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 symptoms resolve themselves.

Chronic alcohol use can lead to impotence, poor sperm quality, and further complications from liver damage. If alcohol damages your liver, you may have elevated estrogen (female hormone) levels. When a man's female hormones become excessive, they suppress his sex drive and interfere with his sexual performance. If you stop drinking alcohol, these conditions may reverse provided your liver can recover.

Though not conclusive, there is indication that some of the hundreds of chemicals in cigarettes may interfere with fertility by elevating the number of abnormal sperm forms. It's difficult to know, however, how smoking may affect any one individual. If you have concerns about the effects of smoking on you, the best strategy might be to cut down or quit smoking entirely.

We know that stress and excessive exercise can interrupt the normal flow of hormones from the woman's hypothalamus and pituitary. These abnormal hormone levels can interfere with her menstrual cycles and with her fertility.

Some believe that endorphins (natural narcotics) released by the brain to minimize pain and stress may block the normal release of GnRH, which is essential for maintaining male and female reproductive hormone balance. An example of this would be the abnormal (infrequent or absent) menstrual cycles often seen in women who run fifteen to twenty miles a week. Because of the many similarities in the hypothalamus-pituitary hormone system of men and women, there also may be similarities in their responses to stress and excessive exercise.

If you believe that your life-style is too emotionally or physically stressful, try cutting back. Run fewer miles, try to avoid emotional situations, and incorporate more relaxing activities into your schedule.

A number of childhood and adult diseases can adversely affect fertility. Some of the changes are only temporary; for example, a high fever (over 102 degrees) may cause your scrotum to overheat and your sperm to die. Usually this type of problem resolves itself in a few months.

Some diseases, however, exert a more lasting effect. For example, cystic fibrosis, tuberculosis, and adult mumps can destroy vital testicular tissues and leave you permanently sterile. Consult with your doctor before you write yourself off, however, because these diseases do not affect everyone the same way.

If you have ever contracted sexually transmitted infections such as gonorrhea, chlamydia, syphilis, and ureaplasma, scar tissue left by the inflammation can partially or totally block your sperm ducts. Bacteria, viruses, and your own white blood cells (Iymphocytes) can attack your sperm and reduce your fertility. Finding white blood cells and dead tissue cells in your semen alerts me to the presence of an active infection. These infections are usually limited to the lower parts of the male genital tractùurethra, prostate, and seminal vesicles. Seldom does the infection travel further in toward your testicles. If infection does reach your testicles, it can cause serious damage.

With the exception of prostatitis, which can be difficult to clear up, sexually transmitted infections will usually respond to antibiotics. If your genitourinary tract becomes scarred from repeated infections, the damaged ducts can often be repaired with microsurgery.

It's vital that your sexual partner also be treated for infection because you can pass the disease back and forth between you. As you'll learn later, sexually transmitted diseases produce far more devastating damage in their female victims.

Systemic diseases such as high blood pressure, colitis, diabetes, and hepatitis can deteriorate sperm quality and cause impotence and ejaculatory disorders. When I found that Michael T. had diabetes, for example, I wanted to investigate its effects on his fertility. Sickle-cell anemia, most frequently found in people with black heritage, may also reduce sperm concentration. Insufficient thyroid hormone has also been linked with low sperm motility and other hormone imbalances. I will discuss the specific treatment options available for these disorders in Chapter 8 .

Kidney problems may also affect your fertility. I remember an executive with a major oil company who developed chronic kidney disease in his mid-forties. He'd had two daughters by his first wife; but his disease-induced fertility problem prevented his new wife from having a child of their own. "My wife really cares desperately about carrying our child," he pleaded. I worked very closely with his nephrologist and together we managed to get him a kidney transplant. With his disease under better control, his sperm count improved, and miraculously the couple produced a baby.

Reports of breast disorders such as tenderness, soreness, and milky discharge or neurological problems characterized by visual disturbances, dizziness, chronic headaches, and/or seizures may lead me to suspect multiple sclerosis, nerve damage, or a problem with the pituitary. Since your brain and your master pituitary gland are vital for maintaining your sex hormone balance, any interruption in their function can impair your fertility. I'll discuss the roles your brain and pituitary gland serve in much greater detail in Chapter 8.

If you have no sperm in your semen (azospermia), but have normally sized testicles and normal hormone levels, you probably have blockage in the ducts between your testicles and your penis. If a hernia repair or lower abdominal surgery is part of your medical history, I'd be suspicious that you had an accidental vasectomy (severing of the vas deferens or duct coming from the testis during surgery). I remember one man who was quite surprised when I told him that a hernia repair he had when he was six years old caused his fertility problem. After microsurgery to reverse the accidental vasectomy, his sperm count came up to 40 million. Skilled surgeons can reverse both accidental and elective vasectomies 90 percent of the time if the reversal is performed within ten years of the vasectomy. Chapter 8 will tell you how this surgery can be done with such precision.

I also need to know if you've incurred nerve damage from a colon resection. This injury can cause both erection and ejaculation problems. If you've had bladder or prostate surgery, you may suffer from retrograde ejaculation. This condition causes you to ejaculate into your bladder instead of out your penis. You can read more about how we manage this problem in Chapter 8.

If you've had surgery for the removal of an adrenal, scrotal, or pituitary tumor, I may suspect an endocrine (hormone) imbalance. Once they're correctly diagnosed, hormonal deficiencies often respond well to hormone replacement therapy. The diagnostic procedures and treatment regimens I use for hormonal problems are detailed in the next chapter.

We know that certain medications lower fertility by depressing sperm production or impairing sexual performance. For example, if you take high blood pressure medication (antihypertensives) such as reserpine, methyldopa, and guanethidine; or if you consume alcohol or narcotics, you may have difficulty maintaining an erection and suffer from ejaculation failure. In addition, these drugs can lower your sex drive. Hypertension is often treated with medications called calcium-channel blockers (Captopril, Vasotec, nifedipine). These medications appear to effect the ability of the sperm to bind to and fertilize the egg.

Cytotoxic drugs, anabolic steroids, cimetidine (Tagamet for ulcers), sulfasalazine, spironolactone, opiates, and colchicine all may cause depressed sperm production. We also know that antimalarials, tetracycline, amebicides, nitrofurantoin (for bladder infections), propranolol (Inderal), and barbiturates may cause fertility problems. If you take methotrexate for psoriasis or cancer, you may even suffer irreversible germ cell damage in your testes. Many of the drugs I've mentioned are generic; that is, they are the names for the basic chemical compounds. You can check to see if the medication you're taking contains any of these compounds by looking in the Physician's Desk Reference at your library or by asking your doctor. Often by simply altering your medication your doctor can restore your fertility.

Chemotherapy and radiation therapy for cancer may have irreversible effects on fertility. However, if some of your testicular germ cells remain intact, your sperm production may resume when treatment stops. Since every case is individual, you should check with your doctor about your particular situation.

I also need to know about your sexual development. For example, if you had undescended testes, I need to know if and when you underwent surgery to correct the problem. If you had the surgery before you were six, your testes may be fine. Otherwise, cellular damage that impairs sperm production may have occurred. It's also helpful for me to know if you went through puberty exceptionally early or late (the normal range is nine to sixteen). Sometimes this clues me in to hormone problems.

Sexual Performance

If you have difficulty getting and maintaining an erection, I want to check your general health, your nervous system, your hormone levels, and your exposure to toxic chemicals or medications. Any one of these factors can cause physical impotence. if necessary, your doctor may want a second opinion from a psychologist, neurologist, or psychiatrist. I'll discuss more about treating impotence and erection problems in Chapter 8.

If you become too excited and almost always ejaculate before inserting your penis into your wife's vagina, you'll never get your sperm into her cervix. And you both will be pretty frustrated with your sexual life. Premature ejaculation can often be solved by using the sexual techniques and positions I describe in Chapter 8.

I also need to know how often you have sex and what techniques you use. One of my patients told me, for example, that his father had advised him to have sex three times a day. While this "prescription" for pregnancy may sound reasonable, it actually lowered my patient's fertility potential. He could not possibly make enough sperm that frequently.

It's also helpful for me to know if you've previously fathered a child, or if your wife has had an abortion or miscarriage during her partnership with you. With this information I can establish that you were fertile at one time and begin looking for problems that developed since then. Repeated miscarriages also alert me to the possibility of a genetic problem with either the man or woman.

Since fertility problems often run in families, I need to know if your mother, father, brothers, or sisters have encountered any difficulties. For example, if your mother had a history of repeated miscarriages when she was pregnant with you, she may have taken a drug called DES. Knowing whether or not you were exposed to DES could help me determine if you're suffering from DES-caused testicular abnormalities. I also need to know if your family has a history of hormonal problems such as diabetes, hypothyroidism, or adrenal gland malfunctions. Adding your family history to other clues may help me decide on which areas to investigate more closely.

Your doctor will recommend doing a semen analysis and postcoital test. If these are normal, the doctor's focus will shift toward detecting problems with your wife. If your semen analysis reveals abnormalities, however, your doctor will perform a physical examination and various laboratory tests on you. Your doctor will use the results of your abnormal semen analysis and postcoital test (both discussed in chapter 6), to guide the rest of the investigation into your fertility problem. The following discussion will help you understand what procedures and tests are available and when they should be used.

If your sperm count shows a concentration lower than 20 million sperm per milliliter, I'll first try to eliminate toxic substances or recent illnesses as possible causes. If your history or life-style does not provide any clues, I will examine your scrotum to determine if your testicular size is normal. Under-developed testicles may be caused by a number of problems which I discuss in detail later. I will also look for the presence of a varicocoele (varicose vein in the scrotum), which may be impairing your sperm production. See chapter 8 for a complete discussion of varicocoeles.

If I find a stress pattern in your semen analysis (low count, poor morphology, and low motility), I'll order blood tests to determine your hormone levels. And if I suspect a genetic problem such as Klinefelter's syndrome, I may recommend checking your chromosomes (karyotyping). chapter 8 describes in detail what these tests will reveal and the treatment regimens available for improving sperm production.

If you do not respond to treatment for oligospermia, you are a prime candidate for artificial insemination with your own sperm (AIH) or in vitro fertilization, in which a surgeon retrieves your wife's eggs (ova) and uses your sperm to fertilize them in a petri dish. The fertilized egg (embryo) is then transferred to your wife's uterus in the hope that it will implant and develop into a baby. The first in vitro "miracle baby" was born less than ten years ago. Now in the United States alone over one hundred clinics offer these services. I'll discuss in vitro fertilization and many other technologically advanced options in later chapters.

If your semen analysis shows fewer than 10 million sperm per milliliter, I will check your hormone levels and the size of your testicles. I'll measure your FSH hormone level to determine if your pituitary gland is stimulating your testes to make sperm. If FSH is elevated (indicating testicular failure) and you are not making sperm, the odds of improving your underlying condition are bleak, although in vitro fertilization may work. If I find that your hormones are deficient and your testicles are small, hormone replacement therapy may help you develop normal testicular function.

When your sperm concentration is this low, I may also recommend that a urologist perform a testicular biopsy, which will tell me the condition of your testes at the cellular level. I need to know if your germ cells are dividing and producing immature sperm cells. I also want to know if you have Sertoli, or nurse, cells to shepherd and nurture the immature sperm cells through their five or so stages of maturation. The biopsy will also tell me if your Leydig cells are capable of producing testosterone (male hormone), which is vital for sexual performance and sperm development. I can also see if your testicular (seminiferous) tubules are intact.

If the biopsy reveals that your testicular structures are irreversibly damaged, I probably cannot do anything to improve your sperm production. If the biopsy shows me that your testes are understimulated by hormones, I can prescribe replacement hormones, which may initiate testicular development and establish spermatogenesis. If the biopsy shows me that your testes are normal, then I know that your vas deferens (tube leading from your testicles toward your penis) is partially blocked. Microsurgery may be able to restore the path. Chapter 8 will tell you what can cause these problems and the treatments available to improve oligospermia.

I evaluate azospermia, the condition in which the semen contains no sperm, the same way I evaluate severe oligospermia. However, in addition to performing the tests I do for a severely oligospermic man, I will also test your semen to see if it coagulates and if it contains fructose (sugar). (Azospermic men usually do have semen, because sperm and semen are made in different organs.) Your seminal vesicles make fructose and the chemicals that cause your semen to coagulate. If you were born without seminal vesicles or if your ejaculatory duct is blocked, your semen will not coagulate. I may also examine your urine after ejaculation to see if you have retrograde ejaculation. An ultrasound examination may show a blockage of the ejaculatory ducts where they enter the prostate. Chapter 8 tells you more about the procedures used to manage these problems.

Vasograms (X rays of your ducts) and biopsies of your testicles may damage delicate genital structures. Therefore, your doctor should exhaust all other measures before using these more invasive diagnostic procedures. With less invasive tests, such as an ultrasound of the prostate, I can predict pretty well whether or not you have an obstruction. However, I may need to order an X ray to determine where an obstruction or absent tubal structure exists. This procedure is usually performed under anesthesia at the same time that you are prepared for corrective surgery.

If you have severe oligospermia or azospermia; low or normal FSH levels; and do not respond to hormone replacement therapy.

If you are azospermic; have normal hormone levels and normal testicular size.

If you are azospermic and have a normal testes biopsy, you definitely have a tubal blockage. (See Chapter 8 for a complete discussion of tubal blockage and corrective techniques.)

If you are oligospermic because your testes are performing at an abnormally slow rate, you have hypospermatogenesis.

If you are azospermic because your testes cannot complete the sperm maturation process, you have maturation arrest.

If the biopsy finds hypospermatogenesis (perhaps a phase of maturation arrest), you will show diminished germ (germination) cell activity and marked germ cell loss. Since the germ cells are the precursors of sperm, you will produce low numbers of sperm or no sperm at all. Chemical toxins, drugs, and varicocoeles may cause hypospermatogenesis.

With maturation arrest, one of the most frequent biopsy findings in male fertility, your germ cells divide and produce early sperm forms, and other testicular structures will appear normal. At one stage in their maturation, however, sperm development halts throughout all your testicular tubules. The condition may be complete (azospermic) or partial (oligospermic). Chemical toxins, drugs, and varicocoeles may cause maturation arrest. If your FSH level is high, indicating severe testicular damage, it may be too late for treatment. However, things are brighter if your FSH level is low or normal. Removing the toxins and/or repairing your varicocoele will often restore spermatogenesis.

"Dr. Perloe, we keep getting conflicting information about male fertility treatment. Could you clarify the current thinking for us?" the RESOLVE leader asked.

"The first part of the male formula is what I call pretesticular function. This means that your hormone system must be functioning properly in order to stimulate your testicles to make sperm.

"The second ingredient I call the testicular component. This means that when stimulated by your sex hormones, your testicles must be capable of producing sperm. Testicles can be congenitally deformed or they can be damaged by chemical toxins, illness, systemic disease, or trauma." I saw Steven S.'s hand go up. "Yes, Steven?"

"But I thought your testicles made your sex hormones. If your testicles aren't working, how can your hormones be stimulating them?"

"Your testicles do produce the male hormone testosterone. However, your brain and your pituitary gland, located at the base of your brain, produce chemicals that tell your testicles when to make testosterone and when to make sperm. Without these signals from your brain and pituitary, your testicles may fail to mature and fail to make sperm.

"The third ingredient of the male fertility formula is posttesticular function. The ducts leading from your sperm-producing testicles must provide a clear and continuous path for your sperm to travel out of your penis. Congenital tubal defects, surgeries, and blockage from infections may clog up these pathways."

"What can be done for blocked tubes?" Michael T. asked.

"Today with the aid of microsurgery, most tubal problems can be corrected, including vasectomy reversals." I turned to the chalkboard and wrote down the fourth factor, ejaculatory disturbances, impotence, and sexual problems . "These are the final ingredients of the male fertility formula," I said. "You must be able to deliver your sperm to your wife's cervix in order to make a baby." I set the chalk in the tray and turned back toward the group.

"There are some exceptions to this. Some delivery problems can be overcome with artificial insemination. For example, some men ejaculate backward into the bladder. When this happens, we can retrieve the ejaculated sperm and use artificial insemination techniques to get the sperm to their destination."

"What if the man can't perform?" a woman across the room asked.

"There are two types of sexual performance problems—physiological impotence and psychological impotence. Often it's difficult to separate the two, since men with impaired sexual performance frequently have psychological problems regardless of the source of their difficulty. Physiological impotence may be caused by toxic chemicals, hormone deficiencies, "street" drugs, medications, and nerve damage, for example. A complete fertility evaluation should reveal the source of the problem. And even with physiological impotence, counseling may be needed to ease the difficulties associated with inadequate sexual performance.

"These are the four ingredients necessary for male fertility." I started toward my chair. "If any one of them is out of order, you may have a fertility problem. Working together, you and your physician must identify the deficient factor and direct treatment toward improving that function."

Approximately every ninety minutes a specialized area in your brain (hypothalamus) secretes GnRH (gonadotropic-releasing hormone). GnRH signals your pituitary gland, located at the base of your brain, to produce LH (luteinizing hormone) and FSH (follicle-stimulating hormone). LH tells your testes to secrete the male hormone testosterone. Testosterone stimulates your sexual desires and develops and maintains your male secondary sex characteristics such as hair growth and deep voice. Together, testosterone and FSH stimulate your testes to produce sperm (spermatogenesis). Your body's ability to make and regulate these hormones is vital for maintaining your virility and sperm production.

You have feedback hormones—testosterone and inhibin—that keep a check and balance on your GnRH, LH, and FSH levels. Once the Leydig cells in your testicles produce enough testosterone, your hormone control 00 systems cut back on GnRH and LH production. When the Sertoli cells, which respond to FSH stimulation, produce enough inhibin, the pituitary cuts back FSH production. Examining figure 8-1 will help you visualize your fertility hormone control system. These relationships will become more clear in the discussions that follow.

Each day your testicles make millions of sperm. Your testicles are composed of a number of different types of cells which support and surround masses of microscopic seminiferous tubules. Your sperm grow and mature within these tubules. The germ cells (germinal cells or basic sperm cell factories) line these tubule walls. When they are stimulated by the Sertoli cells, the germ cells divide (mitosis) to produce one primary spermatocyte that contains a full complement of your forty-six chromosomes (genetic material). The germ cells remain intact to divide repeatedly throughout your reproductive life. The primary spermatocytes, containing forty-six chromosomes, however, proceed to divide by a special process called meiosis. Meiosis produces four spermatids (immature sperm) containing twenty-three chromosomes each. These spermatids are destined to fertilize your wife's egg, containing twenty-three of her chromosomes. At this point cell division ends and the sperm maturation process begins.

The spermatids remain attached to your tubule wall, where they are nurtured by the Sertoli, or nurse, cells. It takes about ninety days for the sperm to grow, mature, and travel through the tubules to a central storage area called the epididymis. Here the sperm become powerful swimmers. After each ejaculation, it takes about forty hours for your epididymis to refill with mature sperm (this is why too-frequent intercourse can impair fertility).

Each microscopic sperm carries all the genetic information necessary to fertilize the egg. Half of your sperm carry an X chromosome (inherited from your mother) and half carry a Y chromosome (inherited from your father). If an X-carrying sperm fertilizes your wife's egg (ovum), you'll have a baby girl. If a Y-carrying sperm fertilizes the ovum, you'll have a baby boy. In this way the husband's genetic contribution determines the baby's sex.

When you ejaculate, your sperm rush through a number of channels between your epididymis and the opening of your penis. (You can view the course that your sperm travel during ejaculation in figure 8-2 below.)

At the moment of ejaculation, your epididymis expels the sperm into the pulsating muscular walls of your vas deferens. While coursing through your vas deferens, the sperm pass the seminal vesicles. These secrete fructose (a sugar to feed your sperm), seminal fluids (to protect your sperm), and a chemical that coagulates your semen soon after it enters your wife's vagina. Then your sperm speed through your ejaculatory ducts past your prostate gland, which secretes additional seminal fluids, including a chemical that liquefies your coagulated semen within an hour after ejaculation. As your semen (sperm plus your seminal fluids) rushes past the bladder, a muscle (sphincter) squeezes the bladder opening shut. This guides the semen on course through your urethra and out of your penis.

Erection, orgasm, and ejaculation are three distinct processes controlled both by your conscious mind and by involuntary neural responses. To get sperm to your wife's cervix, all three of these processes must be working properly.

