Miracle Babies & Other Happy Endings

Rawson Associates, 1986; Penguin, paper, 1987. 
Selected as best non-fiction book for 1986 
by the Oklahoma Writers Federation.

Table of Contents

What This Book Will Reveal to You

1. How I Discovered the Secrets of Successful Fertility Treatment

2. Taking Control of Your Fertility

3. Finding Your Happy Ending

4. How to Avoid Hit-or-Miss Fertility Treatment

5. Finding the Right Doctor

6. The Formula for Male Fertility

7. Evaluating Male Fertility

8. Maximizing Male Fertility Potential

9. Clues from Your Past

10. Unraveling Your Fertility Mystery

11. Are you Ovulating? Clues From Your Menstrual History

12. Finding Out Why Your Periods are Abnormal

13. Finding Out Why You Have Never Had a Period

14. The Road to Successful Ovulation

15. Sperm-Mucus Interaction: Is the "Chemistry Right"

16. Sperm-Egg Transport: Solving Tubal Problems

17. Endometrioisis: Conquering the Silent Invader

18. The Drama of Life Before Birth: Fertilization & Implantation

19. Death of a Dream: When Pregnancy Doesn't Work

20. Planning the Rest of Your Life

A  Letter to Friends and Family

B  Glossary

At this moment an epidemic is sweeping the country. Your friends won't call you to find out if you've fallen victim. Charitable organizations won't be formed to rush to your aid. No. If you're having fertility problems, you probably feel that you're completely alone in your struggle. Your reaction may be, "Why me? Everyone else is having babies. It's not fair."

In my ten years of medical practice I have seen many infertile couples experience repeated disappointment, frustration, and disorientation. They cycle between guilt, anger, and despair, trapped in hope that with each new round of treatment they will conceive. When a course of therapy fails to produce a pregnancy, they experience all the stages of mourning as though they had actually lost an infant.

Over the years, however, I have seen many couples learn to deal with their trauma. They manage to get control of their lives and their feelings. They take an active part in their diagnosis and treatment. In fact, they seem to grow stronger and closer as a result of struggling with their fertility problem, It is because of these people that I decided to write this book.

I want to tell you not only how these couples coped but also how they resolved their fertility problems. I hope that by sharing their experiences, you will gain insight into your parenting needs and be able to design a course of treatment and therapy that will meet those goals. In addition, you will avoid unnecessary procedures, unwarranted disappointments, and excess costs. Above all, you will feel less like a victim and, I hope, much less alone.

I want to assure you that your fertility problems, your anger, your hypersensitivity, your feelings of inadequacy, and your eternal optimism aren't unique to just you. Fertility problems strike one in six American couples - 4.5 million people. Each year over I million people consult physicians for infertility evaluation and treatment.

The medical definition of infertility is "the inability to conceive after a year of unprotected intercourse or the inability to carry a pregnancy to term." However, if you already know or suspect that you have a fertility problem, you should seek an evaluation before waiting a year while trying to conceive. For example, a woman may suspect a problem if she suffers extreme pain with menstruation, has a history of pelvic inflammatory disease, or has few menstrual periods. A man may be concerned if he has ever contracted a sexually transmitted disease, has symptoms of genitourinary tract infection, or has an undescended or injured testicle. Infertility should not be confused with sterility, which is an irreversible condition. And it should not be referred to as subfertility, which connotes a borderline fertility problem that may not require treatment. All fertility problems, however, should be evaluated to determine their seriousness.

Recently I have witnessed astounding progress in the diagnosis and treatment of infertility. Only a few years ago most couples with fertility problems had to turn to adoption or remain childless. But now, with the advances in pharmaceuticals, microsurgery, in vitro fertilization, micromanipulation, and egg donation, many viable options have opened up to infertile couples—with the result that "miracle babies" are being born almost every day. There is every reason for hope.

I hope to help satisfy your thirst for medically sound information about your infertility—what may have caused it, what tests are available to diagnose the causes, what can be done to correct the problems, and most important, what your options are. Being informed of the most up-to-date medical technology will help you work with your physician to develop an effective, individualized course of treatment.

It is not uncommon to find fertility problems in both partners. However, even when only one of you must be medically treated, I find that the fertility problem affects both of you because the couple loses control of their destiny, the couple undergoes fertility treatment, and the couple shares the emotional strain of dealing with friends and family. Infertility does not affect just one person—it affects the couple.

Most people respond to infertility with disbelief and anger. As infertility becomes a reality, as they begin medical treatment, and if they experience repeated failures, their anxiety and frustration grow. All infertile couples suffer psychological trauma. All infertile couples feel cheated. All infertile couples feel that they've lost control of one of their most personal rights—the right to bear children. If you suffer from these symptoms, you are not alone.

In this book I will help you rethink the myths that may be haunting you and interfering with your self-esteem, your sexuality, and your progress toward conception. I want to help you stabilize your life so that you can deal with other important, related aspects of your life—your marriage, your family, your friends, and your career. You are entitled to have the freedom to be yourself and to consider new options apart from what others expect or demand. You may even want to give your family and friends a copy of this book so they can become more sensitive to your needs.

I will also inform you of the legal controversies surrounding the latest technologies for infertility treatment. You will learn why attorneys and lawmakers are concerned and even confused about parenting rights, fetal rights, and custody definitions when it comes to miracle baby making. With this information you will be able to sort through the moral and ethical decisions you may face regarding issues such as artificial insemination, in vitro fertilization, egg donation, surrogacy and genetic counseling. I believe that by reading this book, you will find encouragement, understanding, comfort, practical solutions, and the courage to keep trying for your own miracle baby.

I began to grow skeptical about the accepted methods for infertility treatment when I realized that I wasn't meeting the needs of my patients. Although I investing a lot of energy and emotion into their problems, I was becoming more and more frustrated with the way they responded to my care.

Many of my patients acted as if they didn't hear my instructions. For example, every time I told Lori I'd have her test results in three days, she'd call me the next morning for the results. When I tried to schedule an ultrasound examination for Debbie, she'd either cancel at the last minute or simply not show up. Bridgette wasn't able to maintain a basal temperature chart and Jennifer always forgot to bring her temperature chart to her appointment. I couldn't understand why these intelligent and highly motivated people acted so erratically.

The reasons became clear once I discovered how my patients blossomed when they became a positive force in their infertility treatment. I'd like to share with you how I uncovered these secrets and how you can benefit from my formula for success.

Growing frustration forced me to rethink my approach with infertile couples. One day Cheryl said, "I feel like a guinea pig. This whole business is dehumanizing." She broke down and cried, and I wasn't sure what I could do for her. Moreover, I was completely surprised when her husband not only refused to cooperate but even blamed me for her inability to get pregnant!

In retrospect, I realize that I not only underestimated the stress my patients were experiencing but I may have even contributed to their frustration. In my clumsy attempts to defuse their depression with humor, I remember saying such insensitive things as, "You can borrow my kid for the weekend," or, "At least you don't have trouble finding baby-sitters." I wasn't the only one who didn't know what to say to infertile couples. Their families, friends, and coworkers always seemed to be in error, too; even a concerned inquiry about their infertility treatment stirred anger and anxiety. I observed that as treatments extended into months and sometimes into years, my patients seemed to become less communicative and more paranoid. Some even went so far as to isolate themselves from others.

In my quest for answers to these problems I instinctively turned to the literature for guidance. When I checked the local bookstores, I found that infertility books offered few concrete suggestions. Popular literature tended to be cold, technical reproductive biology texts or too generalized to be useful.

My search continued until I saw a newspaper advertisement for an infertility seminar conducted by RESOLVE, Inc., and Serono Laboratories. RESOLVE is a nationwide, nonprofit support organization for infertile couples. What I learned from RESOLVE and subsequent studies changed my whole approach to infertility practice.

I became aware that in the face of a diagnosis of infertility many people experience as much or more trauma than people who are told that they suffer from a life-threatening disease. Typical are Bret and Nancy L., who discovered they were infertile in their early thirties. Feeling trapped by circumstance, they became angry and depressed. They felt guilty about their use of birth control pills for ten years. The ten-year "delay" shortened the number of fertile years Nancy had for treatment, and her increased age reduced her chances for pregnancy even further. They had always had some problems communicating with each other, and their complex and demanding treatment regimen began to aggravate the strain. My requests for temperature charts, semen analyses, and scheduled intercourse only seemed to add to their frustrations.

