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FAQs About Infertility
From the Woman's Diagnostic Cyber - Frederick R. Jelovsek MD
   
Double uterus
Yes. It can be as much as a full period although most of the time
it is less -- light bleeding or spotting.
Sometimes pregnancy tests can be negative like with an ectopic
if the HCG levels are low. Other times there can be secretion of
urine proteins that actually interfere with the pregnancy test. A
blood pregnancy test (quantitative serum B-HCG) is the most
accurate and if it's negative, you aren't pregnant.
Ask the doctor to order an MRI (magnetic resonance imaging).
It's expensive but it is most likely to answer the question short
of surgery to "look".
Almost always there are still only two ovaries even though there
are two uteri. 4 ovaries would be a reportable case.
Its likely that there is not a 2nd cervix if they can't see
one. Abnormal development of the genital tract can do that. You
may have 2 cavities but only one fully formed cervix.
It's possible but you need to get the quantitative beta-HCG to
be sure, or wait a week for the regular pregnancy test to be sure.
How often is there a male factor causing infertility?
Male factor contributing to infertility is about 40-50%. In
less than half of that though, the male is totally sterile (about 10-
20%).
See the two abstracts listed at the end of this response.
If there is any sperm at all, it can be concentrated or even
micro-injected into an egg (intracytoplasmic sperm injection -
ICSI) by infertility specialists using advanced reproductive
technologies such as in-vitro fertilization. This is the most
common way this problem is currently treated
Be sure to see the Infertility FAQs at:
Infertility FAQs
***** Abstracts
Endocrinol Metab Clin North Am 1994 Dec;23(4):783-793
Male infertility.
Baker HW
Department of Obstetrics and Gynaecology, University of
Melbourne, Royal Women's Hospital, Australia.
Male infertility is a common problem but only about one quarter
of patients have specific or defined conditions that make them
either sterile or severely infertile. About half of these
patients have untreatable primary seminiferous tubule failure,
and donor insemination or adoption are the only possibilities of
having a family. The other half have potentially treatable
conditions, including genital tract obstruction, sperm
autoimmunity, gonadotropin deficiency, coital disorders, or
reversible toxin effects. The majority of men seen for
infertility (75%) have reduced semen quality, which impairs
fertility to a variable degree. Thus far no treatments have been
shown unequivocally to increase semen quality and fertility in
this group. Assisted reproductive technology has improved the
outlook for pregnancy in couples with male infertility and the
new technique of intracytoplasmic sperm injection promises to
further improve results for those with severe sperm defects or
previous failure of in vitro fertilization.
*****
Arch Androl 1997 Nov;39(3):197-210
Relationship between etiological factors and total motile sperm
count in 350 infertile patients.
Martin-Du Pan RC, Bischof P, Campana A, Morabia A
Department of Obstetrics and Gynecology, University of Geneva,
Switzerland.
The prevalence of different etiologic factors has been evaluated
in 350 male patients consulting the same physician in an urban,
ambulatory setting for primary or secondary infertility of more
than 1 year. Environmental factors such as alcohol or drugs
represented 12% of the etiologies, acquired diseases such as
varicocele and prostatitis 40%, congenital diseases and primary
testicular failure 16.2%, idiopathic cases 19.4%, and abnormality
of sperm transport 7.4%. The severity of sperm alterations in the
different etiologic categories was evaluated by the total motile
sperm count per ejaculate (TMS) (normal > 16). The TMS was less
than 5 in classical causes of male infertility such as testicular
failure, endocrinopathy, cancer, or antisperm antibodies. It was
more than 10 in controversial causes of infertility such as
varicocele, prostatitis, chlamydial infections, and professional
exposure to heat. After treatment, there was a nonsignificant
increase of the TMS in the latter cases. In cases of azoospermia
of pituitary origin, the TMS was normalized by a hormonal
treatment. In some cases of azoospermia of possible obstructive
origin, sperm appeared in the ejaculate after diclofenac
treatment. The utility of andrological investigation and
treatment is discussed.