Erection may occur when you have an erotic thought or when your penis is touched. During an erection, nerves signal the blood vessels in your erectile tissue to dilate and become engorged, and your penis swells and becomes rigid. Friction from manual and vaginal stimulation sends more signals to the brain and stimulates orgasm and ejaculation. Psychological factors can stimulate or interfere with your erection; however, once you reach orgasm your automatic reflex actions run their course.

Orgasm is the name given to the physiological and sensory thrill that accompanies ejaculation. The first stage of orgasm, called ejaculatory inevitability, occurs two to four seconds before ejaculation. During this interval you sense your imminent ejaculation and cannot continue to control the process. Your prostate gland and your seminal vesicles start to pulse. The second stage of orgasm begins when you involuntarily expel semen in several convulsive waves. Typically you ejaculate about one teaspoon of semen, which contains 40 to 150 million sperm. The first squirt (semen fraction) generally contains the largest number of sperm.

After orgasm, most men and many women experience a recovery (refractory) period during which they cannot have another orgasm. This period may last many minutes and sometimes several hours. You may also experience an erection refractory period.

As I discuss the various causes of male fertility problems, the statistics in table 8-1 will help you place each condition into proper perspective.

Problem                                                     % Infertile Population

Hormone

Endocrine                                                                        9

Hyperprolactinemia (elevated prolactin)                     10-40

Congenital adrenal hyperplasia                                 1

Stress                                                                            ?

Sperm Production

Varicocoele                                                                 40

Testicular failure                                                         14

Smoking, heat, drugs                                                   ?

Sperm Delivery

Obstructed ducts                                                         7

Congenital obstruction/absence of ducts                 2

Erection, Orgasm, Ejaculation

Sexual problems                                                         5

Ejaculation problems                                                   2

In the rest of this chapter I will describe how each of the four fertility factors may malfunction, how specific disorders can be diagnosed, and how they can be corrected.

Several things can go wrong with your hypethalamus-pituitary endocrine system:

Your brain can fail to pulse GnRH properly.

Your pituitary can fail to produce enough LH and FSH to stimulate your testes.

Your testes' Leydig cells may not produce testosterone in response to LH (pituitary) stimulation.

Your body may produce other hormones and chemical compounds which interfere with your sex-hormone balance.

Any one of these conditions can impair your sperm production. To help you understand the treatment for these hormonal disorders, I'd like to explain what medications are available and how they are prescribed to improve male fertility.

If your pituitary hormones (LH and FSH) are low, but you do have a working hypothalamus and pituitary gland, clomiphene citrate (Serophene, Clomid) should stimulate your hypothalamus to pulse GnRH at regular intervals. When your hypothalamus properly releases GnRH, your pituitary gland will respond by producing LH and FSH. If Serophene does not improve LH and FSH levels, then I will suspect that your pituitary gland may be malfunctioning. (Since Serophene is an oral medication, it is more convenient and less expensive than your other options.)

If your pituitary cannot manufacture the missing sex hormones, you can take hormone supplements. Injections of hCG (human chorionic gonadotropin) will increase your LH supply and often stimulate your testes to produce testosterone and sperm. If your response to hCG is inadequate, I might add Pergonal (FSH and LH) to stimulate sperm production. Pergonal and hCG treatments can be quite expensive, since they require regularly repeated injections.

If these treatment regimens are successful, sperm production and quality will begin to improve within three to four months.

Hyperprolactinemia (elevated prolactin) can be difficult to diagnose because your FSH, LH, and testosterone levels will be normal. We find elevated prolactin, a hormone associated with nursing mothers, in 10 to 40 percent of infertile males. Mild prolactin elevation produces no symptoms; however, greater elevations can reduce sperm production, impair your sex drive, and cause impotence. Hyperprolactinemia responds well to a drug called Parlodel (bromocriptine). A prolactin-secreting tumor will also respond to Parlodel; however, surgery and/or radiation therapy may be necessary.

Found in 1 percent of infertile men, hypothyroidism (low thyroid hormone) can cause poor semen quality, poor testicular function, and/or disturbances in sex drive. You will be lethargic, intolerant of cold, and overweight. Because the pituitary gland is trying its best to stimulate your unresponsive thyroid gland, your pituitary-produced TSH (thyroid-stimulating hormone) level will be elevated. Elevated prolactin levels, frequently found with this disorder, may cause impotence.

You can sometimes bring on hypothyroidism by eating a diet high in iodine—for example, kelp or seaweed—or taking multimineral tablets. Chronic ingestion of iodides in cough syrups (formerly used in treating asthmatic bronchitis) may also produce these symptoms. In addition, hypothyroidism may be caused by radioactive thyroid medications and autoimmune diseases.

Correcting your diet or beginning thyroid hormone replacement therapy should elevate your sperm count to previous levels. I must emphasize that unless you have low thyroid, thyroid hormone replacement therapy will not improve your sperm quality.

When a woman is under a great deal of stress, we can use Serophene to regulate the GnRH pulses from her hypothalamus and restore ovulation. It seems logical to assume that Serophene may help a man in the same situation. Although we don't know the therapeutic effects for certain, I have observed some semen improvement when Serophene has been used with these men.

I especially remember Ted M., who was the typical "Type A" personality. Ted had a borderline sperm count, smoked five packs of cigarettes and drank ten cups of coffee a day, and was a workaholic. I prescribed Serophene and also counseled with him about restructuring his habits. With some help from his friends in RESOLVE, Ted began a moderate exercise program and got his nicotine and caffeine habits under control. Within five months his count began improving and a year later he fathered a child.

Pound in 1 percent of infertile males, congenital adrenal hyperplasia may be suspected when a semen analysis shows a low sperm count, an increased number of immature sperm cells, sperm with long tapered heads, and low motility. These abnormalities occur when the pituitary is suppressed by increased levels of adrenal androgens. Men with this disease may also have hypertension (high blood pressure) and edema (water retention). Early onset of the disease may result in ambiguous genitalia at birth or reaching puberty at an early age. Adult onset may be characterized by infertility, high blood pressure, and/or water retention.

Cortisone replacement therapy will lower your androgens and allow your pituitary to function normally. Therefore, indirectly, cortisone replacement therapy will elevate your sperm count.

Some of these situations are not so easily managed. One time I had the unfortunate job of counseling one of my bearded male patients who was genetically a she. Because the adrenal androgens (male hormones) had dominated this person's hormonal system since before birth, male secondary sex characteristics developed. Fortunately this finding is quite rare.

Hypogonadotropic hypopituitarism is a spectrum of diseases with a complicated name that means low (hypo-) pituitary gland output of LH and FSH. Other stages of this disease are called isolated gonadotropin defect and panhypopituitarism, in which the entire (pan-) pituitary gland is affected.

These diseases arrest sperm development and cause the progressive loss of germ cells from the testes. In addition, the seminiferous tubules and Leydig cells (which produce testosterone) also deteriorate. If the condition persists for a long time, you will have no sperm production at all. (See chapter 7 for a discussion of maturation arrest.) When the disease is associated with a pituitary tumor, elevated prolactin levels may also cause impotence.

Clifford J. showed signs typical of this progressive degeneration. Over a period of three to four years he gradually lost his heavy beard, became less interested in sex, and eventually could not sustain an erection. His blood tests revealed low LH, FSH, and testosterone levels, and his sperm count was 10 million per milliliter. I prescribed Serophene in hopes of improving his sperm count and sexual performance. Fortunately he responded to the drug, and six months later his sperm count increased to 18 million. After performing AIH four times, his wife became pregnant. Following fertility treatment, I discontinued the Serophene (it's too expensive to take all of the time) and continued giving him a testosterone supplement to maintain his virility and sexual performance.

Complete pituitary gland failure (panhypopituitarism) lowers your growth hormone, ACTH level, thyroid-stimulating hormone (TSH), and LH and FSH levels. If you have this rare disease, you will have multiple symptoms that include impotence, decreased sex drive, loss of secondary sex characteristics, and normal or undersized testicles. Your hypothyroidism (low thyroid hormone) will cause you to gain weight, be intolerant of cold, and feel lethargic. If the disorder began early enough in your life, you may even be a dwarf. The hormonal deficiency is often caused by a tumor, surgery, or trauma to the pituitary gland.

No amount of stimulation can improve the performance of the damaged pituitary gland, so I will work with an endocrinologist to supplement the missing pituitary hormones. The thyroid hormone supplement as well as other hormone replacements will restore general health and vigor. At that point I administer hCG to stimulate the testicles to produce testosterone and to begin making sperm.

Kallman's syndrome is a congenital hypothalamic dysfunction. If you are born with this unusual condition, you will have underdeveloped testicles and possibly a harelip, cleft palate, color blindness, and/or the inability to smell. Affected men have varying degrees of sexual infantilism (prepuberty) and no sperm production. Since the hypothalamus fails to stimulate the pituitary adequately, FSH, LH, and testosterone levels are low. I treat Kallman's syndrome similarly to hypogonadotropic hypopituitarism. Although at first it seems hopeless, men afflicted with Kallman's syndrome can achieve normal puberty and eventually become fertile.

Individuals with isolated pituitary growth hormone deficiency do not sexually mature until their mid to late twenties. Hormone supplements can make them look virile, but until they go through puberty, they won't be fertile. Pergonal and/or hCG injections can bring on puberty, although if left alone, sexual maturity and fertility will be achieved in time.

If you have this rare disorder, your virilization (acquisition of adult sex characteristics) will be moderately advanced, but you will not have completed sexual maturation and testicular growth. If I biopsied your rather small testicles (a procedure not usually needed to diagnose this condition), I'd find evidence of sperm production and thus the potential for fertility. Since the arrest of sperm production and low testosterone levels are caused by an LH deficiency, administering hCG will raise both hormone levels and stimulate sperm production.

Let's suppose that your hypothalamus and pituitary are working well. The fact is that some conditions prevent your testicles from responding to pituitary hormone stimulation. Testicular failure, as it's called, can be caused by genetic abnormalities or by damage from drugs, injury, radiation, excess heat, adult mumps, a varicocoele, or toxins from your environment. Sensing abnormal testicular function, your brain responds by telling your pituitary to pump out more FSH to stimulate sperm production. In fact, elevated FSH is the primary diagnostic indicator for testicular failure.

Unfortunately there isn't much that can be done for primary testicular failure, which is caused by a genetic mistake. The malformed testes are unable to produce sperm and no amount of stimulation will improve their function. However, if you have this problem, you and your wife need not go childless. You are a prime candidate for artificial insemination with donor sperm (AID). With AID your baby will inherit your wife's genes and traits and will be your own through your marital bonds and love. I'll talk more about AID techniques in a later chapter.

We have a better chance of treating secondary testicular failure (acquired damage). If, before too much testicular damage occurs, you discontinue potentially harmful medications and illicit drugs; avoid contact with toxic substances such as pesticides; reduce excess heat exposure; or have a varicocoele surgically repaired, you may once again produce sperm. Below is a discussion of what causes testicular failure and the methods available for improving fertility.

"Doctor, I can't get pregnant!" Kathy's voice belied her controlled exterior.

"We want a baby so badly. You're our last hope."

"Kathy," I said, glancing at her history form, "tell me when your periods stopped."

She sat straight and squared her shoulders. "Two years ago."

I scanned the page. "You're a runner. Do you enter the Peachtree Roadrace?"

Her face brightened. "I wouldn't miss it. Last year I came in twelfth."

"That's very good. How long have you been running?"

"I really started training two years ago. Up to then I wasn't so serious about competing."

Two years ago, I thought. And two years ago her periods stopped. Now I had the first important clue to Kathy's fertility problem.

I knew she wouldn't like what I was about to suggest. "Kathy, we know that women athletes often complain that their periods stop. Of course, I need to know a lot more about you, but I wouldn't be surprised if your training regimen is contributing to your fertility problem."

Her smile faded. "You mean I'll have to stop running?"

"Not at all," I assured her. "Many women athletes keep in shape even while they are pregnant. But first, let's figure out how to help you get you pregnant."

She smiled. "Sounds good to me."

Physical exertion is only one of many factors that may affect your fertility. Critical points about your development, medical history, and lifestyle all give me vital clues to solving your fertility problem. In this chapter you'll learn what your doctors investigations into your past can reveal, and gain insight into what may be causing your fertility problem.

This cause of infertility may be grounded in our ancestral heritage. If food supplies were low, we followed herds of migrating animals or ranged far and wide to gather fruits and grain. A pregnancy would impair the woman's ability to keep up with the group. To improve her odds for survival during famine, nature decreased her fertility so that she stopped ovulating and her periods ceased (amenorrhea). This is probably the same protective mechanism that caused Kathy S.'s problem.

Fortunately, resolving Kathy's hormonal imbalance was easy once I identified the cause. I'll tell you how we treat amenorrhea in a later chapter.

Most women with fertility problems appear to be under a great deal of stress. But we don't know for any one person whether the stress contributed to the fertility problem, or whether the fertility problem brought on the stress. Many women in high stress situations become pregnant, so we can't say conclusively that stress will disrupt your hormonal balance.

We do know, however, that stress can affect your hypothalamus, the part of your brain that controls sex hormones. And we know that some women who have no apparent reason for being infertile except stress will often respond to a medication that improves hypothalamic function.

I'm not saying that the old wives' tale "Just relax and you'll get pregnant" will work. However, there's a great deal about the link between fertility and stress that we don't understand.

Low calorie diets, special athletic diets, eating disorders, and other restrictive eating practices may impair your fertility. A number of factors may cause this problem:

Losing the weight itself

Reaching a low percentage of body fat

Reaching an absolute minimum weight

Stressing the body

Suffering from a nutritional imbalance.

The mechanism for reducing your fertility isn't clear and it may vary from one individual to another. Like Kathy S., however, the most common complaint is amenorrhea, lack of menstrual periods. (I frequently find that teenagers who have been on crash diets stop having periods.)

Fortunately this is one of the easiest fertility problems to correct. When you change your diet and gain weight, you usually start ovulating and menstruation resumes.

Strangely enough, I've also seen ovulation stop in women who follow strict vegetarian diets. I remember one woman who ate so many carrots that her genitals turned bright orange. The stress of her diet and high blood levels of carotene (from eating carrots) may have caused her anovulation. Rather than taking medication to induce ovulation, she chose to cut down on her vegetables and add fish and eggs (protein) to her diet. Having thus increased her caloric and protein intake, she began ovulating and soon became pregnant.

Women weighing two hundred pounds or more may also have fertility problems. This may also be one of nature's protective mechanisms, since obesity does not provide the best environment for fetal development and birth. In fact, before the age of modern medicine, many obese women and their babies died in childbirth. Nature apparently prefers to reduce your fertility and wait for you to lose weight.

I remember one woman who, at five foot four and 188 pounds, complained of irregular periods with heavy flow. The reasons for her fertility problem are interesting. It seems that fat cells themselves can convert androgens (male hormones produced by the ovaries and adrenal gland) into estrogen (female hormone). Assessing all her symptoms, I suspected that her fat cells were producing enough estrogen to confuse her brain. Her brain, thinking that the ovaries were producing the estrogen, lowered her pituitary gland hormone production, which in turn led to anovulation. (You'll learn more about how these complex hormonal systems control your monthly cycles and fertility in the next chapter.) Once I explained how this woman's obesity affected her fertility and general health, she was more than willing to start a diet. A well-planned weight-reduction diet and exercise program eventually restored her fertility. And since her "reduced" fat cells no longer produced excess estrogen, she got a bonus: her risk of developing endometrial cancer diminished, too.

Adhesions (scar tissue) inside the abdominal cavity caused by pelvic infections or abdominal surgery can impair fertility. I commonly find scar tissue in women who have had surgery for ruptured appendix, bowel repair, cesarean section, ectopic pregnancy, or the removal of an ovarian cyst. Twisting around the ovaries, fallopian tubes, and even the uterus, these inflexible webs of scar tissue restrict the natural mobility of these delicate organs.

Margaret B., for example, had a ruptured appendix when she was twenty-three. When I looked at her reproductive organs through the laparoscope (telescope), I found that her pelvic adhesions were so extensive they prevented her eggs from entering her fallopian tubes. I clipped and removed the tissue from around the organs so that Margaret's tubes could once again gently flex and coax the ova down the narrow passage toward the waiting sperm.

Scarring may also occur inside the uterus. Debbie W., for example, came to me about a year after having a D & C, saying, "Ever since my gynecologist scraped out my uterus, instead of having a period I just spot each month." When I looked into her uterus with a hysteroscope (small telescope), I found her uterine walls stuck to one another. I used a rather simple yet effective procedure to separate her uterine walls so they could heal and begin functioning normally. I'll discuss more about this procedure in a later chapter.

If you suffer from frequent yeast or trichomonas infections, you may also have chlamydia, which can cause tubal damage. Because of increased exposure, women with a number of different sexual partners have a much greater chance of contracting these infections. A history of frequent vaginitis will alert me to the possibility that you have pelvic adhesions and tubal blockage. Once diagnosed, these abnormalities may respond to corrective surgery.

A number of illnesses can lead to impaired fertility. The most obvious ones are the venereal or sexually transmitted diseases such as gonorrhea, chlamydia, ureaplasma infection, and pelvic inflammatory disease (PID). These diseases can scar your uterus, block your tubes, and cause the formation of pelvic adhesions. I remember one woman who said that four years ago her doctor thought she had a gallbladder problem. "I had a pain right here," she said, holding her hand over the lower right half of her rib cage. "I guess it just went away, because I haven't had any more trouble."

After asking her several questions about her symptoms I suspected that instead of having a gallbladder problem, she had probably contracted PID. After further tests, I discovered that PID had caused her liver to adhere to the inside of her abdominal wall, a condition called Fitzhugh-Curtis syndrome. Once I surgically removed the adhesions and repaired her scarred fallopian tubes, she soon became pregnant.

Other diseases such as hepatitis fever disease and kidney disease can cause fertility problems. Both your liver and kidneys filter and remove waste products, toxic substances, and impurities from your blood. A buildup of wastes and unmetabolized (not chemically broken down) hormones may interfere with your menstrual cycle. When these diseases are brought under control, fertility usually returns.

Thyroid gland disorders may also interfere with fertility. Increased metabolism from an overproduction of thyroid hormone (hyperthyroidism) will burn up your estrogen supply faster than your body can make it. Without estrogen you cannot ovulate. In contrast, if your thyroid gland produces insufficient thyroid hormone (hypothyroidism), you will stockpile too much estrogen and you may have an elevated prolactin level. If you have an excess of these two hormones, your ovaries cannot function normally. Regulating your thyroid production through surgery or thyroid supplements usually restores fertility.

Adult onset diabetes or insulin resistance may interfere with normal menstrual cycles. High levels of insulin abnormally stimulate the ovary to make high levels of male hormones which block normal ovulation.

Hypertension (high blood pressure) may be associated with an adrenal gland disorder that causes excessive production of male hormones (androgens). Increased androgens can disrupt normal ovarian function as well as disturb your female secondary sex characteristics.

I remember one woman referred to me for a fertility workup said, "Doctor, I'm growing a mustache!" The hair growth on her upper lip (a condition called hirsutism), very oily skin, and acne told me she was probably producing excessive androgens. As I expected, her blood tests revealed that she had an overactive adrenal gland. When she received medication to slow her androgen production down, her periods resumed, and much to her relief her mustache stopped growing.

Cone biopsy, laser surgery, Leep, or cryosurgery may be used to treat a condition detected by an abnormal Pap smear. Any of these procedures can degrade the quality of your cervical mucus to the point that sperm cannot travel into your uterus. I performed a cone biopsy on a twenty-seven-year-old patient of mine who had a precancerous Pap smear result. I hoped I could halt the growth of abnormal tissues and prevent Nancy V. from developing cervical cancer. A year later she married and wanted to have a baby. When I performed a postcoital test, I found that her mucus was too scant and thick for the sperm to pass. So I recommended we wash her husband's sperm and inject them directly into her uterus (intrauterine artificial insemination homologous). After three tries Nancy became pregnant.

A cone biopsy can also weaken the cervix and allow premature pregnancy loss. So during Nancy V.'s pregnancy I watched her cervix to make sure that it stayed shut until delivery. Fortunately all went well and she delivered an eight-pound fourteen-ounce baby boy. I'll discuss more about the procedures I used with Nancy in chapter 19.