I realized that in order to establish a positive physician-patient relationship, I also had to address the emotional needs of patients like Bret and Nancy. Since I knew that much of their stress resulted from perceived loss of control, I developed a method that put them back in control of every stage of their infertility treatment. It was a method that improved their communications, provided feedback to my staff and me, and provided better treatment. Most of all, it was a method that improved their sense of self-worth.

My Five-Point Strategy for Fertility Treatment

Because victims make poor patients, I selected restoration of control as the starting point of my plan. To put my patients in charge of their infertility, I instituted the following procedures.

I try to involve both partners in the initial discussions and planning. In these meetings we discuss their medical histories and family goals. We talk about diagnostic alternatives, medical resources, realistic timing, and emotional, time, and financial commitments. I answer their questions and give them the medical information that will help them think through their motives and alternatives. I want both of them to begin fertility treatment with realistic expectations and mutual understanding. I have found that this planning phase is so critical to successful fertility treatment that I've devoted several chapters of this book to showing how you can implement this process on your own. A jointly designed plan puts my patients back in control of their treatment, their bodies, and their immediate future. They no longer complain of being victims or guinea pigs. And they view me as a skilled partner or facilitator who is enhancing their effort to achieve pregnancy.

I offer recommendations instead of rnandates. As their partner, I suggest diagnostic procedures and courses of treatment for consideration. I discuss alternatives, side effects, the odds for success, and other relevant issues. My patients choose their course of action.

I tailor my testing and treatment to their emotional needs and budgets. Some patients want to proceed at breakneck speed, while others are more comfortable with a relaxed approach. I try to adjust my scheduling to their comfort level, and I always consult with them before altering our agreed-upon strategy. A number of patients find that they must adjust their treatment to accommodate their financial resources. An overextended budget only adds to their anxiety and usually isn't necessary for effective treatment. I also help them explore what expenses may be covered by insurance.

I make certain that either my nurse practitioner or I am always accessible to answer questions and offer support. Together we can provide the time, information, and consulting skills that our patients need.

I refer most of my patients to the local RESOLVE chapter for information, peer support, and, if desired, group counseling. I'm very impressed with the quality of information, printed material, and support offered by RESOLVE. The most important service it offers is understanding, companionship, and acceptance. Only in this kind of environment can infertile couples feel that they are not alone in the world and that their feelings are normal. And they can learn effective coping skills from others who are experiencing similar problems. You will learn many of these skills throughout this book.

I know that this five-point approach will work for you because my patients have done so well. Once they see the difference the plan makes in their lives, they seldom experience the trauma I had so frequently observed when I dealt with infertile couples. I remember one patient saying, "I didn't know that I could deal with infertility treatment as just another one of life's hurdles. Our problems used to seem so monumental before Don and I put our goals and treatment plan on paper."

The next few chapters will show you step by step how to lay the groundwork for such a successful plan. Successive chapters will help you:

Become informed about the most up-to-date medical information so you will know how to choose the right physician and how to tell if you are getting the best treatment

Develop an individualized treatment plan with your physician so you can take an active part in your diagnosis and medical care

Get control of your life and feelings of anxiety so you can stop making impossible demands on yourself and others

Become a positive force in your fertility treatment

Identify your "happy ending" and pursue it

So now let's begin to identify the ingredients for your happy ending.

Take a moment to think about your married life before you thought you had a fertility problem. You were happy, optimistic, and looking forward to the day when together you'd create a new life—when you would begin your family. For one reason or another you may have delayed starting one. You may have saved for a house, finished college, taken your dream vacation, or begun a career. You wanted the best possible start for your marriage before you settled down to enjoy having a family.

Then the roof caved in.

"I remember being surrounded by X rays. My mind wandered back to the day Mitch and I decided to wait to have a baby. I had wanted to start my public relations career. We had been able to buy our dream house where our babies could play in their own backyard. As the doctor pointed to the shadowy pictures, he explained how my blocked tubes were preventing my pregnancy. I don't remember much more after that—only my pain and disappointment."

Jeanne is only one of my patients who, late in her reproductive life, discovered a fertility problem. Fortunately, soon after I repaired her damaged fallopian tubes with microsurgery, Jeanne and Mitch conceived and had a beautiful, normal baby boy. She's now pregnant with her second baby.

In my practice I have found that many couples' problems aren't resolved as quickly as Jeanne's. Their diagnosis may be more elusive, their treatment more complex. For example, by the time Michael and Shelley T. came to me, they both were discouraged and worried. For two years they had been trying unsuccessfully to conceive. Their physician had already completed a fertility workup, performed painful tubal surgery, and prescribed powerful fertility drugs—all to no avail. When I first saw them, their quality of life had deteriorated to an unfortunate low.

The advice that I gave Michael and Shelley worked for them and it will work for you, too. I'm going to show you how you can permanently improve your quality of life, even when faced with overwhelming odds. And I'm certain that as a couple you will grow closer and stronger from your efforts.

In this book you will become acquainted with four couples who took charge of their fertility problems and found their miracle babies:

When her doctor recommended a hysterectomy, Shelley T. panicked. She was afraid that Michael would divorce her because she thought that having a baby was the most important thing a wife could do for him.

By the time I saw them, all Michael could do was grumble about mounting medical bills; he thought all fertility specialists were "rip-off artists." Shelley was hurt, angry, and distrustful. She'd put her life and her career on hold, believing that "I'd get pregnant any day." The only reason she had requested a second opinion was the encouragement she received from the RESOLVE infertility support group when they heard that Michael had never had a semen analysis.

By blindly accepting one test and treatment after another, this couple had forfeited their responsibility and control for their fertility. Michael's lack of interest and support not only added to Shelley's difficulties but, as it turned out, also prevented an accurate diagnosis—he had no sperm in his semen. She had undergone years of expensive treatment, but never had a chance for pregnancy. Their situation illustrates what can happen when you have unrealistic expectations and pursue no clear-cut treatment plan.

In this book you will see how Shelley and Michael took control of their fertility treatment and their lives. And you will find out how they got their miracle baby, Tommy.

Debbie believed that until she had a baby she would not be a complete woman. When spontaneous bleeding disrupted her third month of pregnancy, Debbie became desperate: "I've already lost two babies. If I lose another, I don't know what I'll do." Unfortunately after her spontaneous abortion began, there wasn't much I could do to save their baby. But I could do a lot to keep her from losing their next baby.

In later chapters you will learn how Debbie and Bryan coped with their loss and grief. And you'll learn how Debbie's exposure to DES, while she was still in her mother's womb, destined her for repeated abortions.

When I secured Debbie's incompetent cervix during her next pregnancy, she was able to have a beautiful blue-eyed baby girl.

Kathy's periods probably stopped because of the excess running she did to prepare for amateur competition. Running, however, was very important to Kathy's self-image. She wanted to maintain her life-style and have a baby, too.

"Before we commit to a bunch of tests, we want to know what to expect," Kathy S. said on their first visit. "We want a baby, but we have our lives to live, too." Kathy and Steven wanted to understand the big picture: what tests I'd recommend, what the results would mean, how long it would take, what the odds were that she'd conceive, and what it would cost.

After the initial workup, they were surprised to find that Steven had a poor semen analysis. I suspected that his varicocoele (varicose vein in the scrotum) might also be impairing their ability to have a child.

As their story unfolds, you will find out how this couple's take-control attitude and their desire for having a fertility treatment plan led them on a direct path toward their goal. You will also find out how their persistence and hard work during ovulation induction treatment eventually paid off.

Since graduating from college, Margaret had pursued a successful career. When she was thirty-one she and Richard decided that she should stop taking the Pill so they could begin their family. But nothing happened.

Concerned about their progress, a year later Margaret came to me requesting a fertility evaluation. Although her physical examination revealed no obvious fertility problem, I was concerned about possible complications from the ruptured appendix she had suffered at twenty-three. The tubal X ray confirmed my suspicions: it revealed that both of Margaret's tubes were blocked.

When I received the results of Richard's semen analysis, I became concerned that his consistent use of marijuana could be impairing his fertility potential.

In this book you will find out how even though microsurgery restored Margaret's fallopian tubes, the surgery did not make her fertile. And you will learn how the miracle of in vitro fertilization gave them the son they wanted so much.