Anovulation and excess weight
In polycystic ovarian syndrome, usually the LH/FSH ratio is
greater than 3 but not always. It's not the absolute levels that
are key. Your values may or may not represent PCOS. The
ultrasound may help but there can be follicles present in ANY
anovulatory state. If there were more (or equal to) 10 follicles
in one or both ovaries, that would be evidence toward PCOS.
See our news article about Diagnosis of Polycystic Ovarian Syndrome
The rough skin makes me think of hypothyroidism. I assume you
had that checked; its pretty routine for anovulation. The excess
hair growth can represent androgen excess from the ovary
(testosterone) or from the adrenal gland (DHEA). Have both of
those hormones been checked?
Also at your weight, a check for diabetes or abnormal glucose
tolerance should be done. Any abnormal glucose findings would go
along with PCOS. The weight itself is a problem for anovulation
as I'm sure you know. Weight watchers or Overeaters Anonymous may
be helpful for this at your weight. I don't mean to be unkind,
but I know its affect on health.
At this point, I would ask your RE (not quarrelously but
firmly) to do any additional studies such as the above. There is
a tendency on the part of many physicians to skip tests in the
interest of reducing costs if there is not going to be a
difference in the treatment. In your case, there may not be any
difference in how you are going to be treated unless the thyroid
test (TSH) or the adrenal test (DHEA) is abnormal. It may also be
that your RE is just judgmental about "large" women and may be
jumping to the conclusion that the weight is the only
problem.
Are you currently on any medication?
Have you had any treatment for the anovulation or are you just
in the diagnostic process now?
I read your reply, you asked if I am currently on meds. I am
not. My RE told me that Gonal F would be my next step, and as we
cannot afford this, and our insurance doesn't cover treatment,
this isn't an option. I was on 6 cycles of ClomidŽ last yr,
starting at 50 mg and ending at 150 mg. With HCG on day 14 of my
last cycle of ClomidŽ. I failed to ovulate on these (according to
BBT) I was not monitored. I had a glucose tolerance and the GYN
has written to the side of the numbers, "normal". This is why my
2nd GYN concluded that I didn't have PCO and referred me to an
RE. I have my records in front of me, and do not see the tests
for testosterone, DHEA or TSH anywhere, unless they are written
out in some other way. I had a thyroid test done in March of this
yr. The TSH from that test results say 4.26, this test was done
by a diet doctor, not my GYN or RE. If these are all important
tests, why weren't they done on me? Wouldn't a testosterone test
be a given? I don't want to sound argumentive but I would think
they would perform every test possible before I had to give up
with the Gonal F? None of my Dr's have mentioned my weight and I
have even asked them if it was affecting my fertility, they all
said no. Each said losing might help with labor and delivery, but
might not cure my infertility. The diet doctor said with my low
BBTs I wouldn't be able to get pregnant. I haven't heard any
other Dr mention this. They average 96.7 to 97.3 upon awakening.
Thank you very much for your help, and if you have any other
ideas, PLEASE reply. Do you think I should switch REs? He is dead
set on my beginning Gonal F. His reasoning for this was my FSH
was 4.1 and my E2 was 105.
I don't think you need to change REs, but just ask him to
check out the excess hair growth by looking at the ovarian and
adrenal androgens (testosterone and DHEA).
You probably will still need something like the Gonal F
(pituitary gonadotropin releasing hormone) because you failed to
ovulate with ClomidŽ. Moderate weight loss is well known to help
many women resume ovulation whether or not PCOS or adrenal
hyperplasia is a problem. The low basal body temperatures just
reflect the lack of ovulation. They don't CAUSE anything.
Initial infertility consultation
Usually just talk but sometimes will start a schedule for
tests if you and she agree to go ahead.
Tests depend on your history. She is searching for ovulatory
factors(ovary egg release), tubal factors, cervical factors, and
systemic diseases on you part and sperm/semen adequacy on your
husband's part.