Anticancer agents such as methotrexate or radiation treatment may also compromise your fertility. Radiation can cause not only pelvic adhesions but also chromosomal damage to your eggs. If you're concerned about the effects of these treatments, talk with your doctor.

Endometriosis may scar your fallopian tubes, interfere with your ability to ovulate, and prevent embryo implantation. Endometriosis is the presence of endometrial tissue outside the womb. Unfortunately we do not know the exact mechanism by which endometriosis forms. Being sensitive to monthly hormonal changes, this tissue grows and then, as does the endometrium in the uterus, sheds during menstruation. This "bleeding" inside the abdominal cavity is very painful, as Shelley T. testified: "When my period starts, my cramps get so bad I have to go to bed."

When I looked inside Shelley T.'s abdomen with a laparoscope, I found extensive pelvic inflammation and scarring. Since endometriosis can also cause tubal blockage, I injected dye into her uterus and tubes to see if they were open. I was really relieved to see the blue inklike fluid seeping out each fimbria (the opening of the fallopian tube near the ovary).

Fortunately endometriosis frequently responds to hormonal therapy and, when necessary, to surgery. In Shelley's case I decided to use the laparoscope and a small instrument passed through a second small incision to cut her adhesions. Then I used a laser to selectively cauterize and excise the endometrial implants. She received GnRHa (Synarel , Lupron, Zoladex) for three months after her surgery and then attempted pregnancy. A later chapter will explain more about these procedures.

German measles (rubella) does not impair fertility. However, if you contract rubella during the first half of your pregnancy, your baby will likely suffer from severe defects, including deafness and mental retardation. It would be tragic to undergo extensive fertility treatment only to achieve a pregnancy blighted by German measles. Therefore, I always do a blood test to determine if my fertility patient is immune to German measles. If the test is negative, I give her a rubella vaccine. I then recommend that the couple use barrier contraception, such as condoms, for three months to avoid the remote possibility that the live virus vaccine could affect their baby.

If your breasts are tender or if you have a milky discharge, you may have breast tumors. If I cannot detect any abnormal growths, I look for other factors that can cause a hormone imbalance for example, an excess production of prolactin.

Prolactin, one of the primary hormones responsible for milk production (lactation), suppresses ovulation. I remember one patient who came to me because she hadn't responded to the drugs her doctor prescribed to induce her to ovulate. Heather P. complained of milk leaking from her breasts, so I suspected that her pituitary gland was producing excessive amounts of prolactin. When this was confirmed by a blood test, I prescribed Parlodel (bromocriptine, an oral medication. That did the trick and she got pregnant in her very next cycle. I'll discuss this treatment more in chapter 12.

Any disturbance in your central nervous system may interrupt the delicate hormonal coordination between your hypothalamus, pituitary gland, and ovaries. If you suffer from seizures, epilepsy, visual disturbances, poor sense of smell, dizziness, loss of balance, or chronic headaches, you may have a neurological disorder. If you take medication to control epilepsy, nervous tension, depression, and so forth, the drugs themselves may interfere with your fertility. I remember one RESOLVE member who reported that when her doctor changed her antidepressant to a different prescription she began ovulating three months later. I may consult with a neurologist if I feel the disorder requires further diagnosis and treatment. Once we correct the neurological abnormality, fertility may return naturally.

A number of medications may compromise your fertility. If you take hormones, antibiotics, or antihypertensives, they can prevent an embryo from implanting in your uterus. If taken in the middle of your menstrual cycle, Motrin, Anaprox, Indocin, or aspirin usually taken to ease menstrual cramps may prevent your ovary from releasing a ripened egg. Antidepressants, hallucinogens, painkillers, and alcohol may increase your prolactin levels and cause ovulation failure. When you stop these medications (and don't stop taking any medications without consulting your doctor first), fertility usually resumes.

Be sure to tell your doctor about every prescription or over-the-counter drug you take. These drugs may not only play a part in your fertility problem but, should you become pregnant, they may also jeopardize the development of your infant. My general rule of thumb is "When in doubt, do not take it." We honestly do not know the effects of all drugs on a pregnancy, particularly when taken in combination with other medications.

Central nervous system depressants such as heroin or large, frequent doses of marijuana can interfere with your sex drive and with the hormonal balance necessary for ovulation and menstruation. Don't bother to pay for expensive fertility treatment if you plan to continue taking these drugs. Besides, during your pregnancy, a number of these drugs may also threaten your unborn child. Both marijuana and tobacco cigarettes increase the carbon monoxide level in your blood and impair your unborn baby's oxygen supply. Without adequate oxygen, tissues and vital organs may be damaged or killed. Taking hard drugs like cocaine will also reduce the life-sustaining blood supply to your unborn baby. When you stop using these toxic chemicals, your fertility usually returns.

At a RESOLVE meeting I met a woman who had nearly died with the birth of her first child. During her delivery she had suffered a massive hemorrhage. "They gave me twelve blood transfusions," she reported. "My baby and I just barely survived." She picked up her infant and held her close. "I tried to nurse Rachael, but she was starving, so I gave it up. After a few weeks it was all I could do to get out of bed, feed her, and change her diapers."

Her husband interrupted. "I knew something had to be wrong, so I put Sarah and Rachael in the car and drove them to the doctor."

"The doctor told us that massive bleeding associated with pregnancy sometimes shocks the pituitary gland to the point that it dies," Sarah said. "He called it Sheehan's syndrome. He didn't know exactly why this happened to me, but my pituitary may have suffered a temporary loss of its blood supply."

Since Sarah's damaged pituitary gland no longer controlled her thyroid hormone production, adrenal hormone production, and blood sugar levels, she experienced a wide range of symptoms including extreme fatigue. In addition, she could not ovulate, she could not have a period, and she could not have another baby. When her doctor put Sarah on pituitary hormone replacement therapy, she eventually regained her fertility and gave birth to a second child.

Day 1 of your menstrual period is the day your period begins. This seems relatively simple, but you wouldn't believe how many people fail to get pregnant because they count the days from the wrong starting point. (Just recently I spoke to a couple who counted from the day her period stopped. They knew she was most fertile around the middle of her cycle, or approximately days 14 to 16, so they timed intercourse two weeks after her period stopped. However, since her period stopped on what they should have counted as day 6, they were having sex a week too late on days 20 to 22.)

Because on the average a woman's cycle varies in length from twenty-six to thirty-five days, you cannot count forward from day I to find your most fertile days. Since you ovulate approximately fourteen days before your next period begins, you count backward fourteen days from the date you expect your next period will start. That means the woman with a thirty-five-day cycle would ovulate on day 20 or 21 and the woman with a twenty-six-day cycle on day 11 or 12. Since you're fertile for only twenty-four hours each month, these calculations become quite critical.

When an Agatha Christie mystery begins to unfold, at first the investigator suspects every character of having committed the crime. As the plot unwinds, however, our hero gradually pieces together one shred of evidence after another, until, in the final climactic scene, the master investigator pinpoints the culprit.

There's little difference between conducting this kind of investigation and doing a fertility evaluation. When a woman first comes to my office, I suspect a broad range of causes: tubal blockage, endometriosis, pelvic adhesions, uterine abnormalities, anovulation, and so forth. As I review her history, I search for clues that will help me narrow my list of suspects. Repeated pelvic infections, for example, lead me to suspect tubal blockage or pelvic adhesions. If she tells me she's not menstruating, I'll focus my investigation on hormonal problems or uterine abnormalities. If she complains of extreme discomfort when her period starts, endometriosis will be uppermost in my thoughts.

Just as the master detective can be thrown off by misleading evidence, I must also be cautious not to jump to conclusions. It's all too easy to say, "Pain at menstrual onset? You have endometriosis." Although this may be correct, endometriosis may not be the only offender. Intrauterine adhesions or hormonal imbalances may also play a part.

The challenge presented by contradictory clues can seem overwhelming Just as I think I'm about to close in on one suspect, I uncover evidence that doesn't seem to fit the pattern. With my theory blown out of the water, I must formulate a new strategy for tracking down the culprit. By analyzing the clues and continually searching for additional ones, I draw closer and closer to the solution until I reach the climactic day when I tell you that you are pregnant.

Lucy H., for example, had infrequent periods and pain with intercourse. Ovulation induction therapy had regulated her periods but she'd failed to get pregnant. When her doctor referred her to me, I performed a laparoscopy (telescopic examination of the inside of her pelvis) and discovered that she had endometriosis and that adhesions (scar tissue) encased her ovaries. Even if she had ovulated, her eggs could not have reached her fallopian tubes.

The five key elements of female fertility are:

Ovulation

Sperm-mucus interaction

Fertilization

Tubal transport

Embryo implantation

During the physical examination and fertility workup, I attempt to confirm or eliminate each of these candidates as hindrances to your fertility. Your history may point strongly to some of them. The clues I gather during the physical examination will offer additional evidence. Once I've pinpointed the areas of greatest concern, I can recommend specific tests and procedures to confirm my diagnosis. For now, though, I'd like to discuss what clues I can gather from the physical examination.

During the physical examination I look for evidence that you are ovulating, that your mucus allows sperm to reach the egg in good shape, and that the fertilized egg can successfully implant and grow in your uterus. A number of things may go wrong during this process. The sperm may not be able to journey through inhospitable cervical mucus or, having reached the egg, they may be unable to penetrate its surface. The egg may get lost in the body cavity and never find its way into the fallopian tube. Fallopian tubes, damaged by infection or trapped in adhesions, may not be capable of moving the egg toward the uterus. The growing, fertilized egg may become entangled in webs of intratubal adhesions caused by infection and develop into an ectopic pregnancy. Or the uterine lining may fail to nourish the early embryo. Once I determine where these processes are breaking down, I have a good chance of restoring your fertility.

Any woman who comes to me complaining of very heavy menstrual flow, very light menstrual flow, no menstrual flow, irregular cycles, breast discharge, or scanty or overabundant body hair growth is telling me that she may not be ovulating. This may be due to an intrinsic malfunction of her reproductive organs or hormones, or to a systemic disease causing other body chemistry problems.

During the physical examination I look for evidence of systemic disease: jaundiced (yellow) skin and eyes are indicative of liver disease; tenderness in the middle of the back and water retention (edema) may indicate kidney malfunction.

Nancy F., for example, had been trying to get pregnant for six months. When I examined her, I found that her ankles and fingers were swollen. Further tests indicated that her kidneys were not functioning well. I referred her to a kidney specialist, since once her kidney function improved, her periods would probably return to normal.

Since your liver and kidneys filter impurities from your blood (including "old" hormones), their function is vital for maintaining hormonal balance. If I find high blood pressure together with excessive body hair, I may suspect - adrenal gland abnormalities, which can affect ovarian function. (I discuss more about how we diagnose and correct these problems in the chapters on - ovulation.) I also look for other clues pointing to ovulation problems. For example, if you weigh over two hundred pounds, if you're severely underweight, or if; you have a highly developed athletic build, I may suspect a hormonal imbalance. Kathy S., who ran fifteen to twenty miles a week, had leg muscles; a man would be proud of. It didn't take much imagination to know that she was exercising to the point that she would cause ovulatory failure. (Chapter 9 explains the mechanisms for these disorders.)

When I examined Dorothy L., I found that her thyroid gland was swollen, and she appeared lethargic. Suspecting a thyroid deficiency, I ordered a thyroid hormone blood test. After she began taking a thyroid supplement, she became more energetic, had much more interest in having sex with her husband, and her periods returned to normal. Five months later she called to tell me she was pregnant.

Both hyperthyroidism (overproduction of thyroid hormone) and hypothyroidism (underproduction) may interfere with your menstrual cycle by disturbing estrogen supplies. I'll discuss more about how your hormonal system works in chapters 11, 12, and 13.

When I examined Gale P., I found that she had a translucent, white discharge from her breasts. She said that she'd had a milky discharge ever since she'd stopped nursing her toddler. I suspected she was producing excess prolactin, a hormone usually associated with nursing mothers. This hormone prevents ovulation and pregnancy so that you can give your baby the best nutrition possible. When you're trying to get pregnant, however, you don't need prolactin's birth control protection. With treatment, Gale's fertility quickly returned.

Your body build and secondary sex characteristics may provide additional clues to hormonal imbalance. Undersized breasts, scanty pubic hair, and underdeveloped hips all suggest a female hormone deficiency. An enlarged clitoris and abnormal hair growth such as a mustache may suggest excess male hormones. Rarer conditions such as ambiguous genitalia (not clearly male or female) and duplicate reproductive organs may point to genetic or enzyme defects that can interfere with ovulation. Although breast size, body conformation, and hair distribution are not conclusive evidence, they may corroborate suspicions created by other clues.

If your menstrual history and evidence from your physical examination point to ovulatory problems, I will recommend a number of tests to confirm this diagnosis. Like the detective, I need corroborative evidence to prove my case. Chapters 11 through 14 describe in detail what can cause ovulatory problems and how, with treatment, most women with ovulatory disorders can get their miracle babies.

The complexities of regulating ovulation remind me of the difficulty a musical conductor faces when combining a hundred individual performances into a symphony. Although each individual plays an important part in the production, the overall performance ultimately depends on the precise coordination of all the players. If even one instrument is unsynchronized or off-key, the delicately balanced harmony can turn into disorganized noise.

In the "ovulation symphony" harmony can be disrupted by disturbances in the menstrual cycle. Instead of an unwavering pattern repeated from month to month, infertile women frequently complain that their periods are irregular or have stopped altogether, and some women have never experienced menstrual flow. So, like the semen analysis, your menstrual history serves as a simple screening test to guide my investigations. It won't tell me precisely what the fertility problem is, but it will tell me where to look for further clues.

The critical point about this category is that your period is regular from month to month, beginning like clockwork every twenty-five days or every thirty-five days, for example. If your periods are regular, you are probably ovulating. The consistently irregular menstrual cycle, however, where one month you begin menstruating after twenty-five days, the next month after thirty-four, and the next in thirty, may indicate that you have a fertility Problem. If a woman reports a regular menstrual history, I'll usually look at other areas of the reproductive system for a breakdown in the fertility formula.

This is the most common complaint found with fertility problems, The woman's menstrual periods occur infrequently and at unpredictable intervals. Some women, like Kathy S., even report that at some point their periods stopped altogether. Because these women are capable of menstruating (as demonstrated by their history), there is a good chance that with the proper treatment ovulation and a regular menstrual cycle will resume.

Women who have never menstruated may have genetic abnormalities, congenitally deformed reproductive organs, delayed puberty, or a pituitary malfunction. If by the age of sixteen a woman has not started menstruating, she should be concerned. It is important to diagnose the problem early and to determine if such women will respond to hormonal therapy or surgical correction. The emerging new technologies offer the most promise to these people.

Ovulation is a fascinating harmony performed by several different "players" — your hypothalamus, your pituitary gland, and your ovary. Your hypothalamus maintains the hormonal "tempo" by regularly pulsing GnRH (gonadotropic-releasing hormone). These pulses stimulate your pituitary gland to produce LH (luteinizing hormone) and FSH (follicle-stimulating hormone).

Your pituitary gland plays the chorus—a pattern repeated from month to month in a beautifully precise rhythm. Each month the pituitary secretes FSH to stimulate the development and growth of over one thousand eggs. This phase in the ovulation cycle is known as the follicular phase. At puberty a woman has about half a million primitive germ cells. Only four or five hundred, however, will ever reach maturity. Due to some mysterious mechanism which we don't yet understand, usually each month only one of the thousand developing eggs becomes dominant and grows to maturity. This egg, or ovum, is cradled within the ovary in a tiny, fluid-filled capsule called the follicle.

During the follicular phase of your cycle, LH acts on the ovary's theca cells to initiate estrogen production by the granulosa cells. The estrogen makes the follicle even more responsive to FSH, which further stimulates follicular growth and development of the egg. As the follicle expands toward the surface of the ovary, the egg increases in size nearly forty times. The ovary tells the pituitary when it needs more or less FSH to finish the job of egg maturation by making a feedback hormone called inhibin (folliculostatin) .

Shortly before ovulation, the genetic material (nucleus) in the egg divides (meiosis) to half the number of chromosomes in the cell. If the egg is fertilized a second meiotic division leaves the ovum with twenty-three chromosomes—a perfect complement to the sperm's twenty-three. To form an egg, the female germinal cell divides twice, as does the male germinal cell. During female germ cell divisions, however, the "surviving" ovum jealously hoards the bulk of cellular material (nutrients) and casts off the excess genetic material (polar bodies). The egg or (if the egg is fertilized) the embryo survives on these nutrients until the embryo successfully implants in the woman's uterus.

The two critical facts I need to know about a fertility patient who is having irregular or absent periods are:

Can you menstruate?

Can you ovulate?

Once I've answered these questions, I have a good idea of what's causing your fertility problem.

I'd like to share this information with you, as well as some of the questions and concerns my patients have brought up from time to time.

Normally each month estrogen and progesterone stimulate the growth of the uterine lining. When the progesterone-producing corpus luteum deteriorates toward the end of the cycle, "progesterone withdrawal bleeding" occurs: you have a period. Waves of vasoconstriction (blood vessel spasms) restrict the blood supply to the endometrium and thus provoke the onset of menses. At the conclusion of menses, clotting factors seal off exposed bleeding sites, and resumed estrogen production begins restoring the endometrium.

Several basic tests will help determine why your periods are abnormal. Table 12-1, "Diagnostic Approaches for Irregular Menstrual Periods or Amenorrhea," which appears later in this chapter, will give you an overview of the diagnostic approaches used to determine if you are ovulating and the conditions that can interfere with ovulation and menses.

This may seem surprising, but pregnancy is the single most common reason for women reporting to me that their periods have stopped. Before I initiate any type of fertility treatment, I conduct a pregnancy test to rule out the possibility of pregnancy.

Normally the cervical mucus is thick and relatively impervious to the outer environment. Throughout the first half of the cycle, increasing amounts of estrogen produced by the ovary cause the mucus to "fern." When placed on a slide and dried, the estrogen-primed mucus crystals form a beautiful fern-like pattern. Around the time of ovulation, high estrogen levels transform the mucus into a clear, watery, viscous fluid that sperm can easily transverse. After ovulation progesterone from the corpus luteum "opposes" the action of the estrogen, and the mucus once again thickens. I use this simple test to tell me if you've ovulated during this cycle. If you have not yet ovulated, I will observe the telltale ferning. I will then perform the progesterone withdrawal test to find out if you are capable of menstruating.

Transvaginal ultrasound is a sample painless procedure that can be performed in less than 15 minutes. It provides helpful information that unlocks the clues to your ovulation problem. This picture demonstrates a 12mm "triple-line" pattern indicating normal estrogen stimulation. As your follicles develop and release estrogen, the uterine lining thickens and takes on a very specific appearance. Immediately prior to ovulation in a natural cycle, the endometrium measures 8-12mm and follicles reach 20-24mm, while if you are receiving ovulation medication follicles may be ready at 16-18mm. After ovulation, the endometrial echo (shadow) becomes more opaque (white) indicating that the corpus luteum is now making progesterone.

If your ovaries are not making estrogen the endometrium will be thinner, 6mm or less and the ovaries will usually contain either many small follicles surrounding the margin of the ovary (polycystic ovaries) or no follicles at all. This may be due to ovarian failure or abnormal hormonal stimulation. You will soon learn how I can decide which is causing your menstrual cycle problems.

The progesterone withdrawal test will confirm if your uterus is capable of menstruating. If it is, then the cause of your menstrual irregularity lies with your hormonal systems. If your uterus cannot "bleed," then the problem lies with the uterus itself.

I can bring on your period either by giving you oral progesterone over a five- or ten-day period or by giving you a progesterone injection. After taking the progesterone, your period should begin within fourteen to twenty days.

If progesterone withdrawal causes your period to start up, as it did with Kathy S., I learn a number of things.

First, I know that your ovaries are producing enough estrogen to build up your uterine lining. I also know that your uterus is capable of responding to estrogen and progesterone stimulation. Since your uterus is functioning normally, your fertility problem lies somewhere in your hormonal system.

Second, you are failing to menstruate because you are failing to ovulate. For some reason your pituitary is not producing the LH spike necessary to release the ovum from your follicle.