Seeing how each of these couples managed their fertility problems will provide you with insight into the many options you have in coping with fertility and its treatment.

The steps I recommend for planning a fertility treatment program make common sense and are easy to follow. As you learn more about your fertility and about your treatment, you will become less tense and anxious. You will be able to formulate a short-term plan and set long-term goals as well.

Together with your physician, you will be able to take an active part in your individualized diagnosis and treatment.

I have heard all of these statements and more from patients and friends— normal men and women with normal feelings and concerns. I find, however, that many of my fertility patients are afraid to explore or discuss their feelings, both positive and negative, about having children. They are so intent on resolving their fertility problems—on creating a pregnancy—that they lose sight that what they are really trying to do is make a baby.

They seldom stop to ask themselves, "Why?" and, "How is this baby going to change our relationship and lives?" and, "Do I welcome those changes—or most of them—wholeheartedly?"

A fertility treatment plan should lead to results that will satisfy your basic needs. Since the happy ending that's right for you may be different from the one that another may choose, it is vital at the outset that you both identify how having a baby will meet your needs. Will the baby carry on your family name and genes? Will having the baby make you feel like a complete person? Will the baby be your companion—someone to nurture and love?

The answers to these and other questions will greatly influence your treatment options. If like Steven and Kathy you want a baby to carry on the family name and genes, donor artificial insemination will not be a happy ending for you. If like Debbie you want to carry a pregnancy to make your life experience complete, then adoption won't be a happy ending. But if you just want a baby to nurture and love, as Richard and Margaret did, you won't be as concerned with how you get your baby as with just getting one.

To help you identify your happy ending, I have developed an evaluation test for you and your spouse. I use it with my patients before we sit down to work out a fertility plan. Discussing your responses with one another will help you understand your motives, concerns, interests, attitudes, and feelings. You will both gain insight into why your fertility problems cause you pain and frustration. And you will be able to identify which happy ending will resolve your fertility problem.

Even my patients who have been receiving fertility treatment for a year or more enjoy and benefit from taking this test. "When we discussed our answers to the test, it was the first time we'd talked about our problem when we weren't in the middle of a crisis," Shelley T. reported. "It was very refreshing."

I recommend that my patients retake the evaluation every six months or so. This renews their dialogue and identifies significant changes in their attitudes. People like Michael and Shelley who at first completely rule out adoption, for example, will often find that it becomes more attractive after years of unsuccessful treatment.

It's okay to change your mind. If you don't achieve your first goal, you may wish to reexamine your needs and select another. You probably didn't succeed at getting a date with your first love either, but that didn't stop you from trying again or finding an alternative. Besides, you may not have had all of the facts when you made your initial decisions. Once you have discussed your answers together, you will be better prepared to find medical and professional services that will meet your needs.

Since you may wish to use the evaluation test several times throughout your fertility treatment, I suggest that you write your answers on a separate piece of paper. Number the sheet from I to 70 for your responses. By placing your completed answer sheet beside your spouse's, you can easily identify points of agreement and conflict. You may wish to save your answers and discuss them from time to time and compare them with future scores.

When you respond to the statements, do not ponder too long on any one issue. I find that an initial response is often more accurate than one analyzed to death. You should be able to complete the test in just a few minutes. After that, I will tell you how to interpret your answers and what they mean to you, to your spouse, and to your fertility treatment.

Examining each of these areas will help you understand how internal and external forces influence your reaction to infertility. By tuning in to these forces you can learn to accept your emotional responses, choose to accept or ignore the needs of others, discover your spouse's needs, and together control your future.

"You had surgery before your husband was tested?" The RESOLVE group members looked at each other in disbelief.

"Well, we thought it was my problem," Shelley T. said. "I've always had pain with my periods. It made sense."

"The same thing happened to us," Steven S. commented from across the room. "We thought our doctor was a specialist. That's the way he's listed in the phone directory. But when he wanted to put Kathy through a six thousand-dollar workup and never even asked about me, we knew something was wrong."

"What did you do?" Shelley asked.

"We paid our two hundred-dollar consultation charge and found a different doctor." Steven glanced at his wife. "One who would work with us as a couple. Infertility affects the couple, not just one individual."

"But how do you know if your doctor is doing the right thing?" Shelley asked.

The group leader spoke. "Learn as much about fertility problems and treatment as you can so you'll be able to ask the right questions and spot potential trouble.

"Coming to RESOLVE is the first step," he added. "You learn a lot from our programs and from talking with our members. And if you read our newsletter, you'll see that we have resource people who can talk with you about different fertility subjects like endometriosis, artificial insemination, and in vitro fertilization. We also have an extensive lending library of books and articles on just about any fertility topic you'll want to know about."

"You mean I'm going to have to be responsible for my fertility treatment?"

"You and your husband and your doctor," the RESOLVE leader said. "If you work as a team, you'll be able to design a fertility treatment plan that will work for you as a couple."

The leader turned toward me. "Dr. Perloe, how can couples avoid hit-or miss fertility treatment?"

"I agree with all that's been said. It's unfortunate that you cannot expect the same quality of treatment from every doctor or clinic. But I guess that's true of any kind of service." I glanced at Steven and Kathy. "I guess Steven and Kathy are one of the best prepared couples I've ever worked with. Prior to coming to me, they'd read everything they could get their hands on. Before they hired me as their doctor, they wanted to know what to expect."

Shelley interrupted. "Like what?"

"They wanted to know things like what tests I'd recommend, what the results would mean, how long the workup would take, and how much it would cost."

"Didn't you feel like they didn't trust you?"

"Not at all," I answered. "The more you know about your treatment, the better you can work with your doctor. In fact, I usually give every couple an overview of fertility treatment before we even start."

"That's right, Shelley," the leader added. "If your doctor doesn't want to answer your questions or doesn't tell you what to expect, you're probably seeing the wrong doctor. Why don't you see me after the meeting and I'll give you some of our newsletters to read or where you an find information on the Internet."

"That sounds great," Shelley said. "And I want to see your library, too."

Even if you already have been through months or years of fertility treatment, it is not too late to begin a plan. Shelley and Michael T. were able to regain control once they knew what to expect and began to participate in the decisions about their treatment, and so can you.

In this chapter I'd like to acquaint you briefly with the conditions necessary for conception. And as I do with my patients, I'd like to give you an overview of fertility treatment. With this understanding you will be able to help your physician provide the best opportunity to reach your fertility potential.

I realize that many of the things I'll touch on will stir up more questions in your mind. However, hold your questions while I give you the big picture. In later chapters I'll discuss all of this information and more in greater detail.

The goal of fertility treatment is to help you have a child. If you understand the factors necessary for making a baby, you will also understand what factors your physician will evaluate during your fertility workup. The nine key ingredients of fertility are:

The woman's health must allow her to safely carry a pregnancy.

The male must be able to produce and ejaculate functional sperm.

A healthy egg must mature and escape from a woman's ovary at regular or predictable intervals.

The egg must be able to travel through the fallopian tubes toward the uterus.

A couple must have intercourse at the right time.

The sperm must be able to travel through the cervix and uterus to the fallopian tubes to join with the egg.

The sperm must be able to penetrate the egg.

The fertilized egg must be able to travel through the fallopian tube to the uterus for implantation.

A woman's hormone system and uterus must be able to maintain the pregnancy.

To pinpoint where things are breaking down, your physician must check out each of these fertility factors. Later in this book you will learn about the methods your doctor can use to investigate fertility problems and what treatment is available. When you understand your options, you will know how to get your miracle baby.

First your doctor will ask you both to complete a general health and fertility history questionnaire. Your fertility problems may be rooted in your past-exposure to toxic chemicals, medications, illnesses, and infections, for example. I remember one couple whose problem crystallized when I learned that he'd been exposed to Agent Orange in Vietnam. When I added this incident to his complaints of lethargy and low sexual desire, I began to suspect he could have a fertility problem.

Your doctor should interview you not only together but also individually so you will feel free to reveal your closest held secrets having had an abortion, a sexually transmitted disease, or an illegitimate child, for example. If either of you withholds information, your doctor may perform unnecessary tests and it may take longer and cost more to identify your missing fertility factors. Honesty and completeness pay off.

