thyroid problems, low testosterone levels, elevated FSH, and excess prolactin (see next entry). Hyperprolactinemia (excess prolactin): can inhibit GnRH, resulting in lower LH and testosterone. Also low FSH. Idiopathic oligospermia: A fancy way of saying, "You don't have much sperm, and we have no idea why." Immune problems: Both men and women can have immune reactions to sperm. There is a lot of controversy about how prevalent this is. Immune reactions to sperm in the man (autoimmune) can be a problem post-vasectomy, but may also have other causes. Anti-sperm antibodies in the male are often indicated by hyperviscosity which may inhibit forward progression. In mild cases, anti-sperm antibodies in the male or female (alloimmune) may be overcome by IUIs, for which the man will be asked to ejaculate into a cup with a special preparation in it. If IUI does not work, or if the problem is considered too severe, IVF may be necessary, with ICSI likely for male anti-sperm antibodies. Predisone, a steroid, may be given to the party producing the antibodies. Impotence: One of the less common causes. Note: impotence is a *medical* problem. There are a variety of medical causes that can contribute, including diabetes mellitus, certain required medications such as antidepressants, etc. Sexual advice from friends is generally *not* welcome. Some useful advice on impotence can be found at http://www.impotence.org. The drug Viagra, according to the manufacturer, does not appear to have any negative impact on sperm. See http://www.viagra.com/hcp/pro_pack_insert.htm. Infection: Postpubertal mumps, and, occasionally, venereal diseases such as gonorrhea and chlamydia can harm male fertility. Also, recurrent infections such as prostatitis can lower sperm count and motility. Klinefelter's Syndrome: Men with Klinefelter's syndrome have two X chromosomes and one Y chromosome, rather than the normal one X and one Y. They are generally tall and thin, with small testicles. More information can be found at http://www.globalwebsol.com/vv/ and http://www.genetic.org . Both sites include listserv and support group addresses. Lifestyle factors: These include factors which raise the temperature of the scrotum (such as the use of hot tubs or long baths), or harm sperm production. A variety of medicines and recreational drugs can decrease male fertility. These include alcohol, marijuana, cocaine, cigarettes, anabolic steroids, sulfasalazine, cimetidine (Tagamet, used for ulcers), nitrofurantoin (used for UTIs), anti-hypertensive drugs (specifically calcium channel blockers), aspirin, Dilantin (for epilepsy), colchicine, and antidepressants (note that some of these drugs should *not* be simply discontinued, because they may be required for other serious medical problems). Exposure to certain chemicals, such as lead and arsenic, and many types of paints or varnishes, can also adversely affect male fertility. Obstruction: Can occur at various points, blocking sperm from getting out. Treated surgically. Often may be easier to work around obstruction by doing MESA or TESA instead of trying to repair surgically. Prior surgery: The vas may be damaged during surgery fo hernia repair, orchiopexy, and even during varicocelectomy. Retrograde ejaculation: Can be caused by certain medications, surgeries, and nerve damage (for example, from diabetes mellitus). Sperm goes in the wrong direction and can be found in the urine. Sexual Dysfunction: Reported in up to 20% of infertile men. May include decreased sexual desire, inability to maintain an erection, and premature ejaculation. This could result from low testosterone or performance anxiety. Trauma to testicles: Injury to testicles, such as from being hit, followed by atrophy. May also be the result of having the mumps and develop bi-lateral orchitis. Undescended testicle: If the testicles do not descend during puberty, their body temperature may be too high, reducing quality and quantity of sperm production. Rare. Varicocele: An enlarged vein in the scrotum, which causes pooling of blood and an elevated temperature. This one is controversial. According to some, it is one of the most common and readily treatable causes of male infertility. Others say that varicocele is also common among fertile men, and question the connection with infertility and the need for treatment. Large varicoceles that go untreated can cause permanent damage to the testicles. This can lead to testicular failure or atrophy. Testicular failure is indicated by an elevated FSH and means that the testicles are starting to stop producing sperm. Testicular atrophy is indicated by small testicle size and often leads to lower testosterone levels. This affects sperm counts and can also lead to the need for testosterone replacement therapy as the man ages. Note: Testosterone replacement _should not_ be used while pursuing fertility treatments as it will make the brain think it doesn't need to make testosterone and sperm counts will diminish even further. Description of surgery with graphics is available at http://www.maleinfertility.org/new-varicocelectomy.html Vasectomy reversal: Though vasectomies are meant as a permanent means of birth control, it turns out that they can often be reversed. However, it is easier to reverse them if not too much time has passed since the vasectomy. The more time has passed, the more likely it is that the man will have an immune reaction to his own sperm. ------------------------------------------------------------------------ 8.2 - CAUSES OF INFERTILITY IN WOMEN Adhesions and scarring: Can be caused by sexually transmitted diseases left untreated, Chlamydia being the most common. Scarring can lead to blockage of the fallopian tubes, or damage to the delicate membranes within the tubes. It can also be formed by endometriosis and prior surgeries in the abdominal area. Age: A woman's fertility begins falling off after the age of 25, though pregnancy can be achieved and maintained for most women into their early 40s. The rate of miscarriage and birth defects increases after 35. See http://noah.cuny.edu/pregnancy/march_of_dimes/pre_preg.plan/after30.html Asherman's Syndrome: This is a condition where the walls of the uterus adhered to each other. Usually caused by uterine inflammation. Cancer treatment: Chemotherapy and radiation can cause early menopause. Information on how cancer treatment affects fertility is posted at http://oncolink.upenn.edu/specialty/med_onc/bmt/bmt_11.html DES (diethylstilbestrol) exposure: Synthetic estrogen used in the 50s and 60s to prevent miscarriage. Can cause abnormalities in the reproductive organs such as shortened cervix, deformities of the vagina or cervix, T-shaped uterus, abnormal fallopian tubes, ovulation problems, increased risks of ectopic pregnancy, repeated miscarriage, and premature delivery. See hhttp://www.teleport.com/~skeely/ Endometriosis: Growth of endometrial tissue outside the uterus. Can cause blockage of the fallopian tubes and adhesions. May not cause any symptoms beyond infertility, but could cause crampy periods and painful intercourse. FAQ posted at http://www.bioscience.org/books/endomet/babaknia.htm. Environmental hazards: Pesticides may damage a woman's eggs leading to early menopause. Some materials are linked to early miscarriage. Ethylene oxide, used in chemical sterilization of surgical instruments. Exposure by healthcare professionals (including veterinary) to nitrous oxide. Vinyl chloride, used in plastics, and metallic compounds including manganese, arsenic, and nickel. Hyperprolactinemia (elevated levels of the hormone prolactin): Can be caused by pituitary tumors, and breast milk production after giving birth. May lead to weak or skipped ovulation. Lowering prolactin levels can be achieved with Bromocriptine (Parlodel). Hypothyroid: Underactivity of the thyroid gland. Symptoms include low basal body temperature and unexplained weight gain. Can throw off the endocrine system leading to ovulation problems and to miscarriage. An article about thyroid disease and pregnancy, fertility and pregnancy loss is posted in two parts at http://thyroid.miningco.com/library/weekly/aa063097.htm (part 1) and http://thyroid.miningco.com/library/weekly/aa070797.htm (part 2). Immunological problems: The most common immune problems, testing positive for anti-phospholipid antibodies or the lupus anticoagulant, can lead to blood clots in the placenta that prevent nourishment from reaching a fetus. There are other more controversial causes of immunological fertility problems -- please check http://www.inciid.org for more information. Luteal phase defect (LPD): There are two types of luteal phase problems that fall under the category of LPD. One is a short luteal phase -- 10 days or less. The second is when the length of the phase is not necessarily shorter than the standard 12-16 days, but it is out of phase and progesterone production is low. Typical treatment is to enhance ovulation and/or to use hCG or progesterone support after ovulation. Luteinized unruptured follicle syndrome (LUFS): Failure of the follicle to release an egg even though it has reached maturity. Commonly seen when an LH surge is not followed by ovulation. Can be confirmed with ultrasound. May account for 5-30% of women with unexplained infertility. Medication: Non-steroidal anti-inflammatory drugs (NSAIDs -- see http://www.fertilityplus.org/faq/nsaids.html), radiation and chemotherapy for cancer treatment, antihistamine and decongestants may lead to fertility problems. Vitamin C in large doses is also considered an antihistamine - which can lead to cervical mucus drying out. Menopause: When a woman stops having regular ovulation and menses. Pregnancy may still be achieved through drug therapy and perhaps IVF with donor egg. Obesity: Excess weight can lead to elevated estrogen levels which act as birth control and prevent a woman from ovulating. Drugs to induce ovulation can bypass this problem. For more information on weight and infertility, please check http://www.fertilityplus.org/faq/bbwfaq.html. Polycystic Ovary Syndrome (PCOS): Symptoms include infertility, irregular cycles, obesity, acne, excess facial and body hair, obesity, skin tags, dark skin patches (back of neck, under arms, under breasts, groin), cystic ovaries, excess male hormones, insulin resistance, and dyslipidemia. It should be diagnosed through a combination of a physcial exam, ultrasound evaluation to look for possible cysts in the ovaries or ovarian enlargment, and blood tests to check LH and FSH (check ratio as well as levels on these two as LH higher than FSH is indicative of PCOS, especially when 2:1 or 3:1), testosterone, DHEAS, SHBG, androstenedione, prolactin, TSH, fasting glucose and insulin testing. Check http://www.inciid.org/faq/pcos.html and http://www.pcosupport.org for lots of information and support options. Premature ovarian failure (POF): Characterized by high FSH in a younger woman (usually in her 30s). Cancer treatment and environmental hazards may play a role in the development of POF. Recurrent miscarriage/pregnancy loss (RPL): When a woman miscarries more than one pregnancy. Testing can be done to try to determine the cause of such losses. If an underlying condition is found, the woman may need to be treated for the problem before a pregnancy can be carried to term. Testing information can be found at http://www.fertilityplus.org/faq/miscarriage/rpl.html. Smoking: Associated with an approximately 5% increase in miscarriage rate. Smoking also doubles the chances of an ectopic pregnancy by damaging the cilia in the tubes. Studies have shown a marked decrease in effectiveness of IVF and GIFT. More information on smoking and GIFT can be found in the April 2, 1997 section of "What's up Doc?" at http://www.ivf-et.com/ (direct to the information is http://www.ivf-et.com/wud970407.html) Tubal ligation (and failed surgery to reverse): Surgical sterilization of a woman by obstructing or tying of the fallopian tubes. May be reversed surgically with varying degrees of success. Turner's Syndrome: Women should have cells that are 46XX, but Turner's women are missing an X -- hence a karyotype of 45XO or a mosaicism of 46XX and 45XO. Turner's women with a 45XO karyotype are sterile while those with a mosaicism may be able to get pregnant and carry to term. Women tend to be ultra-feminine and small in stature. Check http://www.onr.com/ts-texas. Uterine abnormalities: Include problems from DES exposure, septums, T-and heart-shaped uterus. Vegetarian lifestyle: Vegetarians may experience irregular ovulation that reduces the chances of conception. ______________________________________________________________________ ______________________________________________________________________ continued in Infertility FAQ (part 3/4) ~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~ mailto:bec@fertilityplus.org Fertility FAQs and Info - by patients, for patients http://www.fertilityplus.org/toc.html