Two conditions must exist before your pituitary will release an LH surge: The follicles growing in your ovaries must release enough estrogen to signal your pituitary that it's time to release the LH surge-in other words, that at least one egg has reached maturity. And your pituitary gland must be capable of generating the LH spike.

I may suspect that your hypothalamus just isn't prodding your pituitary well enough. If your follicles do not grow to maturity, you'll never produce enough estrogen to trigger the LH spike to release the egg and thus ovulate. A pituitary malfunction can cause the same problem; however, in Kathy's case, I suspected a hypothalamic insufficiency from excess running.

"How can you be sure?" Kathy asked.

"Well, that's exactly what my next series of tests will show. I want to make sure that other systems in your body are not adversely affecting your hormonal system."

Like Kathy, most women will "bleed" in response to progesterone withdrawal. However, if you don't, it's possible that your estrogen supply is not adequate to stimulate uterine lining growth. If your uterus is normal, taking estrogen to prime the growth of the uterine lining should guarantee that you'll have a period after progesterone withdrawal. So we'll try it again-this time giving you estrogen before the progesterone, just to be sure.

If the estrogen/progesterone-stimulated cycle fails to produce a "bleed," it means that your uterus cannot respond to estrogen and progesterone stimulation: we've pinpointed your uterus as the problem. My next step will be to examine the inside of your uterus. (I'll discuss uterine abnormalities, hysteroscopy, saline sonohysterography, D&C, and uterine X-ray procedures in chapters 16 and 19.)

When you have a period after taking estrogen and progesterone, I know that your uterus is capable of menstruating. The reason you have not been menstruating is that your ovaries are not producing adequate amounts of estrogen. At this stage in the diagnostic procedures we don't know for certain why your ovaries are not producing estrogen, but several possibilities exist:

Your ovaries are not capable of producing estrogen,

Your hypothalamus is not stimulating your pituitary to release FSH and LH, which control follicular development and estrogen production,

Your pituitary is unable to produce adequate amounts of LH and FSH,

Other hormonal imbalances are tricking your pituitary into "thinking" that it's doing a good job when, in fact, it is not.

Since estrogen stimulation is vital for the growth of the uterine lining, I will measure your estrogen hormone levels to confirm this diagnosis before venturing into new diagnostic territories. I'll may also do a cytology smear to look at estrogen stimulation of your vaginal cells. In addition, I'll measure your FSH level to rule out ovarian failure. (A high FSH level indicates that the ovaries have been severely damaged or have run out of eggs.)

Ovarian failure occurs when your ovaries are severely damaged or when they run out of eggs. When this happens, your pituitary gland tries to force your ovary to manufacture estrogen and to ovulate by working overtime to produce FSH. The pituitary gland's signals fall on deaf ears, though, because the damaged ovaries cannot respond to the extra FSH stimulation.

Ovarian failure may be caused by a number of conditions including infection, chemical toxins, medications, radiation exposure, tumor, surgery, immunologic dysfunction and genetic abnormalities. Unfortunately ovarian failure is rarely reversible. However, ovarian failure due to infection or endometriosis will sometimes respond to treatment. Since a diagnosis of ovarian failure can be distressing, I always repeat the FSH test before recommending donor eggs or other alternatives.

Nothing is quite as distressing as being "different." And not having your first period by the time you are sixteen (primary amenorrhea) falls into this category, especially if you have not developed breasts and pubic hair as your friends have. I'm told that the girls' locker room can be just as intimidating as the boys'.

However, delayed puberty is only one aspect of this menstrual disorder. Many other factors ranging from anatomical abnormalities to genetic defects can prevent the onset of menses.

It's quite likely that if you have never menstruated, you've already consulted with your physician about which of the four categories of primary amenorrhea you fall into. You may, however, be unaware of some of the new options you may have for bearing your "own" child. The road to your "happy ending" will depend on which of the four categories you fall into:

Women who have a normal uterus and ovaries: If your reproductive organs are normal, you have a hormonal problem which developed prior to your going through puberty: empty sella syndrome, pituitary tumor, adrenal tumor, polycystic ovarian disease, and so forth.

In some rare cases your problem may stem from an anatomical abnormality: you may have been born with an imperforate hymen (closed vagina); with cervical stenosis (closed cervix) or without a vagina. These problems affect about 40 percent of women with primary amenorrhea.

Women who have a normal uterus with nonfunctional ovaries: You may have a normal uterus, but have ovaries that do not contain any eggs (germinal cells). These problems affect about 30 percent of women with primary amenorrhea.

Women who have a nonfunctional uterus with functional ovaries: You may have normal ovaries and a nonfunctional uterus. These problems affect about 20 percent of women with primary amenorrhea.

Women who have no uterus and no ovaries: You may have no ovaries and no uterus. These problems affect about 10 percent of women with primary amenorrhea.

If your reproductive organs are normal, but hormonal problems are keeping you from menstruating, the treatments for hormonal imbalances outlined in chapter 12 will probably restore your fertility. Should your hymen or cervix be closed to the outside, a minor surgical procedure will open them to allow menstrual flow. If you were born without a vagina but have a normal uterus, hysterectomy will usually be necessary to prevent a painful buildup of menstrual blood that can destroy the uterus. Your ovaries will not be removed and will enable you to use in vitro techniques to harvest your eggs and fertilize them with your husband's sperm. Pre-embryos will then be transferred to a gestational surrogate who can carry the pregnancy.

If you have a normal uterus and nonfunctional ovaries, your FSH will be elevated, indicating that your pituitary is working overtime to stimulate follicular development. This may be because you were born without any eggs (Turner's syndrome) or because, due to an enzyme defect, your ovary cannot respond to FSH stimulation (resistant ovary syndrome). I can confirm that you have a normal uterus with an X ray (Hysterosalpingogram).

Even though your chance for having a baby seems hopeless, studies indicate that with the proper hormonal supplement, you should be able to nurture a donor embryo in your womb.

Joe and Toni H. decided to use donor eggs to achieve a pregnancy. They used Joe's sperm to fertilize the eggs retrieved from a donor who remained anonymous. I transferred three embryos to Toni's uterus after providing the necessary hormones. After a few weeks of pregnancy, her placenta provided all the necessary hormones. You may wish to read more about donor embryo transfers in chapter 21.

If you have normally functioning ovaries, you can have your own baby. One particular couple comes to mind: Gary and Bridgette D. Although her ovaries were perfectly normal, Bridgette's uterus had not developed properly. Gary and Bridgette decided traveled to Pennsylvania to undergo in vitro fertilization. Her sister agreed to carry the pregnancy and had three of the pre-embryos transferred to her uterus. Three weeks after the second try, they received a call telling them that they had made a miracle baby.

With in vitro fertilization techniques a doctor can surgically retrieve (harvest) your eggs, mix them in a petri dish (in vitro) with your husband's sperm, and transfer your living embryo to a surrogate mother's womb for gestation. Nine months later you can take home your own baby for a lifetime of joy.

Although these medical techniques are feasible today, many unanswered legal and ethical questions have been preventing widespread use. I suggest you read chapter 21 for the legal and moral issues associated with embryo transfers and surrogate mothers.

If you have no uterus and no ovaries, you have several options for having a child. You cannot have a child genetically related to you, because you have no eggs to pass on your genes. A surrogate mother, however, can offer you the opportunity for having a baby who is genetically related to your husband. Using artificial insemination techniques, your husband can father the child and you can adopt it from the surrogate mother. If you are interested in pursuing this type of arrangement, I suggest you read the information on surrogate mothers in chapter 21.

Another option you may wish to consider is adoption. Once they receive their "chosen" baby, many couples who suffer through years of unsuccessful infertility treatment often wonder why they waited so long before choosing adoption. Adoption can be a very satisfying happy ending.

Most women with primary amenorrhea can be helped. Women with hormonal imbalances can have them corrected; women with eggs and no uterus can "hire" a gestational surrogate; women with a womb and no eggs can give birth using donor oocytes; and women with no reproductive organs can consider a surrogate mother relationship. With the aid of "miracle medicine," nearly all of the women with primary amenorrhea can look forward to a happy ending.

In this chapter I'd like to reveal how we use the newest technologies to overcome ovulatory problems. With the use of ultrasound monitoring and "instant'' hormone assays, ovulation induction has become a science instead of a shot in the dark as it once was. The medications and monitoring techniques work so well that when you fail to get pregnant, I must suspect some other interfering and perhaps undiagnosed condition.

Individualized treatment is far more effective than a preset regimen. Because of this, it is difficult for me to say, for example, that you will be given a certain dosage for so many months and then double that dosage for a certain number of months and so forth. Your doctor will determine the best course of treatment based on your unique response to the medication. I can only share with you what I do, and help you to understand my reasoning. With this knowledge you will be better equipped to understand what your doctor does and to ask questions about your particular situation.

The minimum prerequisites for ovulation induction therapy are the same as those for fertility. The woman needs one open (patent) fallopian tube and an ovary that is able to produce mature eggs. To ensure the best possible response to the medication, all other fertility problems such as abnormal day 3 FSH or clomiphene challenge test, excess prolactin levels, endometriosis, uterine abnormalities, and inadequate sperm should be ruled out.

The progesterone withdrawal test will determine which ovulation induction regimen will work best for you: Clomid, Serophene (clomiphene citrate), Pergonal (human menopausal gonadotropin), or a relatively new treatment option, GnRH (gonadotropin-releasing hormone). Think for a moment about what the progesterone withdrawal test reveals.

If you menstruate in response to the test, your pituitary is stimulating your ovaries to make some estrogen. In order to do this, both your hypothalamus and pituitary gland must be intact and working-at least to some extent. So by prescribing Serophene I can trick your hypothalamus and pituitary into making more LH and FSH, which will "kick" your ovaries into high gear. About 20 percent of women treated with Serophene will not ovulate. They may respond, however, to a combination of Serophene and Metrodin treatment, which I'll describe later in this chapter.

If progesterone withdrawal does not cause you to have a period, I suspect a uterine abnormality or that your hypothalamus and/or pituitary cannot stimulate your ovaries to make estrogen. Once I've eliminated uterine abnormalities as your problem, you become a candidate for gonadotropin hormone replacement therapy with GnRH or Humegon/Pergonal (LH and FSH) or Metrodin (FSH). Women with low estrogen production (hypoestrogenic) respond best to gonadotropin treatment: about two thirds of them will conceive.

Women with a functional pituitary may respond to GnRH. Studies suggest that using GnRH to stimulate a "natural'' pituitary hormone release may improve results as well as reduce the number of adverse side effects associated with Serophene and gonadotropin injections-hostile mucus and multiple births' for example. I'll discuss more about this technique later in this chapter.

Clomiphene citrate is available in two popular brand-name medications Serophene and Clomid. For the sake of simplicity, throughout this discussion I'll refer to either of these medications as clomiphene.

Clomiphene is indicated for the woman who withdraws to progesterone and thus demonstrates an intact hypothalamus and pituitary gland. Clomiphene works by stopping up the estrogen receptors on the hypothalamus and the tricking the hypothalamus into thinking that you don't have enough estrogen In response, the hypothalamus "beats the drum'' harder and your pituitary gland produces more FSH (follicle-stimulating hormone) and LH (luteinizing hormone) which initiate follicular growth.

The exact procedure for clomiphene treatment will differ from one couple another. Kathy and Stephen S. had a bumpy but fairly typical experience.

"Dr. Perloe, before we get started could you tell me exactly how all of this is going to work?" Kathy asked.

"Sure.'' I handed her the clomiphene prescription. "Before you leave I'll give you Provera pills to start your period. In less than a week or two your period should start. If it doesn't, please call me. On the third day of your cycle I want you to begin taking 50 milligrams of clomiphene-that's one pill each day for five consecutive days.

Kathy tucked the prescription into her purse. "How does clomiphene make me ovulate?"

"As your follicles develop, they release estrogen into your bloodstream. Normally this estrogen would tell your hypothalamus to slow down. Clomiphene, though, is masking the presence of the estrogen. Thinking, that your ovary isn't working at peak efficiency, you will continue to stimulate the growth of the follicles in your ovaries. Giving your follicles this extra boost for a few days will help them grow to maturity. When your estrogen level peaks a week or so after you stop taking the clomiphene, your pituitary gland should release a large dose of LH to free your egg from the follicle."

"Do I need any blood tests", Kathy asked.

"After you take clomiphene for the first time, I like to check the LH and FSH blood levels a few days after clomiphene. In some women, clomiphene brings about an increase in LH but very little FSH increase. Or the FSH level may be very high. Both of these situations mean pregnancy may be less likely and we'll need to discuss your options before proceeding."

"When should we have sex?" she asked.

"You should ovulate around cycle days 13 to 16. Four days after finishing the clomiphene, you can begin testing for the LH surge by using a simple urine test kit. You don't want to start checking too soon, because clomiphene causes a rise in LH which may show up on the urine test. So if you test too early you may think you are ovulating, but, in fact you may not be ready for a few more days." Call me around cycle day 16 if you have not seen a urinary LH surge. We can check an ultrasound to see if you have developed follicles and the uterine lining is ready. If so, an hCG injection can trigger ovulation. If the follicles are still small, we will increase your dose next month. If you ovulate, I will recommend that you try at least three months. If it doesn't work by then, we may choose to add hCG injections and inseminations to try and improve the pregnancy rate.

I showed her to my office door. "Now, don't get discouraged if you don't ovulate the first month. It may take several cycles to find the right dosage for you. "Thank you, Dr. Perloe, I'll see you in a few weeks. Wish us luck.''

"You've got it."

About a month later Kathy called to say that the progesterone had brought on her period and she had taken the clomiphene, her cycle day 9 LH and FSH were fine, but her urinary LH surge kit never changed colors. It appeared that she had not ovulated. I asked her to come in for an ultrasound.

"Did I ovulate?"

"Well' I'm not sure we've made that much progress. But anything is possible. I also want to do an ultrasound examination to let me look at your ovaries to see the size and number of your follicles. That will tell us if the clomiphene is doing its job.''

I picked up the smooth vaginal ultrasound wand (transducer) and gently placed it into Kathy's vagina. "Ultrasound works by bouncing sound waves off your internal organs. We use sound waves because they don't expose you to radiation.

"You won't feel a thing except me pushing against your bladder and the top of the vagina.'' I centered the probe over her right ovary. "This will produce a TV picture that shows me how many follicles you're developing and what size they are."

"There it is-a follicle 10 millimeters in diameter. Let's try the other side.''

When I saw just two small follicles on vaginal ultrasound, I recommended a progesterone shot so we could try again at 100 mg.

"When your next period starts, I want you to increase your dose to two tablets a day."

"Do you think the clomiphene is going to work?", Kathy asked.

"Remember, I told you that it may take several cycles to fine-tune your dosage. If the 100-milligram dosage fails, we may decide to add a few days of Metrodin injections.''

A few weeks later, after trying two clomiphene tablets (100 mg) for five days, Kathy called and told me that her BBT chart was still "flatter than a pancake'' and her LH stick still hadn't changed. She seemed a bit discouraged, but I assured her this wasn't unusual.

I recommended that she come in for another ultrasound and asked her to stop by my office for a few minutes to talk.

"You think this will be the month I'll get pregnant?"

I positioned the wand over her left ovary, and to my delight I found an 19 mm and 20 mm follicle and a thickened midcycle uterine lining measuring 12 mm.

"Kathy, you should be having an LH spike any moment. I want you to continue testing your urine each morning. When you've had a surge, we can schedule a postcoital examination for the next morning. We need to know whether or not clomiphene is adversely affecting the quality of your cervical mucus. But, if you do not have an LH surge by Monday, I want you to have intercourse Monday night and come to the office Tuesday for a postcoital test and to give you an hCG injection. This medication should free your egg within forty-two to forty-eight hours.''

Monday morning she called to say that she had not surged and would come in for the postcoital test and the hCG injection. When I did the postcoital examination, I found that Kathy's mucus was scant and very thick. I can't say I was too surprised, since nearly half of the women on clomiphene therapy suffer from mucus problems.

I explained that if she did not conceive this month, I suggested that they try intrauterine artificial insemination (IUI) with Steven's sperm. She said that she and Steven had discussed IUI and that it was all right with both of them.

Kathy returned four days later for an ultrasound and a progesterone blood test to confirm that she'd ovulated. I was happy to report that I saw a large corpus luteum.

Unfortunately, she did not conceive.

"Don't be discouraged"' I told them. "Nearly one-third of all women taking this treatment have a poor postcoital test and many get pregnant with insemination. We'll check Kathy's ovaries and then give you another clomiphene prescription for next month. Go ahead and use the urinary LH test again. I believe we'll still have to give Kathy an hCG injection before she'll ovulate, but there's no sense in giving the hCG injection if she has an LH spike on her own. We may need to repeat the ultrasound just before midcycle because the hCG must be given at exactly the right time or it won't work.

"I believe we have most of your problems under control." I leaned against the counter. "You know, it's discouraging for me, too, when a new problem shows up in each cycle. But if you look at it as tackling one problem at a time, it makes solving your fertility problem manageable. The only thing I'm still concerned about is Kathy's cervical mucus, you may want to try artificial insemination.''

The next month she repeated the procedure: 100 mg of clomiphene for five days, urinary LH test strips to detect the LH surge, ultrasound examinations until a mature follicle developed, an hCG injection to stimulate ovulation, and an intrauterine insemination. We began monitoring the development of a 16 mm follicle. When it reached 20 mm, I gave her hCG and told her to bring Steven with her the next day for IUI.

"Before this is over, you are going to know as much about this process as I do." I laughed.

The inseminations went well, and her BBT rise confirmed that she had ovulated and that the corpus luteum had formed. Now all we had to do was wait. If her BBT stayed up and her period did not start, we'd know she was pregnant.

I guess it wasn't meant to happen-not that month, anyway. Kathy called a couple of weeks later to tell me that her period had started.

"Don't worry,'' I said. "We've got you on the right routine now and it's only a matter of time. It may take three or four normal cycles before we make that baby. If you are not pregnant after finishing three cycles we need to review all your options."

Each month I could tell that it was becoming harder for them to keep up their optimism. I assured them that Kathy's cycles were working fine on this regimen and that it was only a matter of time. Three weeks after their third IAIH she called me. "Dr. Perloe, I think we did it. My period is four days late."

Sure enough, that month, Steven and Kathy started Jamie!

"When my doctor did our postcoital test, she said Larry's sperm were dead," Kelly M. told the RESOLVE group. "She also found some white blood cells. She thought one or both of us might have an infection, so she ordered cultures on my cervical mucus and Larry's semen. She also ran some tests to see if we had sperm antibodies,"

"What did she find out?," the support group leader asked.

"Well Larry's sperm survived in donor mucus. And donor sperm survived in my mucus.''

"Then what was killing Larry's sperm in your mucus?'' a woman asked.

"The cultures didn't show infection, so she said it was antibodies," Kelly M. said. ."My doctor told me that I was rejecting Larry's sperm just like I might reject a kidney transplant."

"What can you do about it?" her friend asked.

"Several things", Kelly answered. "First, we want to try washing Larry's sperm and using intrauterine insemination. If we can get around my mucus, we may be able to get around the antibody problem."

Kelly and Larry M. belong to a special group of infertile couples whose problem we are just beginning to understand and resolve. I'm very excited about the fertility research taking place in the field of immunology. Antibodies, however, are only one reason why cervical mucus may be hostile to sperm. Other mucus problems may also impair their journey to the egg.

Acting as the gateway between the vagina and the uterus, the cervix secretes a thick, impermeable mucus to plug the canal. Normally this "hostile" mucus protects the woman's reproductive tract from invading organisms and foreign particles. At the time of ovulation, however, the mucus transforms into a "friendly" path through which sperm can travel in safety. Under the influence of estrogen the thick and sticky mucus becomes clear and stringy. Like lanes in an Olympic swimming pool, tiny tubular paths form to guide the sperm toward the uterus.