I remember one woman who told me in confidence about an abortion she had before she was married. Since I knew she had been fertile at that time, I began looking for events that occurred since then. When I learned she'd had a ruptured appendix at age twenty-one, I suspected the infection and surgery could have adversely affected her reproductive organs. So I began to formulate a series of tests that would give me definite answers.

Sometimes your fertility history reveals obvious problems. If like Kathy S. you have only one or two periods a year, I quickly suspect ovulatory problems. If like Shelley T. you complain of extreme pain during menstruation, I'll look for endometriosis. Or if like Margaret B. you've had one or more episodes of pelvic inflammatory disease (PID), I'll check you for tubal blockage. You will learn more about how I diagnosed and treated each of these women and their husbands later.

Some less obvious factors that can contribute to your fertility problem are:

Previous abdominal surgeries, which may impair fertility in both men and women

Diabetes or a case of childhood mumps, which can lead to a poor sperm count

Drugs and high blood pressure medications, which can impair a man's sexual performance or the ability of the sperm to fertilize the egg

As you are filling out your history form, you may not realize the significance of these events or conditions, but if you do your job well, your doctor will have the information he or she needs for piecing together the puzzle.

To father a child you must be able to produce and ejaculate good quality semen. "Good" semen contains large numbers of normally formed sperm which can swim actively in a straight line. In addition, semen should be free of infection. To deliver your semen to your wife, you must also be able to ejaculate. This requires that you have open passages from your testicles to your penis and an intact nervous system for controlling your ejaculatory processes. Chapter 8 discusses all the hormonal and physiological systems necessary to support male fertility.

If the semen analysis is normal, I can be almost certain that the fertility problem lies with the woman's reproductive system. So I will switch my attention to diagnosing her problem.

If the semen analysis reveals a problem with the husband's fertility, he should have a physical examination to assess his general health and the condition of his reproductive organs. Shelley T.'s husband, Michael, had almost no sperm in his semen. I needed to find out if this was because he was not making sperm or because his sperm could not get out through his ducts.

Based on my examination findings, I may order additional tests to detect if the man has tubal blockage, impaired ejaculation, impaired sperm production, or a hormonal problem, or refer him to a urologist for further evaluation and recommendations.

Finding a fertility problem with the husband doesn't relieve my responsibility to make certain that the wife's reproductive system is working well. I find that in 20 to 30 percent of my cases, both partners contribute to their fertility problems. In Steven and Kathy so's case, for example, Steven had a poor sperm count and Kathy wasn't ovulating. Until I was fairly certain that Kathy's problem could be overcome, it would have been irresponsible for me to condone Steven's varicocoele surgery.

Chapters 6 through 8 describe in detail the tests that are conducted for male fertility problems, what the test findings reveal, and what courses of treatment are available for male fertility problems.

Even if a woman's periods are regular, I cannot assume that her menstrual cycle is working normally. So once I've reviewed the wife's history and current complaints, I do a physical examination to evaluate her general health and the condition of her reproductive organs. I also order laboratory tests that will tell me if she's ovulating and if her hormone levels are adequate.

I frequently include an endometrial biopsy in the initial workup because examining the uterine lining will tell me whether she's ovulating and whether her uterus can support a pregnancy. In addition, I may order an X ray to obtain valuable information on the structure of her fallopian tubes and uterus. Many of these tests must be performed at specific points in the monthly cycle. Therefore, I ask her to do some "homework" to help me time the tests.

I ask her to keep a basal body temperature (BBT) chart. This cycle will not only help me synchronize the tests to her menstrual cycle but also tell me what time of the month she is most fertile. If your temperature chart line remains level throughout the month, for example, I may suspect that you are not ovulating (anovulation). If you are timing sex after your temperature rises, I'll know that you are practicing rhythm birth control, which is certainly no way to get a miracle baby! (You are most fertile twenty-four to forty-eight hours before your temperature rises.)

I also perform a postcoital test to tell me if the "chemistry" between the partners is right. If the wife's cervical mucus is impairing or destroying the husband's sperm, there are a number of things I can do to improve their situation.

You will learn more about the woman's workup in and 10. You may even discover what's causing your fertility problem and learn how to overcome it.

Your initial workup usually takes six to eight weeks and may cost up to $2,500. (This cost may vary in different parts of the country.) Once your doctor has the results from your examinations and preliminary tests, you can begin to discuss your options:

Beginning a treatment program to improve your fertility

Undergoing surgery to correct anatomical problems

Seeking other alternatives such as artificial insemination with donor sperm (AID), in vitro fertilization, adoption, or enlisting a surrogate mother

Performing more tests to pinpoint your fertility problem

Your doctor should outline a tentative treatment schedule as well as estimate the cost. Together you should develop a plan that will optimize your fertility while still taking into consideration your lifestyle needs and financial resources.

Shelley looked toward me. "Dr. Perloe, how can couples find out which doctor to go to?"

"There are a number of alternatives. Resolve's list of physicians is an excellent beginning." I paused. "However, one thing that concerns me greatly is the thinking that says that only a fertility specialist can treat fertility problems. That simply is not true."

"But I wasted over a year going to my gynecologist before I realized he was just bouncing from one thing to another," Shelley said.

"I know that can happen. But even a fertility specialist may use hit-or-miss procedures. You see, there is nothing to prevent any doctor from hanging up a shingle that says 'fertility specialist.' "

"I didn't know that," Debbie said.

"First consult with your family physician or obstetrician-gynecologist. She or he knows your medical history better than anyone. If your problem requires specialized knowledge, ask your doctor to refer you to a specialist.

"Read everything you can about fertility problems and fertility treatment. Talk to RESOLVE members and other infertile couples about their experiences and compare what's happening to you with what you learn. Talk to your doctor. Discuss your treatment plan and ask lots of questions. If it seems to you that your doctor does not have a plan, is not using 'accepted' procedures, or resents answering your questions, you may want to seek a second opinion."

"What if you don't have a doctor?" a woman across the room asked.

"Get a list of names in your area from the American Society of Reproductive Medicine or your local county medical society. Call or write fertility clinics for additional information. Talk to family and friends, too. Perhaps they know someone who's seeing a doctor for fertility treatment. With one in six couples in the United States seeking treatment for fertility problems, help can't be too far away. The best insurance you can have is being prepared by reading attending workshops, and joining support groups."

In this chapter I will tell you how to find a physician, what types of physicians or clinics to look for, and how to spot the "poor treatment" danger signs.

I encourage you to consult your family practice physician or obstetrician-gynecologist first. Since you've already developed a rapport, it will be easier for you to share personal and intimate facts about your sexual history and habits. Both of these physicians are trained to analyze the results from a semen analysis, blood tests, and X rays. And they know how to administer fertility treatment to both men and women. The following is a more detailed breakdown of different medical specialties.

Family physicians can assess your general health and investigate the potential effects of your medical history, environment, and medications on your fertility. These physicians can determine if a woman is ovulating and if a man's semen is functional. Many common fertility problems may be resolved at this initial level - for example, using a basal body temperature chart to time coitus, changing blood pressure medication, and counseling on the discontinuance of sperm-killing douches and lubricants. If your fertility problem is such that it demands it, your physician should refer you to a specialist. Since your records and test results will be provided to the specialist, you won't have wasted your money by seeing your family doctor first.

This physician specializes in the study and treatment of women's diseases especially of the genitourinary and rectal tracts. In addition, he or she is concerned with the care and treatment of women during pregnancy and childbirth. Most OB-GYNs, as they are commonly called, also perform surgery. However, depending on their skills, they may or may not be able to perform microsurgery on your fallopian tubes, which is required in about 10 percent of fertility patients. Most OB-GYNs can perform a diagnostic laparoscopy, but if they can't do microsurgery, the laparoscopy may have to be repeated by the microsurgeon so he or she can plan your corrective surgery. OB-GYNs have access to all of the fertility diagnostic tests available including the semen analysis. The OB-GYN should be able to treat anovulation with clomiphene and to perform artificial insemination.

This is an American Board of Obstetrics and Gynecology subspecialty for OB-GYNs who receive extra fellowship training in the endocrinology of women (the study of hormones) and infertility. Generally these physicians are affiliated with fertility research programs at universities, infertility clinics, or in vitro fertilization centers. They have the most up-to-date information on fertility and are skilled in microsurgery techniques. By providing a full range of infertility treatments, the reproductive endocrinologist can work with you to develop a cost effective treatment plan offering you the greatest chance for success. The reproductive endocrinology practice often provides financial counseling to enable you to better plan ahead and make insurance decisions.