To some extent, our other responder is correct about seeing reproductive
endocrine person. Infertility is their full time job. On the
other hand, general gynecologists across the country treat many
infertility patients and then they refer the ones who did not get
pregnant to the reproductive endocrine/infertility specialist. If
you are one of the people who ends up being referred, then you
feel you have wasted time and money. It's important when you see
your doctor that you both agree when to go on to further
"advanced reproductive technologies" that the infertility
specialist does.
Missed abortion after ClomidŽ therapy
2.96 is completely normal in our lab. Was that a normal value
in your doctor's lab?
Possible but if the TSH is normal, the antibodies (if they
existed) aren't enough to affect the thyroid function.
Most general gynecologists can prescribe ClomidŽ if that is
needed. They can also order thyroid studies. What are your
specific goals?
Your thyroid levels appear normal so the next step is to get
pregnant again, probably using ClomidŽ. The most likely
explanation for the missed miscarriage is either unknown or due
to age. Chances are still 2 out of 3 that if you get pregnant,
you will not miscarry.
Where are you starting the count for your luteal phase, from
the drop to the 1st day of your menses? What does OPK stand for?
What is total length of cycle?
Count from the temp drop to the start of menses to get luteal
phase. See past messages on luteal phase. Luteal phases don't
have to be short to be inadequate.
You should be detecting an LH surge with the kit. Double check
to see that you are following the directions correctly. You may
need to call your physician to see if you are doing it correctly.
Make sure the kit isn't outdated.
Ovulation prediction with a kit
I can't tell why it didn't work. Sometimes they just seem so
miss the short LH surge. How many days after your
temperature drop (before the rise) did your menstrual period
start? Were you testing at that time of the drop? For how many
days on each side?
If your cycles are fairly regular, it will probably be on the
same day but it can vary up to two days normally. If your cycles
are more variable, ovulation will be just as variable.
Be sure to use the kit before you think you will ovulate. By the
time the cervical mucus changes and you get an ovulatory temp
rise, the LH surge has already passed.
Short luteal phase
Normal luteal phases are 11-17 days measured from after the LH
surge, usually by an ovulation predictor kit. Ten days is
considered short. About 5% of all menstrual cycles have a short
luteal phase. This is one form of luteal phase defect that many
(but not all) infertility specialists think may affect fertility.
The classic form of luteal phase defect, however, is a normal
length luteal phase but evidence by endometrial biopsy that the
histologic appearance of the endometrium is at least 2 days
behind what is considered normal. These happen in about 30% of
cycles. Because of the frequent occurrence of these "defects", the
specialists say that you need to diagnose at least two of these
(usually in a row) in order to consider treatment.
Since we are a Diagnostic Cyber, I think its appropriate to focus
first on whether you really have a luteal phase defect and then,
if so, the treatment. Luteal phase defect, either a short phase
or an inadequate hormonal phase, is usually not diagnosed by BBT.
You may suspect it from the BBT but they are not that accurate. I
assume you are counting the days of elevated temperature. Many
normal BBT charts have only 10-12 days of good temperature
elevation. What is the total cycle length? I assume you've done
?2 cycles since your surgery?
The diagnosis is made one of two ways:
- Biopsy on day 24-26 that is read by an experienced pathologist
and lags by two or more days from what it should be.
- Serum progesterone on day 7 after ovulation that is greater
than 10ng/mL (some use 12 and others use 14ng/mL as the cutoff).
Almost all the scientific studies used the 1st criteria. Keep in
mind that many experts interpret those studies as not really
confirming that luteal phase defect has any effect on fertility.
Treatment is either progesterone suppositories or progesterone
vaginal cream for defects that are normal length but with
histology out of phase, or ovulation induction with ClomidŽ for
short phases or normal length, out-of-phase luteal phases. The
reason for this is that the luteal defect is thought to be due to
poor follicular development.
Have you asked your doctor about this yet?
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