When the mucus fails to become "friendly" as it does with 5 to 10 percent of all infertile women, the sperm cannot safely begin their journey toward the egg. The hostile mucus, as it is called, will either block the sperm's passage or will damage the sperm so severely that they can no longer function. The aim of fertility treatment is to restore the quality of the mucus so it can:

Facilitate or interfere with sperm transport at appropriate times of the month

Protect the sperm from the acidic vaginal environment

Preserve the sperm in the cervical canal and release them in a steady stream over a period of time

Filter out abnormal sperm

Protect the sperm from white blood cells which may destroy them as they would invading microorganisms

Provide nutrients to the sperm

Prevent bacterial contamination of the uterus

The postcoital test is the primary tool for diagnosing cervical mucus problems. Performed at the time of ovulation, it assesses mucus quality. When I examine the cervical mucus approximately 8 to 12 hours after intercourse, I look for three things:

If the husband delivered good quantities of sperm to the cervix

If the sperm are swimming vigorously through the mucus

If white blood cells are present, indicating an infection in either partner

If the results of the test are good, I don't worry about the mucus being a fertility problem. If the results are poor, I know that a mucus interaction problem exists or that the test was performed at the wrong time in the cycle (the most common reason for a poor postcoital test). The best way to insure that the test is performed at the correct time is to plan intercourse with a urine LH test kit. Since we can predict ovulation more accurately than we could when only the BBT chart was available, we are less likely to get poor results from poor timing.

A number of factors can cause an abnormal postcoital test:

Infection in either partner (indicated by white blood cells in the mucus)

Sperm antibodies produced by either partner will cause the sperm to die, to agglutinate (clump together), and/or to shake.

Abnormal mucus quality: High-viscosity and/or low-volume mucus can block sperm.

Abnormal semen: Sperm antibodies produced by the man as well as infections in the man can adversely affect test results, as can a low sperm count and poor motility.

Poor coital technique or ejaculation disorders can also prevent the sperm from reaching the cervix.

Infectious organisms in either partner may kill or maim sperm. I suspect an infection if I find dead sperm, white blood cells, and/or cellular debris in the postcoital specimen. Specific microorganisms can often be identified by performing a culture of the cervical mucus but, often I more it more cost effective to initially treat each couple with a short course of antibiotics. In the presence of white blood cells, however, I may prescribe an antibiotic even if the culture comes back negative.

Both partners must be treated to ensure that they are not passing the disease back and forth. The semen and mucus cultures for Dan and Marie C., for example, revealed the presence of chlamydia. I prescribed an antibiotic (doxycycline) for both of them. To avoid exposing an early pregnancy to antibiotics, Marie took the medication during the ten days following the start of her menses.

If I continued to find white blood cells in Marie's mucus, I would try to isolate the problem. To make sure Dan was not depositing white blood cells with his sperm, I would ask them to abstain from sex until just before their next postcoital. A normal semen analysis and the presence of the white blood cells only immediately following intercourse would tell me Marie was producing them in response to Dan's semen, which could indicate a sperm antibody problem. I was relieved when I found Marie's mucus free of white blood cells after antibiotic therapy.

If treating an infection with antibiotics restores a normal post coital test, up to 42 percent of the couples treated will conceive within three months, and 84 percent within one year.

Normally antibodies attack foreign substances invading your body. For some unknown reason, however, 4 percent of all men produce antibodies against their own sperm. (The incidence of this autoimmunity increases from 4 percent to 50 to 60 percent in men with vasectomies. The sperm antibodies are probably a protective mechanism to help get rid of millions of unused, trapped sperm.) The effects of antisperm antibodies will usually show up in the semen analysis: the sperm may clump together (agglutinate) or shake in random motions.

Sperm antibodies are also found in the cervical mucus of 30 percent of women with unexplained infertility problems. If a fairly recent semen analysis shows that unexposed sperm have normal forward motility, but the postcoital test shows them shaking or clumping, I'll suspect that the woman is the source of the sperm antibodies.

A sperm-mucus cross test will help me understand the exact nature of a couple's sperm antibody problem.

John and Leslie P. were referred to me after four years of unexplained infertility. John's semen analysis was normal and their cultures were negative. When their family doctor did a postcoital, however, he found dead sperm. Since they used a urinary LH test kit to predict ovulation, I knew they had timed the test perfectly. The couple obviously had a sperm-mucus interaction problem.

If I suspect an antibody problem, I can order special tests to look for antibodies in the woman's blood, cervical mucus, and attached to sperm using an immunobead sperm test.

When the sperm from the man are antibody-bound, they can achieve only a 15.3 percent pregnancy rate. Sometimes, though, we can reduce the adverse effects of the antibodies by having the man ejaculate into a nutrient liquid, washing the semen from the sperm and using them for intrauterine insemination. When washing restores function to more than half of the sperm, we can achieve a 66.7 percent pregnancy rate.

IUI may also be helpful for women producing sperm antibodies. This is what John and Leslie P. decided to try. By washing John's sperm and injecting them directly into Leslie's uterus, we gave his sperm a head start against her hostile mucus. I cautioned them, however, that since Leslie's antibodies could be anywhere in her genital tract, IUI might not work. Moreover, women with sperm antibodies are twice as likely to have a spontaneous abortion. If IUI didn't work, they might want to consider in vitro fertilization.

Although a sensitive pregnancy test showed a pregnancy after the second insemination, Leslie's period started a week later. I was sorry to tell them that she had probably aborted. They were not discouraged; in fact, they were elated. Now they knew that John's sperm could swim to her egg and fertilize it. Undaunted, they continued with IUI two months later Leslie's period was late again. We didn't know whether or not to celebrate because she wasn't out of the woods yet-and wouldn't be for a few months. We all sighed a breath of relief when she entered her second trimester with Mom and baby doing well-Dad too. Now they have a red-haired, green-eyed baby girl who's made them forget they ever had a fertility problem.

Use of condoms during intercourse for a prolonged period of time may reduce the level of the woman's antibodies to the extent that the sperm will not be affected. The woman must avoid all contact with the man's sperm for three to six months; this includes oral sex as well as skin contact. (If the man is producing antibodies to his own sperm, however, condom therapy will not work.) Many people do not want to go this time-consuming route and will elect to use IUI instead. This method was more popular prior to availability of IUI and has fallen out of favor because it is less successful.

Experimental therapy with high-dose steroids for men with antisperm antibodies appears to produce a 30 to 40 percent pregnancy rate. Although few studies have been done with women producing sperm antibodies, steroid therapy may prove to be more effective than condom therapy. In addition, suppressing the antibodies may diminish the spontaneous-abortion risk. However, this therapy is not without risk. High dose steroids result in loss of calcium from the bones. There have been cases reported where steroids used to treat infertility have resulted in hip fractures requiring hip replacement surgery. At this time, I fell that the risk of this therapy is too great to warrant its routine use.

By washing antibodies from the sperm and fertilizing the woman's egg outside her body through in vitro, we can avoid exposure to antibodies in the semen and in the mucus. Before attempting in vitro fertilization, a hamster penetration test should be performed on the man's sperm to ensure that once they are treated they will be able to fertilize an egg.

Since sperm antibodies produced by the man or woman are associated with a high spontaneous-abortion rate (50 percent), many couples may wish to try IAIH first. IAIH is much less demanding on the couple and quite a bit less expensive More research is needed before in vitro can be considered a viable option for resolving sperm antibody problems.

Mucus viscosity and volume abnormalities may be caused by surgical procedures performed on the cervix, by in utero DES exposure, and by clomiphene citrate ovulation induction treatment. About 40 percent of the time a low-dose estrogen supplement will improve mucus volume and viscosity. However, I generally recommend IUI to bypass the mucus problem as the result is more predictable.

Women suffering from cervical stenosis (scars sealing the cervix) may respond to gradual dilation and estrogen therapy. Ejaculation Disturbances or Poor Coital Technique

When the semen is poor or when the coital technique does not provide an adequate supply of sperm to the cervix, the postcoital test may appear abnormal, even though neither of these abnormalities represents a sperm mucus interaction problem. Artificial insemination with the husband's sperm and/or counseling on coital techniques may be helpful in overcoming these problems.

Immediately before ejaculation, a muscle at the opening to the bladder constricts so that sperm rushing from the ejaculatory ducts are forced out through the penis and not back into the bladder. Occasionally diabetics or men with neurologic disorders and men who have undergone prostate surgery may have difficulty constricting that muscle. At the time of ejaculation, the semen spurts into the bladder rather than out the penis. I will suspect this if the amount of semen is very low. I can check for this by testing a urine sample immediately after ejaculation. If I find sperm in the urine, I know retrograde ejaculation is the problem.

Although urine is normally toxic, we can often collect a good sperm sample for intrauterine insemination by draining the bladder and instilling a small amount of nutrient media into the bladder. I will ask the man to empty his bladder immediately after ejaculation and will often retrieve healthy sperm for insemination. When coupled with ovulation induction medication, intrauterine insemination can often be successful. If this fails, a specimen can be retrieved as mentioned above and used for in vitro fertilization or intracytoplasmic sperm injection. But more about that in Chapter 21.

The sperm's journey from your vagina to the egg through your fallopian tube is fraught with peril. Only a hundred or so will survive to encounter this precious genetic package, provided your egg can pass into and through your fallopian tube. Unfortunately tubal problems are the most common cause of infertility. In the next chapter you'll learn what can cause tubal problems and what you can do to correct them.

"I've had abnormal and painful periods ever since I went through puberty, "Carrie Y. told the support group. "To stop bleeding all of the time, I had to go on the Pill when I was fifteen. The doctor told my mother that I wasn't ovulating and might never conceive.

"I lost my virginity on the operating table. I can't even remember how many D&Cs I had before I was twenty-five."

"Did you cramp a lot?" one member asked.

"Yes, but I thought everyone cramped and that having pain with your periods was normal. The pain eventually got so bad that when I was in my early twenties, I had to stay home during the first two days of my period. I learned later that discomfort from normal periods shouldn't interfere with your daily routines. But since I never knew any differently, all of those years I didn't question it." She paused. "Not until that awful day. My husband and I had decided to try to have a baby. I'd been taking clomiphene for several months, to get me to ovulate, and my period was a week late. That wasn't anything unusual, since my periods were frequently forty to fifty days apart. But I'd been regular since I'd been on clomiphene. When my basal body temperature stayed up that week, we both became pretty excited. After two years of trying, I was sure I was pregnant.

"But that morning at work I had terrible cramps, like I needed to have a bowel movement. The pain in my side was so bad that I had to go home. Later that afternoon I did go to the bathroom and the pain stopped. But not for long. It became so severe that I thought I was going to pass out. I called the doctor. I cried all the way to the hospital.

"After running some tests, he told me that I had either appendicitis or a tubal pregnancy. I'd begun to spot, so I was afraid I was losing a baby. He had me stay at the hospital overnight.

"The next morning I was weak but I felt better. Since they'd found some blood in my urine, the doctor thought I was passing a kidney stone. And he sent me home.

"The pain continued and the bleeding got worse, so I went back to the hospital and had a D&C. The doctor didn't think I was pregnant because he couldn't find any tissue in the material he removed.

"When I returned home, the pain in my right side was gone, but I was bleeding like a leaky faucet. I knew it wasn't right. I was a D&C expert by then. Another thing that puzzled me was that my breasts were still swollen and tender. But when I called the doctor, he didn't seem very concerned. He just said, 'You can expect some bleeding after a D&C.'

"Even though the bleeding continued, I returned to work. In the middle of the morning, searing pain doubled me over. My secretary rushed me to the hospital. I had an ectopic pregnancy and had lost a quart of blood. That wasn't all I could have lost. I nearly lost my right tube and ovary."

The group was quiet.

"What caused it?" a voice asked from the back row.

"When they did my laparoscopy, they found out that I have endometriosis. That's probably why my periods were screwed up. The doctor said that my adhesions were so thick he could hardly find my tubes."

"What did you do?" a woman asked.

"First of all, I changed doctors. After all I'd been through, I'd lost faith in him. My new doctor is performing a laparoscopy next week. He believes he can clean out the adhesions and endometriosis and possibly restore my tubes to normal. We'll know more after the surgery."

Tubal problems are the leading cause of female fertility problems. With the tremendous increase in PID and sexually transmitted infections, and with the increased incidence of endometriosis, tubal problems account for half of female infertility.

What Causes Tubal Problems?

A number of different problems can impair fallopian tube function:

Abdominal adhesions and scar tissue that immobilize fallopian tubes

Adhesions and scar tissue that prevent the egg from entering the tube and

traveling toward the uterus

Damage from an ectopic pregnancy or sterilization surgery

 

These problems can be caused by a variety of events:

Ruptured appendix

Pelvic inflammatory disease (PID)

Gynecologic surgery

Postpartum infection

In utero DES exposure

Salpingitis isthmica nodosa

Endometriosis

Cesarean section

Bowel surgery

Ectopic pregnancy

Tuberculosis (genital)

When infection and disease attack delicate tubal structures, the tubes may become deformed and cease to function. Trapped in adhesions and scar tissue, they can no longer retrieve the egg and coax it toward the uterus. Infection and damage from ectopic pregnancy may strip the vital ciliated lining from the inner walls. When this happens, sperm cannot meet egg, and fertilization cannot occur. If the tubes are obstructed only partially, sperm may be able to meet egg, but the developing embryo can become trapped inside the tube and cause a painful and even life-threatening ectopic pregnancy.

The PID epidemic alone is claiming the fertility of hundreds of thousands of women each year. Up to 60% of women who have antibodies to chlamydia are unaware that they ever had an infection will this stealthy invader that can destroy your fallopian tubes and rob your fertility without the slightest hint. Fortunately microsurgery, laser surgery, and in vitro fertilization techniques can restore fertility to many of those victims.

The fallopian tube is an active, muscular organ that retrieves the egg from the ovary and coaxes it toward the oncoming sperm. If adhesions restrict the tube's mobility or if infection has stripped the tiny cilia from the tubal lining the tube cannot perform its vital job. The various tests I use will help me determine if:

The tubes are open (patent)

The fimbria are open and free to grasp the ovary

The tubes are free from adhesions so they can move

The inner lining of tiny hairs (cilia) is intact

 

I can evaluate tubal performance by tubal X ray (hysterosalpingogram), sonohysterosgraphy (an ultrasound test), laparoscopy (telescopic look into the abdomen), and tuboscopy (telescopic look inside the tubes).

"When we had sex on our wedding night, instead of having an ultimate experience with my husband, sex was so painful I ended up in tears," Marilyn P. wrote to her Witsendo friends. "I thought something was wrong with me . . .that I was frigid or something.

"When I went to the doctor, I told him I'd always had some pain with my periods but that my cramps were getting worse.

"He did a pelvic exam and I screamed when he touched my left ovary. After doing an ultrasound examination, he told me that my left ovary was swollen to twice its normal size. He also felt small bumps behind my uterus. He recommended doing a laparoscopy to find out what was going on.

"That's when I got the news: endometriosis at the ripe old age of twenty-three, and that I had probably had endometriosis as a teenager! What a way to start married life."

Endometriosis is described as the presence of endometrial tissue in locations outside the endometrial (uterine) cavity. Endometriosis is commonly found in the cul-de-sac (behind the uterus), the rectovaginal septum (the tissue between the rectum and vagina), on the surface of the rectum, the fallopian tubes and ovaries, the uterosacral ligaments, the bladder, and the pelvic side wall. Generally endometriosis in the rectovaginal septum is more likely to deeply invade the underlying structures.

Studies have shown that sisters have a six times increased risk compared to their husband's sisters. Other studies show up to an eight times increased risk when compared to other women. Affected sisters are more likely to have severe disease than other. Although these studies suggest a genetic basis, presently, the mode of inheritance is unknown. The OXEGENE Study is enrolling family members with endometriosis to try and identify the genetic basis of this disease.

At the time of tubal ligation 2-5% of women will have endometriosis, while between 25-50% of infertile women have been reported to have endometriosis. Endometriosis affects 5 million U.S. women, approximately 6-7% of all females, 30-40% of whom are infertile.

No one theory seems to explain all cases. Several theories, however, have been postulated:

The endometrial tissue migrates from the uterus through the tubes into the pelvis. (This doesn't explain how women with their tubes tied develop the disease or why it remains after hysterectomy.)

An abnormality in the immune system allows normally shed endometrial cells to attach and grow.

The disease is caused by a genetic birth defect as evidenced by the tendency for it to run in families. Patients with an affected mother or siblings are more likely (61 percent) to have severe endometriosis than those without affected relatives (23 percent).

Tissue in the abdominal cavity changes into endometrial tissue as a result of repeated inflammation (sheer speculation at this point).

The endometrial tissue spreads from the uterus to the abdominal cavity through the lymphatic system or bloodstream.

Commonly during the menstrual period, cells can be found in the fluid behind the uterus. The most widely held theory, retrograde menstruation, states that endometriosis occurs when endometrial fragments attach to nearby pelvic structures and grow. Other theories include tissue transplantation, induction of changes in peritoneal lining cells, spread through uterine veins, and direct extension through the lymphatic system.

As endometrial cells are frequently seen in peritoneal fluid in all women at the time of menses, one would expect endometriosis to develop in everyone. Obviously this is not appear the case. Unfortunately, we don't really know why. Is the immune system the cause? Immunological changes have been demonstrated in women with endometriosis, however, it is uncertain whether these immunologic findings are responsible for the endometriosis or are a result of the inflammation caused by endometriosis.

In cases where there is obvious disruption of the normal anatomy, endometriosis is a known cause of fertility problems. In fact 30-40% of patients with endometriosis are infertile. This is two to three times the rate of infertility in the general population.

In patients with endometriosis, the monthly fecundity (chance of getting pregnant) decreases by 12-36%. However, the long term cumulative pregnancy rates are normal in patients with minimal endometriosis and normal anatomy. Studies provide contradicting information, but the bulk of research at this time indicates that pregnancy rates are not improved by treating minimal endometriosis.

Under the influence of cycling female hormones, each month the displaced endometrial tissue grows and sheds blood at the time of menses. Instead of flowing harmlessly outside the body, however, the excrement wreaks havoc in the abdominal cavity.

The resulting chronic tissue inflammation leads to the formation of adhesions and scars, which surround and entrap delicate reproductive organs. The adhesions can be so extensive that they literally freeze the tubes, ovaries, and uterus into place (stages III and IV). The eggs themselves are trapped in the heavy shrouds of scar tissue surrounding the ovaries, and infertility results. As the disease spreads, the older endometrial cells burn out, leaving dead scar tissue in their wake.

Even mild forms of the disease (stages I and II) may interfere with fertility. It is hypothesized that the prostaglandins (hormones) secreted by the active, young endometrial implants or other chemicals secreted by white blood cells may interfere with the reproductive organs by causing muscular contractions or spasms. The tube may be unable to pick up the egg, and the stimulated uterus may reject implantation. In addition, sperm motility may be adversely affected along with the ability of the sperm to penetrate into the egg. Although the mechanisms are not fully understood, endometriosis may also result in anovulation (17 percent), cause a luteal phase defect interfering with implantation, or cause a luteinized unruptured follicle.

Some researchers suggest that the woman's body may form antibodies against the misplaced endometrial tissue. The same antibodies may attack the uterine lining and cause the high spontaneous-abortion rate: up to three times the normal rate. (Fortunately, removing the endometriosis with medication or with surgery will reduce this risk to normal.)

The normal tissue surrounding the endometriosis implant becomes puckered and ischemic (suffering from lack of oxygen), causing pain similar to that from a heart attack. Attacked over a prolonged period, the fallopian tubes may become inflamed and swell shut. Blocked by adhesions, the tubes can no longer provide safe passage for egg, sperm, and embryo. Ectopic pregnancies become a real danger: up to sixteen times more likely than the normal population (16 percent vs. 1 percent). Let's evaluate the specific factors that may contribute to infertility in patients with endometriosis.

Compared to a normal cycle, the follicular phase may be shorter in patients with endometriosis, the estradiol may be lower, and a blunted LH surge may be seen. Progesterone levels and luteal phase endometrial biopsies, however, are normal. There is a tendency towards greater number of follicles which are smaller at the time of the LH surge in patients with endometriosis. However, this data does not prove that endometriosis is the cause of infertility. Women with subtle ovulatory dysfunction are more likely to have infertility and it may be that infertility or an abnormal hormone profile increases the likelihood of endometriosis.

In women with severe pelvic adhesions where the ovary is encased, luteinized unruptured follicle (LUF) may be noted. This is believed to occur when, despite normal hormonal parameters (LH surge), the egg is not released from the ovary. Endometriosis is found in 63% of those patients reported to have LUF. LUF is seen in 35% of patients with endometriosis versus 11% of patients without endometriosis. However, the detection of follicular rupture by ultrasound and laparoscopy is very subjective and the diagnosis of this condition is complicated. Therefore, studies that look at endometriosis and LUF must be held suspect.