This physician specializes in the male genitourinary tract. The urologist can perform a semen analysis and can examine a man for a varicocoele, endocrine problems, genetic defects, or other physical abnormalities that may cause fertility problems. In addition, the urologist can perform a testicular biopsy, surgery for varicocoele repair, and vasectomy reversal.

This physician-scientist performs laboratory evaluations of male fertility. The andrologist need not be a medical doctor and may hold a Ph.D. degree in any number of technical areas, including microbiology, biochemistry, or andrology. Many andrologists are affiliated with fertility treatment centers and play a key role in performing in vitro fertilization.

This healthcare professional can help you better communicate your feelings and needs to your spouse, family, friends and coworkers. An infertility counselor can help you plan to deal with stress you may encounter during treatment or explore ethical issues surrounding your chosen therapy.

If you trust your doctor, you'll be inclined to trust the quality of the referral. Referral from another physician is one of the quickest and best ways to find a doctor.

If you're faced with finding a new physician on your own, you may want to utilize some of these resources:

RESOLVE, Inc. Contact your local RESOLVE, Inc., chapter or national RESOLVE, Inc., for a referral.

The American Society of Reproductive Medicine and local county medical society. As noted, these organizations can provide you with a list of physicians who have expressed an interest in fertility treatment. Although membership in these organizations doesn't certify fertility treatment competency, this may be a good list to work from.

Fertility clinics. A number of fertility clinics exist across the country. Some of them are for-profit clinics. Others are nonprofit research organizations usually associated with universities. Many of these clinics can perform your fertility workup. If not, they can provide you with a list of physicians whom they work with in your community. Later I will discuss the different types of fertility clinics.

The Endometriosis Association can provide referral to local physicians experienced in managing endometriosis related infertility.

Through your reading and search for information, you may have noticed that many sources recommend you avoid your family physician and obstetrician-gynecologist and go directly to a fertility specialist. I have heard couples say, "If you go to the in vitro clinic for your workup, you're getting the best." While it is certainly true that you can receive very good care through these facilities, the erroneous conclusion drawn by some couples is: "If you don't go to the in vitro center, you're settling for second best." Or even worse: "If the in vitro center can't help you, that's the final word."

You may also have heard that you can identify a fertility specialist by the fact that he or she "specializes" in fertility and doesn't deliver babies_the logic apparently being that if doctors are busy delivering babies, they're too busy to know enough about fertility to practice it. I don't believe this is an adequate description, however, of a physician who is qualified to treat your fertility problem. So for a number of reasons, which I'll share with you, I disagree with this generalized recommendation for fertility specialists.

Any physician can be listed as a fertility specialist. There is no regulation, licensing, or certification required for advertising this specialty. Before you make your first appointment, however, you can inquire if the physician is fellowship-trained in the reproductive endocrinology and infertility subspecialty.

Membership in the American Society of Reproductive Medicine is available to any physician showing an interest in the specialty. While membership in this organization does not guarantee a known standard of technical competence, it does demonstrate the physician's interest in fertility treatment (a definite plus) Specialists may charge more for the same services. An article in Money magazine stated that fertility specialists may charge up to five times more than nonspecialists. This may be overstated, but before you settle on the physician you want, ask about the charges for common tests and procedures.

You may find that you'll pay twenty to twenty-five dollars more for a semen analysis from a specialist, even though the same medical laboratory provides these services to all of the doctors in your community. While a fertility specialist may charge more for a particular test or surgical procedure, that your treatment costs no more. A reproductive endocrinologist can best determine whether surgery or in vitro is a more cost effective option for you and help you develop a treatment plan that avoids wasting time and money on unnecessary testing and outdated treatments. Do a little price comparison first and remember that the lowest- or highest-priced doctor is not necessarily the worst or best.

Another question that arises is whether to consult with a private physician or go to a large fertility clinic. A private physician can treat most fertility problems. The additional skills and expertise provided by in vitro centers and large fertility clinics are needed only for about 10 percent of fertility problems. I have some additional ideas on this matter that I'd like to share with you:

For-profit fertility clinics and in vitro centers are not certified. Fertility treatment has become a big money making business. It's little wonder that the clinic's interest in attracting customers influences the way in which they may report their pregnancy success rates. For example, a clinic may report that 50 percent of their patients get pregnant within two cycles. So you may assume that you have a one in two chance of pregnancy if you go to them. These could look like pretty good odds to some couples. However, the clinic's statistics do not show that they eliminate more than half of the applicants before completing the in vitro procedures. In fact, some clinics quote success rates based on a positive pregnancy test rather than babies delivered.

The Society for Assisted Reproductive Technology publishes an annual clinic specific report documenting success rates at each clinic. While this report ensures that each clinic defines success in a similar fashion, it may still not provide all the information you need to base your decision. At first glance, a program with a high success rate may seem the obvious choice. But, after a closer look, you learn that the clinic with a lower success rate treats older patients with more severe fertility problems while the clinic with the better pregnancy rates refuses women older than 35 and any couple with an abnormal semen analysis. Don't get me wrong: Reviewing statistics is important. Just try to be objective when you read or hear about success rates.

Research-oriented clinics may perform unnecessary tests and procedures to meet research criteria and to pay their expenses. In order to conduct scientifically sound fertility research, medical professionals must have similar information about each couple. Thus this kind of clinic may perform expensive tests not only on patients who warrant them but also on those who do not need them. In this way the researchers can compare their results between "abnormal" and "normal" populations. Consequently the research clinic may not tailor your workup to your unique set of problems. Money charged for these "extra" tests also helps pay the bills for expensive laboratory and research capabilities which may not be needed for your basic diagnostic workup. Before signing up with a research clinic, find out what diagnostic procedures they recommend and how much they charge. If this information doesn't correlate with what you've learned about fertility treatment, you may wish to get a second opinion.

Larger clinics may contribute to your feeling of isolation and anonymity. Often couples who have gone to large clinics complain that they didn't receive much of the physician's personal time; no one in the clinic knew them by sight; and a different resident physician saw them at each visit. Also, many people who travel considerable distances to these clinics don't feel comfortable expressing their concerns: they feel isolated and dissatisfied. One patient said, "I feel like I'm being herded like cattle." If that's the way you feel, you probably are not getting the personal attention you need, and the clinic you're going to may be too large. I must say, however, that a number of large clinics provide services that many smaller organizations cannot: educational videotapes, nurse practitioners to answer questions, on-site X-ray and testing laboratories, and counseling and support groups--all of which can be of great value.

Many communities are not large enough to support fertility specialists and in vitro clinics. Traveling to distant medical facilities may add unnecessarily to your out-of-pocket expenses, absenteeism from work, and overall level of stress. If you have a good family practitioner and/or OB-GYN in your community who knows quite a bit about fertility treatment, I'd encourage you to begin there rather than travel hundreds of miles to a stranger. The "expert" isn't necessarily better just because he or she is located over one hundred mile s away. Often, you will find that your physician can work together with a fertility specialist to minimize your travel, expense and time.

Fertility treatment isn't magic. It is a structured, organized investigation. An obstetrician-gynecologist working together with a reproductive endocrinologist or urologist can diagnose and successfully treat the majority of people with fertility problems.

Ultimately you should judge any doctor's ability based on the treatment plan he or she outlines especially for you and on the doctor's responsiveness to your problems and concerns.

The day that Michael T. heard that he had no sperm in his semen, he almost stormed out of my office. Hearing the news didn't do much for Shelley either:

"A year of tests for nothing!" she said.

"Don't be so hasty. They weren't exactly for nothing," I assured her. "You did find out you have endometriosis, which impairs your fertility. Only now we know that we must treat both of you. You may have that baby yet."

Many couples overreact to the results of a single semen analysis, just as Michael and Shelley T. did. However, since many factors can "spoil" or influence a single test result--errors in collection, errors in handling the specimen, and errors at the laboratory I'll always advise performing a second semen analysis in a month or so. Convincing Michael and Shelley of this wasn't easy.

"The semen analysis is only a screening test," I explained. "It does not provide a definitive diagnosis. It tells me the quality and quantity of your sperm, the motility or movement of your sperm, the volume of your semen, and the concentration of your sperm. In plain English it tells me if you are producing the right amount of good quality sperm and semen."