Studies in rabbits have shown that surgical induction of endometriosis leads to a decrease in fertility from 75% to 25%. This may be due to anovulation associated with endometrial implants. Studies have evaluated immune modification in the rabbit model to attempt to restore fertility.

We know that during in vitro fertilization endometriosis patients have normal hormonal profiles. There is a tendency towards fewer oocytes and it appears that oocytes derived from ovaries with endometriomas may have a lower fertilization rate and implantation rate.

In order to understand whether this effect is due to the embryo or the uterine environment we can look at donor embryo studies. Dr. Simon found decreased donor oocyte implantation rates when the oocytes were from women with endometriosis. In his study, endometriosis in the recipient had no effect on implantation while other studies have found conflicting results.

On the other hand, Dr. Bruce Lessey performed endometrial biopsy surface at the time of implantation and found lower levels of vitronectin (an adhesion molecule on the endometrial surface) in women with unexplained and endometriosis related infertility. Treatment with Lupron and ovulation induction appeared to restore this implantation marker and fertility.

The effect of endometriosis on the peritoneal environment may adversely affect fertility. There is an increased volume of peritoneal fluid, and peritoneal macrophages (scavenger white blood cells), are increased both in number and activity. Cytokines (white blood cell chemical messengers) such as IL-1, IL-2, IL-6, TNF-alpha, Interferon, C3, C4 are all increased. These may adversely affect sperm oocyte interaction, sperm mobility and survival, and oocye pick up. In addition, serum samples obtained from women with endometriosis were found to be embryotoxic in mouse embryo cultures 78% of the time versus 20% in women without endometriosis.

The immune system is affected by endometriosis and may adversely affect fertility. Patients with endometriosis may show decreased nature killer cell function, and decreased reactivity to transplanted endometrial tissue. In addition, complement, an immune component that breaks apart abnormal cells, is elevated in patients with endometriosis.

Nearly one-third of the women having endometriosis have no symptoms other than infertility. The others have varying degrees of symptoms, depending on the stage of the disease. Oddly enough, the early stages or milder forms are frequently more painful than the later stages. We believe this is because the young endometrial tissue liberates spasm-causing prostaglandins, whereas the older endometrial tissue simply burns out and turns into inactive scar tissue. The most common symptoms associated with endometriosis are pain and infertility, however, premenstrual spotting, urinary urgency, rectal bleeding, painful urination, bloody cough, and skin nodules may also be noted. Endometriosis may frequently mimic other disorders such as pelvic adhesions, dysmenorrhea (menstrual cramps), irritable bowel syndrome, colitis, and ulcer disease. Careful evaluation is necessary to ensure accurate diagnosis. Diarrhea or rectal bleeding and tenesmus (sense of rectal fullness) at the time of menses are particularly telling symptoms.

Table 17-l gives a profile of the endometriosis patient and tells where the implants, which can be found anywhere in the body, are most frequently located.

No symptoms                                                                   33

Infertility                                                                             70

Dyspareunia (painful periods)                                  28-66

Hypermenorrhea (heavy periods)                            12-74

Spontaneous abortion                                          Up to 50

Weight lower than normal                                    Up to 50

Weight higher than normal                                            13

Deep dyspareunia (pain during intercourse)        12-33

Sacral backache (accentuated during menses)  25-31

Pelvic adhesions                                                     24-50

Tender or nodular uterosacral ligaments                   34

Uterus tipped anteriorly                                               20

Anovulation                                                                   17

Irregular periods                                                           12

Rectal pain                                                                      4

Mild cases                                                               31-75

Moderate and severe                                        Very low

Inguinal/thigh pain; leg cramps

Intermenstrual bleeding

Spontaneous abortion (habitual)

Premenstrual spotting

Location of Endometrial Implants Site                 Incidence (%)

Ovaries                                                                       61-78

Posterior cul-de-sac (behind uterus)                       14-34

Uterine surface                                                           17-55

Intramural sigmoid and rectum                                     3-4

Cervix, vagina, vulva                                             Very low

Depression

Decreased sex drive because of association with painful sex

Doubts about sexuality

Heightened guilt about sex

Poor self-image

Any complaint related to menses suggests endometriosis. Endometriosis associated with the classic symptoms of painful menstrual periods and/or painful sexual intercourse is relatively easy to diagnose. However, when the symptoms are less suggestive-unexplained infertility, irregular periods, or spotting, for example-identifying the disease may be more difficult. Occasionally while doing the pelvic examination I can feel the telltale beading on the outside of the reproductive organs. The only definitive diagnostic procedure for endometriosis, however, is a direct look inside the abdominal cavity and a biopsy of the tissue.

Since laparoscopy requires general anesthesia, I try to rule out all other male and female fertility factors before performing it. Depending on the woman's age, history, and findings from the workup, however, I may choose a more aggressive diagnostic approach for a particular couple. If the woman is in her thirties and if she complains of pelvic pain or has unexplained infertility, I'm likely to perform a laparoscopy sooner.

Viewed through the laparoscope, the endometrial lesions look like raised shaggy brown or blue-black areas ranging from 2 to 10 cm (1 to 4 inches) in diameter. If the disease has been present for a prolonged period of time, the tissue adjacent to the implants will pucker and burned-out areas will show fibrotic scars. Advanced endometriosis (stage III or IV) may invade, pucker, and erode the walls of affected organs, and adhesions may be so dense that they "freeze" the pelvic organs into distorted positions.

Dr. Redwine has described the progressive nature of endometriosis lesions. They are first seen as clear vesicles, then become red, and then progress to black lesions over a period of 7-10 years. Dr. Karnaky described water blister lesions becoming blue dome cysts over a period of 4-10 years. The clear lesions are seen are at an average age of 21.5 while black scarred lesions are seen at a mean age of 31.9. This progression from clear to red to black lesions with age confirms the progressive nature of this disease if left untreated. Disease will progress in 47-64% of women without therapy and approximately 20% of women with therapy.

While performing the laparoscopy, I'll force a colored dye through the cervix, uterus, and tubes to demonstrate tubal patency. Many times, the dye will flow through only one tube (preferential flow) because that tube provides the least resistance to the colored liquid. Although this does not mean that the other tube is blocked, it does not rule out that possibility, either.

There is poor correlation between the degree of pain or infertility and the severity of disease. Early lesions which are clear or red are metabolically more active than older, dark, fibrotic lesions. This metabolic activity may be responsible for the associated infertility, immune abnormalities, urinary urgency, pelvic pain or diarrhea.

"It seems like everything is on hold until we get a baby," Margaret B. said.

"We did that, too. We put off buying a house, getting a car, changing jobs, taking a vacation..."

"So have we," Bryan W. interrupted. "We spend all our extra money on medical bills. We can't do anything else."

"The menstrual cycle takes over your whole life," Steven S. added.

Kathy agreed. "Every time we want to leave for the weekend, I have to go in for ultrasound or Steven has to collect a specimen for AIH. There's no time for making other plans. "

"We don't even go to my parents' house anymore," Shelley T. said. "I can't stand all the questions: 'When are you going to give us a grandchild?' Or, 'Why don't you just relax? Let nature take its course.' "

Kathy interrupted. "I don't go to baby showers anymore either. I used to cry for days afterward and I don't need that kind of grief."

"You have the right to avoid painful situations," the RESOLVE leader agreed. "There's no rule that says you have to force yourselves to face these situations all of the time. You have to plan your own life and be true to your own needs.

"You need to give yourselves permission to move on with your lives. Putting off buying new clothes because you may need a maternity wardrobe instead; delaying your vacation because you might miss a call from the adoption agency; keeping your old job because if you get pregnant you don't want to lose your maternity benefits—it can go on and on. Giving up your other dreams and all the fun in your life only adds to your frustration and anger."

Then Margaret B. spoke: "I'm beginning to understand what you're saying. We aren't just upset about our fertility problem; we're also upset about how our fertility problem is ruining the rest of our lives."

"So if we would try to live like normal people, we would be happier." Richard B. reached for Margaret's hand. "It would do a lot for our marriage, too."

Even when only one partner must be medically treated, I find that the fertility problem affects them both 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 just affect one person; it affects the couple .

In this chapter I want to help you rethink the attitudes that may be interfering with your self-esteem, your sexuality, and your progress toward pregnancy. You are entitled to have the freedom to be yourself and to consider new options apart from what others expect or demand. I want to put you back in control of your life so that you can deal with your marriage, your family, your friends, and your career. And I'm certain that as a couple you will grow closer and stronger from your efforts.

Coping with a fertility problem is as significant a life crisis as adjusting to the death of a loved one. Because of the ambiguity of the loss, however, couples with fertility problems have difficulty getting over their crisis: there is no body to bury and no clear-cut stopping point. Perhaps it's more like having a loved one missing in action. There's always hope: just one more month of treatment, just one more surgery, maybe next month will be The One. With each attempt the couple develops renewed hope, and with each failure the couple mourns their loss. Then, once again, they muster up enough strength to get back on the emotional crisis roller coaster: they try again, and again, and again.

Shock and denial. When you learn that you are "infertile" or that your fertility treatment has failed, at first you become numb. You may have difficulty thinking, experience emotional swings and outbursts, and show impaired judgment. You may only be able to function from day to day and not really believe the facts: "This can't be happening to me. I'm not infertile, I just can't get pregnant." "Until now I had a perfectly ordered life; then everything just hit the wall." This period of adjustment may last several weeks or even a couple of months

Searching and learning is a period during which you want to learn everything you can about infertility, so you can make some sense of it. you read everything you can get your hands on and talk to infertile couples every chance you get. you may frequently find yourself becoming angry, restless, impatient, and indecisive. You begin to feel guilty about what you perceive as past transgressions: an abortion you had as a teenager, an affair that caused PID, or using birth control for so many years. During this time, studies show that you are at greatest risk for developing an illness.

Bargaining and guilt is a stage where you attempt to regain control of your life and do a lot of crying. You may look to God for answers or promise to "be good" if you get pregnant. You may find yourself saying, "What did I do to deserve this?" "Maybe I'm too selfish," "It's your fault," or "Maybe we don't deserve children; our marriage isn't the greatest in the world."

Anger grows from the senselessness and futility of the situation. You become resentful, enraged, and feel helpless. You feel that you've lost control of one of your basic rights. You say, "Why me? All sorts of other people can have babies. I'm a good, wholesome person, so why do I have to suffer?"

Optimism and hope grow as you begin to believe that treatment will help. You work hard at your treatment, but your anger and frustration increase with each failure. You may even start to con yourself: "I'm sure everything will work out," "It doesn't really matter anyway," "I should feel happy— I've got everything else I could want," "Maybe if we adopt, I'll get pregnant," "Maybe we shouldn't have any children."

Depression descends from your pain, despair, emptiness, and sadness. For many, life loses its meaning and pregnancy becomes an obsession. You try more bargaining: "We'll do anything." Any failure—at workup at school, in bed—is seen as "another example of my inadequacy." You begin to think that you may be going crazy: "I'm trapped in hope; I don't want to hope anymore."

Reorganization follows depression and is characterized by better judgment, better eating and sleeping. The obsessive drive is gone; you are healthier; you begin to get your priorities into perspective. You stop fighting what's happening and realize that like it or not, fertility problems are part of your life and need to be dealt with, not denied.

Acceptance and resolution take place when the doctor says, "We've done all we can." Once the pain subsides, you begin to say, "Maybe it would be okay to decide not to have children"; "If I never have a baby, I at least have a husband who loves me. We're going through this together and he's right with me"; "I was courageous to get this far." You begin to laugh and make plans to get on with life unless you have renewed hope—a new treatment, a new doctor, a breakthrough in technology—and then you hop aboard the emotional roller coaster for another round.

The time people spend in each stage of emotional crisis varies from one person to another. Their ability to help themselves, to communicate, to handle their thoughts, to manage anger, to adjust to stress, and to resolve conflicts help them move through the stages. People who fail to deal with any one stage of grief get caught—caught in bargaining and guilt, caught in anger, caught in depression. People who learn to deal with each stage, one step at a time, accept their situation, take control of their lives, and start living again. Many of my patients have done this and you can learn to do it, too.

Sometimes stress levels build to unreasonable levels. Your coping skills fail and you begin to use inappropriate and ineffective techniques to resolve your problems. If you find yourself resorting frequently to the mechanisms described below, you may want to seek outside counseling or do some quiet thinking and talking with your spouse or close friend about what is happening.

Displacement—redirecting your feelings from the original person or problem to another person or object. For example, when Michelle P. became upset with her mother, she would take it out on her husband. After her husband gently called this to her attention, they worked out a strategy for her to deal more effectively with her mother.

Dependency—letting someone take care of you and make all of your decisions for you so you are free to "opt out" of life. For example, Vicky M. let her husband take care of all the funeral arrangements for their stillborn child. Vicky always regretted that she hadn't picked out the dress their daughter was buried in. she hated her weakness.

Aggression—moving against another person. Dan M. spent all of his time figuring out how to get back at someone instead of figuring out how to level with the person about how he felt. When he learned to say "Ouch!" he found that people really didn't intend to hurt him, they just didn't understand.

Passivity and evasion—seizing power by becoming passive, by avoiding responsibility, or by pouting. John T. used to say, "I don't care—do what you want," when he really didn't feel that way. Then he learned that people would consider his feelings if he shared them. That was the first step John took toward taking control of his life.

Sexual withdrawal—expressing disapproval or anger by withholding sexual favors. Not wanting to make love after an argument is understandable, but using sex to get your way is inappropriate.

You may wish to rate yourself on the checklist below. If you have too many pluses for your own comfort, you may want to seek outside counseling. Often a counselor can quickly relieve your anxiety by helping you get your priorities in order and pinpointing the key elements of a problem so you can deal with each stressful situation one step at a time.

Appendixes

Dear Friend:

I realize that sometimes it's difficult for you to know what to say to a couple who has a fertility problem. Sometimes it seems like no matter what you do, it's the wrong thing. I'd like to give you a few suggestions that may help you be the friend I know you want to be:

Be ready to listen. Infertile couples have a lot on their minds and need someone to talk to. Sometimes a good ear helps people get things off their chests. A good listener can help people express their anxiety, anger, and guilt; or help people work out solutions to problems. Without offering any suggestions your attentiveness and interest may provide the comfort and reassure ance these couples need most.

Don't offer advice unless you are really well informed. Infertile couples read everything they can get their hands on. Sometimes it seems as though they know more about fertility treatment than their own doctors. So talking off the cuff about something you don't really know about will only make them angry and defensive.

Be sensitive and don't joke about infertility; attempts at levity will only anger them. Joking about infertility is as inappropriate as joking about death at a funeral. Remember, infertile couples are hypersensitive about many things. Try to put yourself in their shoes whenever you insist they come to a baby shower, when you brag about your children's achievements, or when you tell them about your friend's daughter who got pregnant at fourteen.

Be patient. This couple may experience mood swings with every treatment or monthly cycle. One week they may be high because a new treatment promises hope; the next week they may be in mourning for the child they lost (didn't make) this month. They may be riding an exhausting emotional roller coaster which makes their actions and moods unpredictable. Try to understand and flow with their changes. And remember that when they want to be alone, they are not rejecting you. Don't get your feelings hurt by the preoccupation they have with their problems; keep in touch.

Show that you understand their difficulty. Say things like, "I know this is difficult for you," "I don't envy what you're going through," or, "If there is anything I can do to help, don't hesitate to ask." If you aren't sure about what they are experiencing, read some articles and books that discuss the emotional aspects of fertility problems.

Be realistic and supportive of their decisions for or against fertility treatment. Once they've reached a difficult decision, don't say, "Shouldn't you see another doctor?"; "Are you sure that you really want to adopt?"; or, "I'd never consider doing that!" These couples usually weigh each issue as though it were a life-or-death decision. Don't take their decisions lightly unless you have good reason to.

Don't put down their doctor or choices for treatment. Refrain from making comments like, "I never heard of a doctor doing that. Does he know what he's doing?" or, "You don't need surgery. What you need is a vacation." Unless, from your reading or experience, you are certain that their physician is not using accepted methods, keep quiet about these topics.

Be truthful. Don't, for example, try to hide a pregnancy in the family. The truth does not hurt, provided you are not brutally frank.

Let them know when you don't know what to say. The couple will appreciate your honesty and will probably suggest how you can help them in that particular situation, even if it means remaining quiet. Admitting your problem will help establish honest communication.

Be an advocate for infertile couples. Educate others and speak up for the couple's decisions. Promote your local RESOLVE chapter. If you do not have a support group in your community, help form one.

Understand that individuals and couples respond to fertility problems differently. Learn to recognize the normal emotional stages they are experiencing—denial, anger, depression, mourning, acceptance, and so forth. And realize that they may cycle through these stages with each new round of treatment and with each lost opportunity. Accept them when they are angry accept them when they are depressed, and accept them when they feel guilty. Unless they remain in a single stage for a prolonged period of time, don't become overly concerned.

Above all, be there when they need you and show them that you care.

This is a stressful time for everyone. Don't underestimate how important you and your relationship are to this couple. Your understanding and support can make a significant difference during this difficult period.

Infertility Glossary

Abortion, Habitual:

A term referring to a condition where a woman has had three or more miscarriages.

Abortion, Incomplete:

An abortion after which some tissue remains inside the uterus. A D&C must be performed to remove the tissue and prevent complications.

Abortion, Missed:

An abortion where the fetus dies in the uterus but there is no bleeding or cramping. A D&C will be needed to remove the fetal remains and prevent complications.

Abortion, Spontaneous:

A pregnancy loss during the first twenty weeks of gestation.

Abortion, Therapeutic:

A procedure used to terminate a pregnancy before the fetus can survive on its own.

Abortion, Threatened:

Spotting or bleeding that occurs early in the pregnancy. May progress to spontaneous abortion.

ACTH:

A hormone produced by the pituitary gland to stimulate the adrenal glands. Excessive levels may lead to fertility problems.

Adhesion:

Scar tissue occurring in the abdominal cavity, fallopian tubes, or inside the uterus. Adhesions can interfere with transport of the egg and implantation of the embryo in the uterus.

Adrenal Androgens:

Male hormones produced by the adrenal gland which, when found in excess, may lead to fertility problems in both men and women. Excess androgens in the woman may lead to the formation of male secondary sex characteristics and the suppression of LH and FSH production by the pituitary gland. Elevated levels of androgens may be found in women with polycystic ovaries, or with a tumor in the pituitary gland, adrenal gland, or ovary. May also be associated with excess prolactin levels.

Alpha-fetoprotein Test (AFP):

A blood test performed to evaluate the development of the fetus and to look for fetal abnormalities.

AID (Artificial Insemination Donor):

See Artificial Insemination Donor.

AIH (Artificial Insemination Homologous):

See Artificial Insemination Homologous.

Amenorrhea:

Refers to a woman who has never had a period.

Amenorrhea, Secondary:

A term describing a woman who has menstruated at one time, but who has not had a period for six months or more.

Androgens:

Male sex hormones.

Andrologist:

A physician-scientist who performs laboratory evaluations of male fertility. May hold a Ph.D. degree instead of an M.D. Usually affiliated with a fertility treatment center working on in vitro fertilization.

Anorexia Nervosa:

A life-threatening eating disorder; self-imposed starvation. Severe weight loss and malnutrition from this disorder cause anovulation.

Anovulation:

The failure to ovulate; ovulatory failure.

Antibodies:

Chemicals made by the body to fight or attack foreign substances entering the body. Normally they prevent infection; however, when they attack the sperm or fetus, they cause infertility. Sperm antibodies may be made by either the man or the woman.

Antisperm Antibodies:

Antibodies are produced by the immune system to fight off foreign substances,like bacteria. Antisperm antibodies attach themselves to sperm and inhibit movement and their ability to fertilize.

Artificial Insemination (AI):

The depositing of sperm in the vagina near the cervix or directly into the uterus, with the use of a syringe instead of by coitus. This technique is used to overcome sexual performance problems, to circumvent sperm-mucus interaction problems, to maximize the potential for poor semen, and for using donor sperm. See also Artificial Insemination Donor; Artificial Insemination Homologous.

Artificial Insemination Donor (AID):

Artificial insemination with donor sperm. A fresh donor semen specimen or a thawed frozen specimen is injected next to the woman's cervix.

Artificial Insemination Homologous (AIH):

Artificial insemination with the husband's sperm. The sperm may be washed and injected directly into the wife's uterus (IAIH). Often used with poor semen or to overcome sperm-mucus problems.

Artificial Spermatocoele:

An artificial, surgically created pouch used to collect sperm from men with irreversible tubal blockage.

Asherman's Syndrome:

A condition where the uterine walls adhere to one another. Usually caused by uterine inflammation.

Assisted Reproductive Technology (ART):

Several procedures employed to bring about conception without sexual intercourse, including IUI, GIFT and ZIFT.

Asthenozoospermia:

Low sperm motility.

Azozoospermia:

Semen containing no sperm, either because the testicles cannot make sperm or because of blockage in the reproductive tract.

Bacterial Vaginosis Infection:

A vaginal infection that causes a burning sensation and a gray, malodorous discharge. May interfere with fertility.

Basal Body Temperature (BBT):

Your body temperature when taken at its lowest point, usually in the morning before getting out of bed. Charting BBT is used to predict ovulation.

Basal Body Temperature, Biphasic:

A basal body temperature pattern consistent with ovulation and the formation of the corpus luteum, which secretes progesterone. This hormone will elevate the basal body temperature about one-half degree during the latter half of the menstrual cycle.

Basal Body Temperature, Monophasic:

An anovulatory basal body temperature pattern where the temperature remains relatively constant throughout the cycle.

Beta hCG Test:

A blood test used to detect very early pregnancies and to evaluate embryonic development.

Bicornuate Uterus:

A congenital malformation of the uterus where the upper portion (horn) is duplicated.

Bromocriptine (Parlodel):

An oral medication used to reduce prolactin levels and reduce the size of a pituitary tumor when present. This medication often causes dizziness and upset stomach and must be started with a small dose which is gradually increased as needed. This medication is equally effective when the tablet is placed into the vagina.

Bulimia:

An eating disorder characterized by voracious eating followed by forced vomiting. The resulting weight loss and malnutrition may cause anovulation.

Buserelin:

A long-acting GnRH available in Europe as a nasal spray and used to create the pseudomenopause desirable for reducing the size and number of endometriotic lesions. It can also be used to treat fibroid tumors, PMS, hirsutism, ovulation induction and for in vitro fertilization.

Candidiasis (Yeast):

An infection that may be uncomfortable and itchy and may impair fertility.

Capacitation:

A process that sperm undergo as they travel through the woman's reproductive tract. Capacitation enables the sperm to penetrate the egg.

Cauterize:

To burn tissue with electrical current (electrocautery) or with a laser. Used in surgical procedures to remove unwanted tissue such as adhesions and endometrial implants. Also used to control bleeding.

Cervical Mucus:

A viscous fluid plugging the opening of the cervix. Most of the time this thick mucus plug prevents sperm and bacteria from entering the womb. However, at midcycle, under the influence of estrogen, the mucus becomes thin, watery, and stringy to allow sperm to pass into the womb. See also Cervix

Cervical Smear:

A sample of the cervical mucus examined microscopically to assess the presence of estrogen (ferning) and white blood cells, indicating possible infection.

Cervical Stenosis:

A blockage of the cervical canal from a congenital defect or from complications of surgical procedures. See also Cervix.

Cervix:

The opening between the uterus and the vagina. The cervical mucus plugs the cervical canal and normally prevents foreign materials from entering the reproductive tract. The cervix remains closed during pregnancy and dilates during labor and delivery to allow the baby to be born.

Cervix, Incompetent:

A weakened cervix, which opens up prematurely during pregnancy and can cause the loss of the fetus. A CERVICAL CERCLAGE is a procedure in which a stitch or two is put around the cervix to prevent its opening until removed when the pregnancy is to term.

Chocolate Cyst:

A cyst in the ovary that is filled with old blood; endometrioma. Occurring when endometriosis invades an ovary, it causes the ovary to swell. Frequently, patients with large endometriomas do not have any symptoms. If the cyst ruptures or the ovary containing the cyst twists, emergency surgery may be necessary. Usually treatment can be carried out through the laparoscope.

Chromosome:

The structures in the cell that carry the genetic material (genes); the genetic messengers of inheritance. The human has forty-six chromosomes, twenty-three coming from the egg and twenty-three coming from the sperm.

Cilia:

Tiny hairlike projections lining the inside surface of the fallopian tubes. The waving action of these "hairs" sweeps the egg toward the uterus.

Clitoris:

The small erectile sex organ of the female which contains large numbers of sensory nerves; the female counterpart of the penis.

Clomiphene Citrate (Clomid, Serophene):

A fertility drug that stimulates ovulation through the release of gonadotropins from the pituitary gland."

Coitus:

Intercourse; the sexual union between a man and a woman.

Conception:

See Fertilization.

Conceptus:

The early products of conception; the embryo and placenta.

Condom Therapy:

Therapy prescribed to reduce the number of sperm antibodies in the woman by using a condom during intercourse for six months or more and by the woman refraining from all skin contact with the husband's sperm. The woman's antibody level may fall to levels that will not adversely affect the sperm.

Cone Biopsy:

A surgical procedure used to remove precancerous cells from the cervix. The procedure may damage the cervix and thus disrupt normal mucus production or cause an incompetent cervix, which may open prematurely during pregnancy.

Congenital Adrenal Hyperplasia:

A congenital condition characterized by elevated androgens which suppress the pituitary gland and interfere with spermatogenesis or ovulation. Women may have ambiguous genitalia from the excess production of male hormone.

Contraception:

A congenital condition characterized by elevated androgens which suppress the pituitary gland and interfere with spermatogenesis or ovulation. Women may have ambiguous genitalia from the excess production of male hormone.

Contraceptive, Oral:

A medication that prevents ovulation and pregnancy. Up to 3 percent of women taking the Pill will become anovulatory when they stop taking it. The regulatory effects of the Pill can also disguise symptoms of fertility problems-- for example, an irregular cycle or endometriosis. May be used to control the symptoms and development of endometriosis.

Corpus Luteum:

The yellow-pigmented glandular structure that forms from the ovarian follicle following ovulation. The gland produces progesterone, which is responsible for preparing and supporting the uterine lining for implantation. Progesterone also causes the half-degree basal temperature elevation noted at midcycle during an ovulatory cycle. If the corpus luteum functions poorly, the uterine lining may not support a pregnancy. If the egg is fertilized, a corpus luteum of pregnancy forms to maintain the endometrial bed and support the implanted embryo. Picture of a corpus luteum. A deficiency in the amount of progesterone produced (or the length of time it is produced) by the corpus luteum can mean the endometrium is unable to sustain a pregnancy. This is called Luteal Phase Defect (LPD).

Cumulus Oophorus:

The protective layer of cells surrounding the egg.

Cushing's Syndrome:

A condition characterized by an overproduction of adrenal gland secretions. The person will suffer from high blood pressure and water retention as well as a number of other symptoms. A concurrent elevation of adrenal androgens will suppress pituitary output of LH and FSH and result in low sperm production or ovulatory failure. A woman may also develop male secondary sex characteristics, including abnormal hair growth. Cushing's Disease is another condition in which these same symptoms occur, but as the result of a pituitary tumor.

D&C (Dilation and Curettage):

A procedure used to dilate the cervical canal and scrape out the lining and contents of the uterus. The procedure can be used to diagnose or treat the cause of abnormal bleeding and to terminate an unwanted pregnancy.

Danazol (danocrine):

A medication used to treat endometriosis. Suppresses LH and FSH production by the pituitary and causes a state of amenorrhea during which the endometrial implants waste away. Many women experience oily skin, acne, weight gain, abnormal hair growth, deepening of the voice and muscle cramps with this medication.

Delayed Ejaculation:

A condition in which the man fakes orgasm and does not actually ejaculate when having sex.

Delayed Puberty:

A condition in which the youngster fails to complete puberty and develop secondary sex characteristics by sixteen years of age. Puberty may be stimulated with hormonal replacement therapy. Some will outgrow the condition without treatment.

DES (Diethylstilbestrol):

A medication prescribed in the 1950s and 1960s to women to prevent miscarriage. Male and female fetuses exposed in utero to this drug developed numerous deformities including blockage of the vas deferens, uterine abnormalities, cervical deformities, miscarriages, and unexplained infertility. DES is no longer prescribed for this indication.

DHEAS:

See Adrenal Androgens.

Doxycycline:

A tetracycline derivative; an antibiotic that inhibits many of the microorganisms infecting the reproductive tract. Often used for treating ureaplasma infections. Many physicians find routine treatment with this antibiotic more cost-effective than performing multiple cultures on both the husband and wife looking for infection.

Dysmenorrhea:

Painful menstruation. This may be a sign of endometriosis.

Dyspareunia:

Painful coitus for either the man or the woman.

Ectopic Pregnancy:

A pregnancy outside of the uterus, usually in the fallopian tube. Such a pregnancy can rarely be sustained, and often leads to decreased or complete loss of function in the affected tube. Methotrexate is now used to dissolve the pregnancy without causing major damage to the tube.

Egg Retrieval:

A procedure used to obtain eggs from ovarian follicles for use in in vitro fertilization. The procedure may be performed during laparoscopy or by using a long needle and ultrasound to locate the follicle in the ovary.

Ejaculate:

The semen and sperm expelled during ejaculation.

Ejaculation:

The physiological process by which the semen is propelled from the testicles, through the reproductive tract, and out the opening of the penis.

Embryo:

The early products of conception; the undifferentiated beginnings of a baby; the conceptus.

Embryo Transfer

Placing an egg fertilized outside the womb into a woman's uterus or fallopian tube.

Empty Sella Syndrome:

A condition that occurs when spinal fluid leaks into the bony chamber (fossa) housing the pituitary gland. The fluid pressure compresses the pituitary gland and may adversely affect its ability to secrete LH and FSH and may elevate prolactin levels.

Endometrial Biopsy:

A test to check for Luteal Phase Defect. A procedure during which a sample of the uterine lining is collected for microscopic analysis. The biopsy results will confirm ovulation and the proper preparation of the endometrium by estrogen and progesterone stimulation

Endometrial Biopsy:

A condition where endometrial tissue is located outside the womb. The tissue may attach itself to the reproductive organs or to other organs in the abdominal cavity. Each month the endometrial tissue inbreeds with the onset of menses. The resultant irritation causes adhesions in the abdominal cavity and in the fallopian tubes. Endometriosis may also interfere with ovulation and with the implantation of the embryo.

Endometrium:

The lining of the uterus which grows and sheds in response to estrogen and progesterone stimulation; the bed of tissue designed to nourish the implanted embryo.

Endorphins:

Natural narcotics manufactured in the brain to reduce sensitivity to pain and stress. May contribute to stress-related fertility problems.

Epididymis:

A coiled, tubular organ attached to and lying on the testicle. Within this organ the developing sperm complete their maturation and develop their powerful swimming capabilities. The matured sperm leave the epididymis through the vas deferens.

Erection:

The process during which the erectile tissue of the penis becomes engorged with blood, causing the penis to swell and become rigid.

Estradiol:

The female hormone produced in the ovary. Responsible for formation of the female secondary sex characteristics such as large breasts; supports the growth of the follicle and the development of the uterine lining. At midcycle the peak estrogen level triggers the release of the LH spike from the pituitary gland. The LH spike is necessary for the release of the ovum from the follicle. Fat cells in both obese men and women can also manufacture estrogen from androgens and interfere with fertility.

Estrogen:

Female sex hormone.

Expectant Therapy (Endometriosis):

A wait-and-see approach used after laparoscopic surgery for mild endometriosis.

Fallopian Tubes:

Ducts through which eggs travel to the uterus once released from the follicle. Sperm normally meet the egg in the fallopian tube, the site at which fertilization usually occurs.

Female Kallman's Syndrome:

A condition characterized by infantile sexual development and an inability to smell. Since the pituitary cannot produce LH and FSH, the woman must take hormone supplements to achieve puberty, to maintain secondary sex characteristics, and to achieve fertility.

Ferning:

A pattern characteristic of dried cervical mucus viewed on a slide. When the fern pattern appears, the mucus has been thinned and prepared by estrogen for the passage of sperm. If it does not fern, the mucus will be hostile to the passage of the sperm.

Fertile Eunuch:

A rare disorder characterized by an LH deficiency leading to low testosterone levels and poor sperm production. Male secondary sex characteristics will be incomplete and sex drive will be low.

Fertility Specialist:

A physician specializing in the practice of fertility. The American Board of Obstetrics and Gynecology certifies a subspecialty for OB-GYNs who receive extra training in endocrinology (the study of hormones) and infertility.

Fertility Treatment:

Any method or procedure used to enhance fertility or increase the likelihood of pregnancy, such as ovulation induction treatment, varicocoele repair, and microsurgery to repair damaged fallopian tubes. The goal of fertility treatment is to help couples have a child.

Fertility Workup:

The initial medical examinations and tests performed to diagnose or narrow down the cause of fertility problems.

Fertilization:

The combining of the genetic material carried by sperm and egg to create an embryo. Normally occurs inside the fallopian tube (in vivo) but may also occur in a petri dish (in vitro). See also In Vitro Fertilization.

Fetus:

A term used to refer to a baby during the period of gestation between eight weeks and term.

Fibroid (Myoma or Leiomyoma):

A benign tumor of the uterine muscle and connective tissue.

Fimbria:

The opening of the fallopian tube near the ovary. When stimulated by the follicular fluid released during ovulation, the fingerlike ends grasp the ovary and coax the egg into the tube. A normal tube and ovary as seen at laparoscopy.

Follicles:

Fluid-filled sacs in the ovary which contain the eggs released at ovulation.

Each month an egg develops inside the ovary in a fluid filled pocket called a follicle. This follicle is one inch in size and is about ready to ovulate.

Follicular Fluid:

The fluid inside the follicle that cushions and nourishes the ovum. When released during ovulation, the fluid stimulates the fimbria to grasp the ovary and coax the egg into the fallopian tube.

Follicle Stimulating Hormone (FSH):

A pituitary hormone that stimulates spermatogenesis and follicular development. In the man FSH stimulates the Sertoli cells in the testicles and supports sperm production. In the woman FSH stimulates the growth of the ovarian follicle. Elevated FSH levels are indicative of gonadal failure in both men and woman.

Follicular Phase:

The pre-ovulatory portion of a woman's cycle during which a follicle grows and high levels of estrogen cause the lining of the uterus to proliferate. Normally takes between 12 and 14 days.

Galactorrhea:

A clear or milky discharge from the breasts associated with elevated prolactin.

Gamete:

A reproductive cell:Sperm in men, the egg in women.

Gamete Intrafallopian Transfer (GIFT):

A technique that may be used in lieu of in vitro fertilization for women with patent tubes. After egg retrieval the eggs are mixed with the husband's sperm and then injected through the fimbria into the woman's fallopian tubes for in vivo fertilization.

Genitals:

The external sex organs, as the labia and clitoris in the woman and the penis and testicles in the man. Also called genitalia.

Germ Cell:

In the male the testicular cell that divides to produce the immature sperm cells; in the woman the ovarian cell that divides to form the egg (ovum). The male germ cell remains intact throughout the man's reproductive life; the woman uses up her germ cells at the rate of about one thousand per menstrual cycle, although usually only one egg matures each cycle.

Germ Cell Aplasia (Sertoli Cell Only):

An inherited condition in which the testicles have no germ cells. Since men with this condition have normal Leydig cells, they will develop secondary sex characteristics. May also be caused by large and/or prolonged exposure to toxins or radiation.

Gonadotropins:

Hormones which control reproductive function: Follicle Stimulating Hormone and Lutenizing Hormone.

Gonadotropin Releasing Hormone (GnRH):

A substance secreted by the hypothalamus every ninety minutes or so. This hormone enables the pituitary to secrete LH and FSH, which stimulate the gonads. See also FSH; LH.

Gonad:

The gland that makes reproductive cells and "sex" hormones, as the testicles, which make sperm and testosterone, and the ovaries, which make eggs (ova) and estrogen.

Gonorrhea:

An infection that is usually asymptomatic, but that may cause a bad-smelling yellowish vaginal discharge and red and swollen vaginal walls. If it reaches the fallopian tubes, the woman will suffer pain, develop a high fever, and possibly develop tubal blockage. The responsible organism may also impair sperm and prevent pregnancy. In the man gonorrhea seldom leads to damage, but it may cause a painful infection.

Hamster Test:

A test of the ability of sperm to penetrate a hamster egg which has been stripped of the Zona Pellucida (outer membrane). Also called SPERM PENETRATION ASSAY (SPA).

Hirsutism:

The overabundance of body hair, such as a mustache or pubic hair growing upward toward the navel, found in women with excess androgens.

Host Uterus:

Also called a "surrogate gestational mother." A couple's embryo is transferred to another woman who carries the pregnancy to term and returns the baby to the genetic parents immediately after birth.

Hostile Mucus:

Cervical mucus that impedes the natural progress of sperm through the cervical canal.

Human Chorionic Gonadotropin (HCG):

The hormone produced in early pregnancy which keeps the corpus luteum producing progesterone. Also used via injection to trigger ovulation after some fertility treatments, and used in men to stimulate testosterone production.

Human Menopausal Gonadotropin (HMG - PERGONAL, HUMEGON):

A combination of hormones FSH and LH, which is extracted from the urine of post-menopausal women. Used to induce ovulation in several fertility treatments.

Humegon (HMG):

The lutenizing and follicle-stimulating hormones recovered from the urine of post-menopausal women. Used to stimulate multiple ovulation in some fertility treatments.

Hyperprolactinemia:

A condition in which the pituitary gland secretes too much prolactin. Prolactin can suppress LH and FSH production, reduce sex drive in the man, and directly suppress ovarian function in the woman.

Hyperstimulation (Ovarian Hyperstimulation Syndrome, OHSS):

A potentially life-threatening side effect of Pergonal ovulation induction treatment. Arises when too many follicles develop and hCG is given to release the eggs. May be prevented by withholding the hCG injection when ultrasound monitoring indicates that too many follicles have matured.

Hyperthyroidism: Overproduction of thyroid hormone by the thyroid gland. The resulting increased metabolism "burns up" estrogen too rapidly and interferes with ovulation..

Hypoestrogenic:

Having lower than normal levels of estrogen.

Hypogonadotropic Hypopituitarism:

A spectrum of diseases resulting in low pituitary gland output of LH and FSH. Men with this disorder have low sperm counts and may lose their virility; women do not ovulate and may lose their secondary sex characteristics.

Hypospermatogenesis:

Low sperm production.

Hypothalamus:

A part of the brain, the hormonal regulation center, located adjacent to and above the pituitary gland. In both the man and the woman this tissue secretes GnRH every ninety minutes or so. The pulsatile GnRH enables the pituitary gland to secrete LH and FSH, which stimulate the gonads. See also FSH; LH; Ovary; Pituitary Gland; Testicle.

Hypothyroidism:

A condition in which the thyroid gland produces an insufficient amount of thyroid hormone. The resulting lowered metabolism interferes with the normal breakdown of "old" hormones and causes lethargy. Men will suffer from a lower sex drive and elevated prolactin (see Hyperprolactinemia), and women will suffer from elevated prolactin and estrogen, both of which will interfere with fertility.

Hysterectomy:

The surgical removal of the uterus. May also include the removal of other reproductive structures, such as the fallopian tubes and ovaries.

Hysterosalpingogram (HSG):

An x-ray of the pelvic organs in which a radio-opaque dye is injected through the cervix into the uterus and fallopian tubes. This test checks for malformations of the uterus and blockage of the fallopian tubes.

Hysteroscopy:

A procedure in which the doctor checks for uterine abnormalities by inserting a fiber-optic device. Minor surgical repairs can be executed during the procedure.

IAIH (Intrauterine Artificial Insemination Homologous):

Artificial insemination where the husband's sperm is injected directly into the uterus to avoid cervical mucus problems or to maximize the potential for poor semen. See also Artificial Insemination.