"What did my test show?"

"I found almost no sperm and very little semen or fluid. This can mean a number of things: You do not produce much semen and sperm. You produce semen and sperm but due to an obstruction they do not come out when you ejaculate. Or, perhaps even more simply, you didn't collect the sample correctly. That's what I need to find out first."

If the semen analysis suggests that the man is fertile and free from infection, no further fertility testing is usually needed of him. Other factors that might impair his sperm are incompatibility between his semen and his wife's cervical mucus or an inability to bind to the egg and fertilize it. Problems with sperm-mucus interaction can be checked by doing a postcoital test which I'll describe. Hamster-egg penetration tests, zona binding tests or in vitro fertilization can tell me if the sperm can function properly when it reaches the egg. However, if his semen analysis indicates a fertility problem, further evaluation is necessary.

Before I could evaluate the validity of Michael's semen analysis results, I needed to find out how he and Shelley had collected the sample. (To collect semen, a man must ejaculate into a sterile cup.) I asked them these questions:

"When you collected the sample, how long had it been since the last time you ejaculated?" Each ejaculation affects your sperm supply, so specimen collection timing should be as close to your normal ejaculation frequency as practical. (When figuring this interval, you need to consider both sex and masturbation.) Having this information is vital for correctly interpreting semen analysis findings. For example, if you ejaculate infrequently, your sample will contain a higher than expected number of dead sperm and sloughed-off cells. If you ejaculate very frequently (for example, once a day), you may not have time to replenish your sperm supply between emissions. Altering your normal pattern just to perform the test either sooner or later can distort the results. Michael reported that he produced the specimen at his normal frequency of ejaculation.

"How long did it take you to get the specimen to our laboratory for testing?" Normally I suggest collection at our laboratory site in our specially prepared soundproof room. However, a number of men have difficulty masturbating on demand in the doctor's office. It's at best embarrassing, and some even refuse for moral and religious reasons. I try to circumvent these obstacles as best as possible without seriously jeopardizing the integrity of the test. If the specimen is collected at home and delivered within one hour, we should be able to evaluate sperm quality. If the "home" results are abnormal, the test must be repeated to determine whether the sample was damaged in transit. If the couple wishes, the wife can help with the collection.

Using on-site facilities ensures that you collect the sample in a sterile container, that you do not expose your sample to temperatures above 80 degrees Fahrenheit, and that your sperm don't deteriorate from remaining in seminal plasma for more than an hour. By testing your sample immediately, we can also examine how it changes consistency. Normally your semen coagulates after ejaculation to prevent spillage. It should begin to liquefy within twenty minutes to one hour. If the semen remains coagulated, it traps your sperm and prevents them from swimming to the egg. Once identified, I can easily solve coagulation problems.

Michael assured me that he had brought the specimen to the office within an hour: "Your nurse suggested that since we live so far away we get a motel room down the street. You should have seen the motel clerk," Michael said, "when they saw we had no luggage."

"How did you collect the sample, and did you save the entire ejaculation?" The best way to collect your semen is by masturbating into a sterile wide-mouth jar. I don't recommend using jars washed in a dishwasher, since they contain harmful soap residue. It's extremely important that you collect the entire specimen because the concentration of sperm varies in different portions of your ejaculate. For 90 percent of the male population, the first squirt (ejaculate fraction) contains more sperm than later portions. Subsequent squirts contain primarily semen (seminal vesicle secretions). For these reasons, you cannot collect a good sample by withdrawing your penis during sex and taking a sample of remaining squirts. You cannot withdraw in time to save the first drop of sperm-rich semen.

Since Michael T.'s religious beliefs forbade masturbation (that's actually why he refused testing with their previous doctor), I provided him with a Mylex condom to fit around his penis during sex. I cautioned him not to use an ordinary condom or lubricants, since they often contain sperm-killing chemicals. Although Shelley complained of some discomfort with the loose-fitting plastic pouch, they both found this procedure more acceptable and were able to collect a complete sample. Where religious beliefs forbid the use of contraceptive devices, inserting a small hole near the top of the collection pouch will satisfy the patient's objections and provide an adequate specimen.

If a man is unable or unwilling to collect a semen sample, I can examine the wife's cervical mucus several hours after unprotected intercourse. If I find living, mobile sperm, the chances of the man's being fertile are pretty good. Under ordinary circumstances, however, the postcoital test does not give me as much information as the semen analysis, because I cannot evaluate the percentage of deformed sperm or take a white blood cell count to test for infection.

"Michael, I feel pretty confident that the results of your semen analysis are correct. However, I want you to repeat the test in four to six weeks.

"I never jump to conclusions from a single negative test result. And you shouldn't either. Too many things can influence the results." I glanced at his medical history form. "I see you're diabetic. I want to do a physical and also evaluate your hormones. You aren't down for the count yet. You and Shelley have many options we haven't even discussed."

I closed his file and leaned back in my chair. "I frequently find a condition called retrograde ejaculation in diabetics. It's possible that your bladder sphincter muscle, which normally directs your semen out through your penis, is not closing. Your sperm may be squirting back into your bladder instead."

"Can you do something for it?" Shelley asked hopefully.

"Yes. But first, we need to find out exactly what we're dealing with."

"Okay, let's do it." Michael turned toward Shelley and said, "We'd better reserve that motel room again."

To fertilize an egg (ovum), your sperm must be able to perform these critical tasks:

Your sperm must be able to swim to the egg with a vigorous straight motion (motility, forward progression).

Your sperm must be able to penetrate the egg to deliver your genes for fertilization (sperm penetration).

The semen analysis tells me if your sperm meet the first criteria. The sperm penetration assay (hamster test) or acrosin test will tell me if your sperm can penetrate the egg for fertilization. I'll discuss egg penetration tests in later chapters.

World Health Organization guidelines say a normal sperm count consists of 50 million sperm per ejaculate with 50 percent motility and 60 percent normal morphology (form). we know that concentrations must be under 20 million sperm per milliliter of ejaculate in order to actually impair fertility. Provided your sperm show adequate forward motility and good egg penetration, concentrations as low as 5 to 10 million can produce a pregnancy.

It's interesting to note that only twenty-five years ago counts of 100 million sperm per ejaculate were the norm. With time, the effects of our toxic environment and/or lifestyle seem to be gradually degrading male sperm counts.

Your total semen volume also influences your fertility. If the volume is too small, say under one milliliter, you may not have enough fluid to bring the sperm in contact with your wife's cervix (the entrance of her womb). In addition, an insufficient quality of protective semen will expose your sperm to the acid, sperm-killing environment of her vagina. I remember one couple who had been trying to have a baby for over three years. When I checked the husband's semen, I found a low semen volume and a depressed sugar (fructose) level. Since the seminal vesicles (glands that produce most of the seminal fluid) produce this sugar, I suspected an obstruction or infection. When I examined him further, I found evidence of infection. After several rounds of antibiotics, his semen volume doubled to normal levels. When semen volume cannot be increased, artificial insemination (AIH) provides excellent results by delivering concentrated sperm to the womb.

If your ejaculate averages more than 3.5 milliliters, your sperm concentration may be too low; that is, your sperm are diluted by excess seminal fluid. We know that for 90 percent of men, the first portion of their ejaculate is richest in sperm. So if you produce too much semen, I'll suggest that you collect an ejaculate by masturbation. I can then concentrate the sperm and place them inside the uterus, intrauterine insemination (IUI).

Semen viscosity (liquid flow) also affects your fertility potential. If your coagulated semen does not liquefy within an hour of ejaculation, your sperm may be trapped in the cottage cheese-like jelly. I remember one man whose semen did not liquefy. Since the prostate gland secretes the chemical required for liquifaction, I did a rectal examination to check his gland. He just about jumped off the table when I pressed on the swollen tissue. Fortunately his infected prostate responded to antibiotic therapy.

The most common way of dealing with persistent coagulation or high viscosity is collecting your sperm through masturbation, washing the semen from them, and using your sperm for artificial insemination (AIH). I'll discuss these procedures in more detail.

A microscopic examination will tell me if your sperm are clumping together (agglutinating). I've seen a number of semen samples where the sperm orient themselves tail-to-tail or head-to-head instead of swimming in a straight line. This clumping prevents them from swimming through the cervical mucus to the egg and attaching if they get there. This finding may indicate a problem with sperm antibodies or the presence of a bacterial infection. I'll discuss how we can solve these problems.

A normal-looking sperm has an oval head and a tail seven to fifteen times longer than the head. You can identify defective sperm by their large heads or strange tails - kinked,, doubled, or coiled. The World Health Organization says good quality semen should contain 60 percent normal sperm morphology. (See figure 6.1 Sperm Morphology) A closer evaluation called a strict morphology (Kruger morphology) is more time consuming and usually predicts normal sperm function when more than 15% are normal.

The reason all men produce abnormal sperm (up to 40 percent) is not known. However, considering the rate at which your production line operates ten million to fifty million new sperm per day some attrition should be expected. We do know that toxins such as lead have been linked to reduced motility; cigarette smoke to abnormal morphology, organic solvents to coiled tails; and excessive scrotal heat to coiled tails in animal sperm. When you lower your exposure to these agents, abnormal morphology levels usually decrease. I remember one man who transferred to a different job at his company so he could avoid exposure to heat from a blast furnace and began taking 1000 mg of vitamin C each day. Within a few months his sperm motility and morphology showed definite improvement.

Too many underdeveloped or immature sperm (germinal cells) in your semen indicate testicular stress from illness or infection. I remember one young athlete who had recently recovered from a case of the flu where he'd run a 104-degree temperature for three days straight. His sperm count, revealing many dead and immotile sperm, nearly blew his mind. "Don't worry," I told him. "Your fever probably caused all the damage." I retested him three months later and found him fully recovered.

If I find white blood cells (leukocytes) in your semen, I suspect an infection. I will want to check both you and your wife for infection, since these diseases are easily passed back and forth between sexual partners. Sexually transmitted infections such as gonorrhea and ureaplasma respond to doxycycline, a tetracycline derivative. Prostate infections, which can be especially stubborn to treat, may take a month or more to clear up.

Asthenospermia (Low Sperm Motility) with Adequate Concentration and Morphology

Low motility may be a sign of infection or exposure to toxic substances. If your semen contains white blood cells and other cellular debris, you probably have an infection, which should respond well to antibiotic therapy. I will also ask if you are using medications or "street" drugs like marijuana, which can impair sperm motility. Changing medications or stopping drug usage will usually improve motility. Low motility is also quite common in the presence of a varicocoele. If other causes have been eliminated, I may recommend that the varicose vein be repaired. Nearly half the men who have this surgery impregnate their wives.

If I find small testicles, scant pubic hair, or a thinning beard, I will run blood tests to confirm a hormonal deficiency. Chapter 8 discusses when varicocoele repair or hormone replacement therapy is a waste of time and money and when it will work wonders.

Your sperm must be: able to survive heir journey through your wife's reproductive system. The first barriers your sperm encounter are her highly acidic vaginal fluids and cervical mucus The vaginal environment does a good job of keeping bacteria under control, so in that way it's beneficial. However, the sperm must be specially equipped to make the journey intact. The postcoital test will tell me if your sperm are getting to your wife's uterus in good shape and in adequate members.

I perform the postcoital test war the middle of your wife's monthly cycle (when she should be most fertile). At the time of ovulation her cervical mucus, which normally seals her womb from the outside, becomes thin and watery to allow your sperm to swim through the cervix toward her waiting egg. If the test is done 'at the "wrong" tine of her cycle, the results will be abnormal, since before rand after ovulation the mucus becomes impervious to sperm. This is why I use a urine LH kit to predict when she is about ready to ovulate. A few drops of urine are placed on the test stick. When a color change is noted, ovulation will usually occur within 24 hours. So, I recommend having intercourse that evening and checking the cervical mucus early the next morning.

When I examine her cervical mucus, I look for three things: (1) if you delivered good quantities of sperm to her cervix, (2) if your sperm are vigorously swimming through the mucus in one direction, and (3) if white blood cells are present, indicating infection in either partner. Assuming your semen analysis was normal, if I find immotile, clumped, or dead sperm in the mucus, I'll suspect that your sperm and your wife's mucus are incompatible. If I find no sperm at all, I may suspect a problem with the way you're having sex.

Even though the postcoital test provides very valuable information, I cannot substitute this test for a semen analysis, which gives me a better picture of morphology 'and the presence of infection (white blood cell count).

If I find no sperm in the cervical mucus, as I did with Michael and Shelley T., I suspect a deliverer problem. Perhaps, the husband is ejaculating prematurely and not depositing the sperm near her cervix. Maybe he is not actually ejaculating at all. Or maybe she is douching immediately after sex. I can often identify the problem by talking with the couple.

I remember one man who had a great sperm count but no sperm at all showed up in their postcoital test. After counseling with him, I discovered that when he had sex he faked his climax and did not ejaculate. After several months of counseling (costing far less than fertility treatment), he and his wife returned for another postcoital evaluation and all looked well. "It's only a matter of time now," I told them. "Just let nature take its course."

If I find agglutinated (coagulated) semen that contains shaking sperm instead of actively swimming sperm, I suspect that something in the mucus is attacking the sperm. Vaginal lubricants or allergic responses to the sperm can also cause this toxic reaction; for example, the woman's immune system may be producing antibodies that are attacking the sperm. In some situations the man himself may be making antibodies in his own sperm. I find this among men with frequent genital infections and with men who have undergone a vasectomy reversal.

Using a condom during sex can sometimes reduce a wife's sensitivity to her husband's sperm. If she avoids all contact with her husband's sperm - hands, her mouth, her genitals, and so forth - for three months or so, her antibodies may decrease in numbers. A repeat postcoital test at three-month intervals will tell me if this procedure is working. Once her antibodies stop attacking his sperm, they can swim to her egg and make a baby.

Some people do not want to wait as long as a year for the possibility that her antibodies will decrease. So usually I use artificial insemination with the husband's sperm to bypass sperm-mucus interaction problems. This is the route Steven and Kathy S. eventually took. AIH often works quite well. I will discuss these procedures in greater detail in Chapter 21.

Sometimes I can improve the quality of your semen without having to diagnose and treat an underlying fertility problem. Concentrating your sperm by natural means or in the laboratory may improve your semen quality enough so that your wife can get pregnant without expensive medications and surgeries.

Centrifuging Semen for AIH

Centrifuging your semen and using the more concentrated Portion for AIH may also improve your semen quality. Sometimes this technique is used with in vitro procedures.

Unfortunately, collecting and freezing several sperm samples will not increase sperm quantity and concentration. The freezing and thawing processes damage the sperm so severely that semen quality actually diminishes. It's interesting, however, that sperm from a fertile donor does not deteriorate from freezing as much as that from an infertile donor.

Many methods are available to separate the sperm from the semen and concentrate them before performing an insemination. Techniques such as percoll, swim-up, swim-down and sedimentation procedures are helpful for in vitro fertilization, they are usually not necessary for insemination. Most of these procedures select only a small percentage of the moving sperm so I usually have many fewer sperm than after a simple centrifuging sperm procedure.

If sperm concentration techniques do not work, I have to look for underlying causes. Chapters 7 and Chapter 8 explain how I can identify the causes of your problem and outline a fertility treatment plan.

In the past the understanding and treatment of male fertility lagged far behind that of female fertility. Infertile men were treated empirically. Without ever undergoing a thorough diagnosis, most men received a random series of treatments.

Many times I've heard my patients say, "I had a low sperm count, so the doctor gave me Serophene. He said if that didn't work, we'd try Metrodin." When I asked them if their doctor ran tests to find out why the sperm count was low, more often than not they said no. This type of treatment consumes a lot of precious time as well as your energy and money. Therefor, you should insist on getting an accurate diagnosis and treatment for a known problem.

Evaluating male fertility can be time-consuming and frustrating because sperm take approximately ninety days to form and mature. So if your doctor does something today to enhance your sperm production, it may be ninety days before the improved sperm show up in your semen sample.

With the advent of inn vitro fertilization techniques, we're seeing rapid advances in male fertility, diagnosis and treatment. Doctors now know how to direct therapy to the source of your problem. Today we can correctly diagnose 80 percent of our male fertility patients. And we can successfully treat over half of those. These results are pretty impressive when you consider the aim—the creation of a new human life.