ICSI:

See also Intracytoplasmic Sperm Injection

Immature Sperm (Germinal Cell):

A sperm that has not matured and gained the ability to swim. In the presence of illness or infection such sperm may appear in the semen in large numbers. Imperforate Hymen: A condition where the membrane (hymen) covering the vagina fails to open and allow menstrual flow.

Implantation (Embryo):

The embedding of the embryo into tissue so it can establish contact with the mother's blood supply for nourishment. Implantation usually occurs in the lining of the uterus; however, in an ectopic pregnancy it may occur elsewhere in the body.

Impotence:

The inability of the man to have an erection and to ejaculate.

Incompetent Cervix:

See Cervix, Incompetent

Intracytoplasmic Sperm Injection (ICSI):

A micromanipulation procedure where a single sperm is injected into the egg to enable fertilization with very low sperm counts or with non-motile sperm.

In Vitro Fertilization (IVF):

Literally means "in glass." Fertilization takes place outside the body in a small glass dish.

Infertility:

The inability to conceive after a year of unprotected intercourse or the inability to carry a pregnancy to term.

Inhibin:

A male feedback hormone made in the testicles to regulate FSH production by the pituitary gland.

Inhibin-F (Folliculostatin):

A female feedback hormone made in the ovary to regulate FSH production by the pituitary gland.

IUD (Intrauterine Device):

A device placed into the uterus to prevent pregnancy. IUD insertion has been associated with an increased incidence of infection, which may damage the fallopian tubes, and is therefore not recommended for women with multiple sexual partners.

Kallman's Syndrome:

A congenital hypothalamus dysfunction which has multiple symptoms including the failure to complete puberty.

Karyotyping:

A test performed to analyze chromosomes for the presence of genetic defects.

Klinefelter's Syndrome:

A genetic abnormality characterized by having one Y (male) and two X (female) chromosomes. May cause a fertility problem.

Laparoscope:

A small telescope that can be inserted into a hole in the abdominal wall for viewing the internal organs; the instrument used to perform a laparoscopy. Used to diagnose and treat a number of fertility problems including endometriosis, abdominal adhesions, and polycystic ovaries. Also used in egg retrieval for in vitro fertilization.

Laparoscopy:

Examination of the pelvic region by using a small telescope called a laparoscope.

Laparotomy:

Major abdominal surgery where reproductive organ abnormalities can be corrected and fertility restored, such as tubal repairs and the removal of adhesions.

Leiomyomata:

See Fibroid.

Leydig Cell:

The testicular cell that produces the male hormone testosterone. The Leydig cell is stimulated by LH from the pituitary gland.

Luteal Phase:

Post-ovulatory phase of a woman's cycle. The corpus luteum produces progesterone, which cause the uterine lining to thicken to support the implantation and growth of the embryo.

Luteal Phase Defect (or deficiency) (LPD):

A condition that occurs when the uterine lining does not develop adequately because of inadequate progesterone stimulation; or because of the inability of the uterine lining to respond to progesterone stimulation. LPD may prevent embryonic implantation or cause an early abortion.

Luteinized Unruptured Follicle (LUF) Syndrome:

A condition in which the follicle develops and changes into the corpus luteum without releasing the egg.

Luteinizing Hormone (LH):

A pituitary hormone that stimulates the gonads. In the man LH is necessary for spermatogenesis (Sertoli cell function) and for the production of testosterone (Leydig cell function). In the woman LH is necessary for the production of estrogen. When estrogen reaches a critical peak, the pituitary releases a surge of LH (the LH spike), which releases the egg from the follicle.

Luteinizing Hormone Surge (LH SURGE):

The release of luteinizing hormone (LH) that causes release of a mature egg from the follicle. Ovulation test kits detect the sudden increase of LH, signaling that ovulation is about to occur (usually within 24-36 hours).

Masturbation:

A technique used to collect semen for analysis and for artificial insemination; manual stimulation of the penis leading to ejaculation.

Maturation Arrest:

A testicular condition in which at one stage of sperm production all sperm development halts throughout all testicular tubules. May result in oligospermia or azozoospermia.

Meiosis:

The cell division, peculiar to reproductive cells, which allows genetic material to divide in half. Each new cell will contain twenty-three chromosomes. The spermatids (immature sperm) and ova (eggs) each contain twenty-three chromosomes, so when they combine (fertilize), the baby will have a normal complement of forty-six.

Menorrhagia:

Heavy or prolonged menstrual flow.

Menstruation:

The cyclical shedding of the uterine lining in response to stimulation from estrogen and progesterone.

Metrodin (Pure FSH):

An injectable form of Follicle Stimulating Hormone used to stimulate ovulation.

Metrorrhagia:

Menstrual spotting during the middle of the cycle.

Miscarriage:

Spontaneous loss of an embryo or fetus from the womb.

Mitosis:

The division of a cell into two identical cells in which all forty-six human chromosomes are duplicated; the first division of the germ cell.

Mittleschmerz:

The discomfort felt on one side of the lower abdomen at the time of ovulation.

Mycoplasma:

See Ureaplasma.

Myomectomy:

Surgery performed to remove fibroid tumors.

Oligomenorrhea:

Infrequent menstrual periods.

Oligospermia, Oligozoospermia:

A sperm count below 20 million; a low sperm count; a sperm count low enough to cause a fertility problem.

Orgasm:

The psychological and physical thrill that accompanies sexual climax. For the man orgasm causes ejaculation.

Ovarian Cyst:

A fluid-filled sac inside the ovary. An ovarian cyst may be found in conjunction with ovulation disorders, tumors of the ovary, and endometriosis. See also Chocolate Cyst.

Ovarian Failure:

The failure of the ovary to respond to FSH stimulation from the pituitary because of damage to or malformation of the ovary. Diagnosed by elevated FSH in the blood.

Ovulation:

The release of the egg (ovum) from the ovarian follicle.

Ovulation Induction:

Medical treatment performed to initiate ovulation. See also Clomiphene Citrate; Pergonal.

Ovulatory Failure (Anovulation):

The failure to ovulate.

Ovum:

The egg; the reproductive cell from the ovary; the female gamete; the sex cell that contains the woman's genetic information.

Panbypopituitarism:

Complete pituitary gland failure.

Parlodel: See Bromocriptine.

Patent:

The condition of being open, as with tubes that form part of the reproductive organs.

Pelvic Inflammatory Disease (PID):

An infection of the pelvic organs that causes severe illness, high fever, and extreme pain. PID may lead to tubal blockage and pelvic adhesions.

Penile Implant:

A device surgically inserted into the penis to provide rigidity for intercourse. Used to treat impotence.

Penis:

The male organ that becomes enlarged and erect for the purpose of depositing semen in the woman's vagina.

Pergonal (HMG):

A medication used to replace the pituitary hormones, LH and FSH. May be used to induce ovulation in women who do not respond to clomiphene citrate. Most frequently used with women who do not normally produce estrogen because of a pituitary gland or hypothalamic malfunction. May also be used with men to stimulate sperm production.

PID:

See Pelvic Inflammatory Disease

Pituitary Gland:

The master gland; the gland that is stimulated by the hypothalamus and controls all hormonal functions. Located at the base of the brain just below the hypothalamus, this gland controls many major hormonal factories throughout the body including the gonads, the adrenal glands, and the thyroid gland.

Placenta:

The embryonic tissue that invades the uterine wall and provides a mechanism for exchanging the baby's waste products for the mother's nutrients and oxygen. The baby is connected to the placenta by the umbilical cord.

Polar Body:

The discarded genetic material resulting from female germ cell division. See also Meiosis.

Polycystic Ovaries (PCO or "Stein-Leventhal Syndrome"):

A condition found in women who don't ovulate, characterized by excessive production of androgens (male sex hormones) and the presence of cysts in the ovaries. Though PCO can be without symptoms, some include excessive weight gain, acne and excessive hair growth.

Post Coital Test (PCT):

A microscopic examination of the cervical mucus best performed twelve or more hours after intercourse to determine compatibility between the woman's mucus and the man's semen; a test used to detect sperm-mucus interaction problems, the presence of sperm antibodies, and the quality of the cervical mucus.

Posttesticular System:

The ducts that store and deliver the sperm to the opening of the penis; also includes the glands that produce seminal fluids.

Premature Ejaculation:

A condition in which the man becomes so sexually excited that most of the time he ejaculates prior to penetrating the woman's vagina.

Premature Ovarian Failure:

A condition where the ovary runs out of follicles before the normal age associated with menopause.

Pretesticular System:

The male hormonal system responsible for stimulating sperm production and the development of male secondary sex characteristics.

Progesterone:

The hormone produced by the corpus luteum during the second half of a woman's cycle. It thickens the lining of the uterus to prepare it to accept implantation of a fertilized egg.

Progesterone Withdrawal:

A diagnostic procedure used to analyze menstrual irregularity and amenorrhea; uterine "bleeding" that occurs within two weeks after taking progesterone; a procedure used to demonstrate the presence or absence of estrogen and to demonstrate the ability of the uterus and reproductive tract to "bleed." Prior to ovulation induction therapy, progesterone withdrawal may be used to induce a menstrual period.

Prolactin:

The hormone that stimulates the production of milk in breastfeeding women. Excessive prolactin levels when not breastfeeding may result in infertility.

Prostaglandin:

A hormone secreted by the uterine lining. It is hypothesized that prostaglandins secreted by active, young endometrial implants may interfere with the reproductive organs by causing muscular contractions or spasms.

Prostate Gland:

A gland in the male reproductive system that produces a portion of the semen including a chemical that liquefies the coagulated semen twenty minutes to go one hour after entering the vagina.

Puberty:

The time of life when the body begins making adult levels of sex hormones - (estrogen or testosterone) and the youngster takes on adult body characteristics: developing breasts, growing a beard, pubic hair, and auxiliary hair; attaining sexual maturity.

Refractory Period:

A period of time after orgasm during which a man or woman cannot have another; a recovery period.

Resistant Ovary:

An ovary that cannot respond to the follicle-stimulating message sent by FSH. Primitive germ cells will be present in the ovary; however, they will not respond to FSH stimulation.

Retrograde Ejaculation:

A male fertility problem that allows the sperm to travel into the bladder instead of out the opening of the penis due to a failure in the sphincter muscle at the base of the bladder.

Salpingectomy:

Surgical removal of the fallopian tube.

Salpingolysis:

Surgery performed to remove adhesions that restrict the movement and function of reproductive organs.

Salpingostomy/Fimbrioplasty:

Surgical repair made to the fallopian tubes; a procedure used to open the fimbria.

Scrotum:

The bag of skin and thin muscle surrounding the man's testicles.

Secondary Infertility:

The inability of a couple which has successfully achieved pregnancy to achieve another. This strict medical definition includes couples for whom the pregnancy did not go to term. The common vernacular, however, refers to a couple which has one biological child but is unable to conceive another.

Secondary Sex Characteristics:

The physical qualities that distinguish man and woman, such as beard, large breasts, and deep voice. Formed under the stimulation of the sex hormones (testosterone or estrogen), these characteristics also identify those people who have gone through puberty (sexual maturity).

Semen:

The fluid portion of the ejaculate consisting of secretions from the seminal vesicles, prostate gland, and several other glands in the male reproductive tract. The semen provides nourishment and protection for the sperm and a medium in which the sperm can travel to the woman's vagina. Semen may also refer to the entire ejaculate, including the sperm.

Semen Analysis:

A laboratory test used to assess semen quality: sperm quantity, concentration, morphology (form), and motility. In addition, it measures semen (fluid) volume and whether or not white blood cells are present, indicating an infection.

Semen Viscosity:

The liquid flow or consistency of the semen.

Seminal Vesicles:

Glands in the male reproductive system which produce much of the semen volume, including fructose (sugar) for nourishing the sperm and a chemical that causes the semen to coagulate on entering the vagina.

Seminiferous Tubes:

The testicular tubules in which the sperm mature and move toward the epididymis.

Septate uterus:

A uterus divided into right and left halves by a wall of tissue (septum). Women with a septate uterus have an increased chance of early pregnancy loss.

Serophene:

Brand name for clomiphene citrate. (See CLOMID.)

Sertoli (Nurse) Cell:

A testicular cell responsible for nurturing the spermatids (immature sperm). Secretes inhibin, a feedback hormone, which regulates FSH production by the pituitary gland. When stimulated by FSH, the Sertoli cell initiates spermatogenesis.

Sheehan's Syndrome:

A condition caused by profuse hemorrhage at the time of delivery. The severe blood loss shocks the pituitary gland, which dies and becomes nonfunctional.

Short Luted Phase:

A condition in which the corpus luteum deteriorates prematurely, causing the menstrual period to begin approximately ten days (instead of fourteen) after ovulation. Frequently found with women undergoing ovulation induction treatment.

Sonogram (Ultrasound):

Use of high-frequency sound waves for creating an image of internal body parts. Used to detect and count follicle growth (and disappearance) in many fertility treatments. Also used to detect and monitor pregnancy.

Sperm:

The microscopic cell that carries the male's genetic information to the female's egg; the male reproductive cell; the male gamete.

Sperm Agglutination:

Sperm clumping caused by antibody reactions or by infection.

Sperm Antibodies:

Antibodies that attack and maim sperm. May be formed by either the man against his own sperm or by the woman against her husband's sperm.

Sperm Bank:

A place where sperm are kept frozen in liquid nitrogen for later use in artificial insemination.

Sperm Count:

The number of sperm in ejaculate. Also called sperm concentration and given as the number of sperm per milliliter.

Sperm Maturation:

A process during which the sperm grow and gain their ability to swim. Sperm take about ninety days to reach maturity.

Sperm Morphology:

A semen analysis factor that indicates the number or percentage of sperm in the sample that appear to have been formed normally. Abnormal morphology includes sperm with kinked, doubled, or coiled tails.

Sperm Motility:

The ability of sperm to swim. Poor motility means the sperm have a difficult time swimming toward their goal---the egg.

Sperm Penetration:

The ability of the sperm to penetrate the egg so it can deposit the genetic material during fertilization.

Spermatogenesis:

Sperm production in the testicles.

Spinnbarkeit:

The stretchability of cervical mucus; the stringy quality that occurs at midcycle under the influence of estrogen. See also Postcoital Test.

Split Ejaculate:

A method used to concentrate the sperm for insemination; separating the semen into two portions: the first portion of the ejaculate, which is rich in sperm, and the second portion, which contains mostly seminal fluid.

Spontaneous Abortion:

See Abortion, Spontaneous.

Stein-Leventhal Disease:

Another name for polycystic ovaries.

Sterility:

An irreversible condition that prevents conception.

Stillbirth:

The death of a fetus between the twentieth week of gestation and birth.

Superovulation:

Stimulation of multiple ovulation with fertility drugs; also known as controlled ovarian hyperstimulation (COH).

Surrogate Mother:

A woman who is artificially inseminated and carries to term a baby which will be raised by its genetic father and his partner.

Testicular Biopsy:

A minor surgical procedure used to take a small sample of testicular tissue for microscopic examination; a test used to diagnose male fertility problems when no other means is available (this is because the biopsy procedure itself may cause testicular damage).

Testicular Biopsy:

A minor surgical procedure used to take a small sample of testicular tissue for microscopic examination; a test used to diagnose male fertility problems when no other means is available (this is because the biopsy procedure itself may cause testicular damage).

Testicular Enzyme Defect:

A congenital enzyme defect that prevents the testes from responding to hormonal stimulation. Will result in oligospermia or azozoospermia.

Testicular Failure, Primary:

A congenital, developmental, or genetic error resulting in a testicular malformation that prevents sperm production.

Testicular Failure, Secondary:

Acquired testicular damage - for example, from drugs, prolonged exposure to toxic substances, or a varicocoele.

Testicular Feminization:

An enzymatic defect that prevents a man from responding to the male hormone testosterone. The man will look like a woman, but karyotyping will reveal a normal XY male chromosome pattern, and testosterone levels will be in the normal male range.

Testicular Function:

The ability of the testicles to produce sperm and testosterone.

Testicular Stress Pattern:

A semen analysis result showing depressed sperm production, poor sperm motility, and poor sperm morphology. The pattern is consistent with secondary testicular failure or illness.

Testosterone:

The male hormone responsible for the formation of secondary sex characteristics and for supporting the sex drive. Testosterone is also necessary for spermatogenesis.

Thyroid Gland:

The endocrine gland in the front of the neck that produces thyroid hormones to regulate the body's metabolism.

Torsion:

The twisting of the testis inside the scrotum. Besides causing extreme pain and swelling, the rotation twists off the blood supply and causes severe damage to the testicle. Torsion of the ovary may also occur in a woman suffering from hyperstimulation, a complication of ovulation induction treatment.

Trichomonas:

An infection that may produce a greenish, bad-smelling vaginal discharge.

Tubocornual Anastomosis:

Surgery performed to remove a blocked portion of the fallopian tube and to reconnect the tube to the uterus. Tubouterine implantation may also be performed to remove fallopian tube blockage near the uterus and reimplant the tube in the uterus.

Tubotubal Anastomosis:

Surgery performed to remove a diseased portion of the fallopian tube and reconnect the two ends; sterilization reversal.

Turner's Syndrome:

The most common genetic defect contributing to female fertility problems. The ovaries fail to form and appear as slender threads of atrophic ovarian tissue, referred to as streak ovaries. Karyotyping will reveal that this woman has only one female (X) chromosome instead of two.

Ultrasound:

A test used instead of X rays to visualize the reproductive organs; for example, to monitor follicular development and to examine the tubes and uterus. The instrument works by bouncing sound waves off the organs. A picture displayed on a TV screen shows the internal organs.

Umbilical Cord:

Two arteries and one vein encased in a gelatinous tube leading from the baby to the placenta. Used to exchange nutrients and oxygen from the mother for waste products from the baby.

Undescended Testicles (Cryptorchidism):

The failure of the testicles to descend from the abdominal cavity into the scrotum by one year of age. If not repaired by age six, may result in permanent fertility loss.

Unicornuate Uterus:

An abnormality in which the uterus is "one sided" and smaller than usual.

Ureaplasma (Mycoplasma):

An infection that may cause the formation of sperm antibodies and an inflammation of the uterine lining, either of which may interfere with implantation of the embryo.

Urethra:

The tube that allows urine to pass between the bladder and the outside of the body. In the man this tube also carries semen from the area of the prostate to the outside.

Urologist:

A physician specializing in the genitourinary tract.

Uterus:

The hollow, muscular organ that houses and nourishes the fetus during pregnancy.

Vagina:

The canal leading from the cervix to the outside of the woman's body; the birth passage.

Vaginitis:

Yeast, bacterial vaginosis, or trichomonas infections of the vagina. Frequent vaginitis may indicate the presence of pelvic adhesions and tubal blockage from other infections, such as chlamydia. Vaginitis may interfere with sperm penetration of the cervical mucus, and the symptoms may even interfere with the ability and desire to have intercourse.

Varicocoele:

A dilation of the veins that carry blood out of the scrotum. The resulting swollen vessels surrounding the testicles create a pool of stagnant blood, which elevates the scrotal temperature. A major cause of male infertility.

Vas Deferens:

One of the tubes through which the sperm move from the testicles (epididymis) toward the seminal vesicles and prostate gland. These tubes are severed during a vasectomy performed for birth control.

Vasectomy:

The accidental or elective surgical separation of the vasa deferential a procedure used for birth control.

Venereal Disease:

Any infection that can be sexually transmitted, such as chlamydia, gonorrhea, ureaplasma, and syphilis. Many of these diseases will interfere with fertility and some will cause severe illness. See also PID.

Virility:

Masculinization; having male secondary sex characteristics; being able to perform sexually.

X Chromosome:

The congenital, developmental, or genetic information in the cell that transmits the information necessary to make a female. All eggs contain one X chromosome, and half of all sperm carry an X chromosome. When two X chromosomes combine, the baby will be a girl. See also Y. Chromosome.

Y Chromosome:

The genetic material that transmits the information necessary to make a male. The Y chromosome can be found in one-half of the man's sperm cells. When an X and a Y chromosome combine, the baby will be a boy. See also X Chromosome.

Zygote:

A fertilized egg which has not yet divided.

Zygote Intrafallopian Transfer (ZIFT):

An ART in which eggs are removed from a woman's ovaries, fertilized with the man's sperm in a lab dish, and the resulting embryos are transferred into the woman's fallopian tubes during a minor surgical procedure.