Evaluating Male Infertility

"Dr. Perloe," Steven S. said as he sat down on the examining table, "this may sound like a dumb question, but how can I be infertile? I thought people like that wouldn't be able to 'get it up.' "

I smiled. "That's not a dumb question at all. But 'getting it up' and getting them out are two different things." I sat on the stool beside the table.

Steven still looked anxious. "You mean you can have one problem without the other?"

"Yes, you can have a completely normal sex drive and still not make enough sperm to get your wife pregnant."

"What a relief." He relaxed and the tension left his face. "I almost didn't have the courage to ask you."

"Please don't ever feel that way, Steven." I picked up his completed medical history form. "Let's see what we can do to raise your sperm count."

Steven's concern about virility is common among men. Although we see a connection between virility and fertility with a few hormonal disorders, sexual impairment is fairly rare.

In this chapter you will discover how your life-style, general health, and sexual experiences may be affecting your fertility. And you'll learn more about how your doctor can identify the source of your fertility problem.

To get your wife pregnant, you must be able to make and ejaculate viable sperm. To accomplish this, a number of mechanisms must be in good working order. I divide my fertility formula into the following categories: pretesticular, testicular, posttesticular, and ejaculatory processes. The interruption of any one of these four processes accounts for about 80 percent of male fertility

problems. The other 15 to 20 percent are very rare conditions or disorders that cannot be diagnosed at this time.

Before covering each of the fertility formula factors in depth, I'd like to give you an overview of the four processes. In the next two chapters I'll discuss these areas in greater detail.

Disturbances in the hormonal system cause about 10 percent of male fertility problems.

Your brain plays a key role in regulating the hormones that affect the development of sperm (spermatogenesis). The process begins when your hypothalamus (a part of your brain) emits a substance (gonadotropin-releasing hormone, or GnRH) that stimulates your pituitary gland, located at the base of your brain. Your pituitary gland then emits LH (luteinizing hormone) and FSH (follicle-stimulating hormone). These stimulate testicular development and sperm production. LH also initiates the testicular production of testosteroneùa hormone responsible for virility, male secondary sex characteristics, and the support of sperm production. (If you got through that, the rest will be a cinch!)

A number of conditions can interfere with the development and timely delivery of these hormones. When the system breaks down, low sperm production (oligospermia) or no sperm production (azospermia) may result. If you have a pretesticular problem, you have a good chance of responding to hormone replacement therapy.

Testicular failure represents about 55 percent of male fertility problems.

To respond to hormone stimulation properly, your testicles, or testes, must be capable of producing sperm (spermatogenesis). To assess your testicular potential, I need to know if your testes descended into your scrotum on time; if they have been damaged by a varicocoele (a varicose vein in the scrotum) or by excessive heat, toxins, disease, or trauma; or if for some genetic reason they failed to develop normally. If the damage or failure is severe, nothing much can be done to improve testicular performance. However, testes damaged by varicocoeles (which are found in 40 percent of men with fertility problems) frequently respond to surgical repair. And testes impaired by toxic substances often recover when the toxins are removed.

Tubal obstruction, including vasectomy, accounts for about 6 percent of male infertility.

Your posttesticular system of ducts must be capable of storing and delivering your sperm. Sperm delivery system problems include obstruction or interruption of the tubes as a result of congenital malformation, disease, surgery, or trauma. Laser surgery and microsurgical techniques offer excellent chances for duct repair and restored fertility. Newer techiques allow the urologist to remove sperm directly from the testicle. These sperm can then be injected directly into your wife's eggs.

Ejaculatory Disturbance, Impotence, and Sexual Problems

Ejaculatory disturbances, impotence, and sexual problems may prevent you from delivering sperm to your wife's vagina. These disorders represent about 10 percent of male fertility problems.

Premature ejaculation, delayed ejaculation, and impotence may stem from surgery, medication, or physiological disturbances which respond well to hormone replacement therapy. Altering sex techniques and counseling often overcome psychologically based sexual performance difficulties.

Fitting you neatly into one of these categories is not always easy. Sometimes a man will have mild or moderate symptoms or he will have several different problems, so complaints and test results will appear confusing or in conflict. For these reasons, I caution my patients not to jump to conclusions from preliminary test results and not to attempt self-diagnosis. If you have a fertility problem, the only way you can get an accurate diagnosis is to have a complete fertility workup, combined with careful analysis by a professional.

Many people suspect that doctors never read those long complicated history forms you fill out. This isn't true, especially with fertility evaluations. Your general medical history, life-style, and current symptoms provide vital clues that help your doctor pinpoint potential difficulties.

We know that certain chemicals can adversely affect sperm development (spermatogenesis) and lower sperm counts. Since Steven S. had a low count (oligospermia), I wanted to find out if he had ever come in contact with toxic chemicals like lead, pesticides, polystyrene, xylene, benzene, mercury, Agent Orange, anesthetic gases, and solvents. Long-term exposure to these chemicals can cause irreversible damage; however, removing the toxin can often restore fertility.

One unusual case surfaced a couple of years ago when a thirty-two-year-old chemical technician with oligospermia was referred to me by his company doctor. When I questioned Paul W., I discovered that several times each day he used various chemical solutions to clean metal parts. He told me that he often didn't use his safety mask because he couldn't see well with it on. After I talked to the company safety director about the composition of the cleaner, I advised Paul that some of the chemicals he used had been linked to depressed sperm production. "Either use the mask or find another job," I told him. I guess he took me seriously, because without any further treatment I found a marked regeneration of sperm three months later. Before the year was out, his wife was pregnant.

Accidental and medically prescribed exposure to large amounts of radiation to the gonads (to combat a malignant tumor, for example) can also impair sperm production. If your tissue damage is not extensive, however, some degree of fertility may regenerate. (Note: Normal, diagnostic X-ray studies do not impair fertility.)

We also know that excessive exposure to heat can interfere with sperm production. One reason that your sperm-producing testicles are located in your scrotum is to lower their temperature one or two degrees below your body's. I remember one man I treated who worked out at the gym four times a week and afterward soaked in the 106 degree whirlpool. His biceps were bigger than my thighs. When I found his low sperm count, I asked him to give up the whirlpool. Several months later I received a phone call from him saying his wife was pregnant.

Some jobs may overheat your scrotum (from the temperature, not from your boss breathing down your neck) for example, the foundry worker or the sedentary long-distance truck driver. Oligospermia in the wheelchair-bound paraplegic also may be due to excessive scrotal heat. In some situations changing from jockey shorts to boxer shorts may offer a solution. Removal of the heat exposure will usually resolve this type of fertility problem.

It's thought that a varicocoele may also damage testicular tissue because of the excessive heat caused by the pooled blood. Some doctors even diagnose varicocoele by measuring the temperature difference between the right and left sides of the scrotum (measuring scrotal temperature, however, is not standardized and is frequently unreliable).

If you travel frequently, you may not be able to have sex during your wife's fertile time of the month. For example, due to business commitments, Richard and Margaret B. often found themselves in different cities on her fertile days. With only twelve or thirteen opportunities per year for pregnancy, and with only a 20 percent chance of achieving pregnancy each time, infrequent sex can seriously hamper your odds for success. If you have some control over your travel schedule, you can improve your odds for pregnancy by staying at home and having sex during your wife's most fertile days. The rest of the month you can travel all you like. Or, you may choose to have your sperm frozen so that an insemination can be performed in your absence. Infrequent sex can also lead to decreased sperm motility and abnormal sperm morphology (shape). I'll tell you later how to calculate which days are best.

Since the 1950s more and more people have experimented with "street" drugs and many have continued using them, especially marijuana. If you've smoked marijuana over a long period of time, your semen analysis may show lower sperm motility and higher incidences of abnormal sperm morphology. Both of these factors are critical for fertility.

I'd noticed that Richard B. checked marijuana use on his history form, so I wanted to talk with him about it.

I explained, "We don't understand exactly how it works but we do know that there seems to be a correlation between sperm motility and marijuana use. If you want to maximize your chances, I recommend that you stop smoking."

His expression became serious. "Margaret and I have waited a long time for this baby. I'll do anything that will improve our chances."

I don't think Richard was totally convinced, but he did stop smoking. When his semen analysis improved in just two months, I think he was pleasantly surprised.

We also know that central nervous system depressants such as barbiturates, heroin, and other narcotics cause impotence and ejaculatory disorders. If you stop using these drugs, usually these symp