Basic Infertility Overview
Frederick R. Jelovsek MD
"We are a couple married 9 years. We don't have a child. I had a cyst on the right ovary and it was removed by open surgery. It seems my tubules are in a mess. For my husband, a testicular biopsy was done, and the report shows that there is a complete maturation arrest of spermatozoa. Could you please help us to overcome this problem and inform us what can be done to have a child? Already we are getting old. My age is 30 and husband's age is 37. I have normal menstrual periods without pain (at times I have severe pain). Otherwise our sexual life is normal and active. ". R.
It sounds as if you have two possible problems, a male factor sperm problem and possibly a faloppian tube patency problem. But first, let us go over a general overview of infertility.
Causes And Treatments
Causes and treatments of infertility can be quite complicated depending upon many factors. Basically, all of the components in the sequence of a sperm fertilizing an egg and then implanting in the uterine cavity to grow, must be evaluated if a woman is having difficulty conceiving. In somewhere between 7 and 10% of couples, pregnancy will not occur within one year of attempting to conceive. In women over 35 years of age, doctors will often start an infertility work-up after only 6 months of trying unsuccessfully to get pregnant because of the maternal age factor and the feeling that time is short.
The parts of conceiving that can be impaired and thus need to be evaluated are:
- adequate sperm from the male partner
- appropriate frequency of sexual intercourse around the time of a woman's ovulation
- adequate, regular ovarian ovulation (release of the egg from the ovary)
- adequate passageway for egg to travel down the faloppian tube, meet sperm coming up the tube, and transport of the fertilized egg down to the uterus to implant and start growing
- and adequate passageway for the sperm to get through the cervix into the uterus so they can swim up into the faloppian tube to meet and fertilize the egg
Therefore in evaluating a couple who is having trouble conceiving, we can divide the diagnostic and treatment evaluation into: male factor (sperm count and quality), ovarian factor (ovulation frequency and regularity), tubal factor (clear passage to egg and sperm), cervical factor (clear passage to sperm from the vagina), and uterine factor (adequate space and tissue for the fertilized egg to implant and grow).
Male factor sperm count and quality
Since a male factor may account for up to 40-50% of infertility problems, doctors will order a semen analysis very early in the work-up of infertility. This includes a sperm count and an evaluation of the normality of sperm shapes as well as the movement ability. Only 10-20% of men have no mature, motile sperm at all. The rest just have low counts or fewer normal shaped and motile sperm than other fertile men. Sometimes men who have no sperm (azoospermia) can still have medicine to produce sperm or have advanced procedures in which sperm are actually aspirated with a needle from the testis. I am afraid from what you describe, that your husband's sperm problem is the major factor preventing you from conceiving but in up to 25% of the cases of azoospermia, doctors can use advanced technological procedures of overcome that lack of sperm as you can see in the article above from Sweden. You will need to see an infertility specialist or a urologist who specializes in male infertility
For usual sperm counts, doctors like to see an absolute motile sperm count of over 16 million. This is calculated by multiplying the amount of semen ejaculate in a specimen in milliliters (ml) by the count of how many million sperm per ml are present times the percent of motile sperm in the specimen. In other words a sperm count of 20 million sperm/ml with 80% motility and a total volume of one ml of ejaculate is probably adequate as is a count of only 10 million sperm/ml with 80% motilityand a total of 2 ml of ejaculate. A total count of less than 5 almost always results in sterility and counts between 5 and 16 can sometimes be overcome with infertility treatments and a couple have a normal pregnancy.
Ovarian factor - infrequent ovulation or anovulation
If a woman does not produce any eggs each month or only produces them every 2 or 3 months, then it will be quite difficult to get pregnant. The most common causes of not ovulating are polycystic ovarian syndrome (PCOS) and what is called hypothalamic amenorrhea which is like a stress-induced or medication-induced lack of ovulation. Rarer causes might include medical problems such as thyroid, kidney or an autoimmune disease or a premature ovarian failure (menopause) due to chemotherapy and other medicines or diseases such as systemic lupus erythematosis (SLE) among others.
Treatments for ovarian ovulation problems might include the fertility pill clomiphene citrate or other shots and medications such as gonadotropins (Pergonal®, Menotropin®).
In your case above, since your menses are regular, you are most likely ovulating. Not always, but most of the time. The doctor will still want to document ovulation using basal body temperature charting (BBTs), day 21 blood progesterone levels or ovulation predictor urinary tests.
Frequency of intercourse around ovulation time
Women who have regular menses usually ovulate about 14 days before a menstrual period. The range, however, is 10-17 days before menses. This means that if a woman has a 28 day cycle from the start of one menses to the start of another, she will probably ovulate on day 14 after the start of a menses. Ovulation can range from day 11 to day 18 so intercourse should take place during those days with a frequency of at least every other day (eg. days 11, 13, 15, 17). If a woman's menses came every 32 days, everything would shift by 4 days so that ovulation would be day 18 and the range might be day 15-21. if you are having intercourse only once during that time frame, it will be more difficult to conceive.
Tubal factor - unblocked and freely mobile faloppian tubes
The tubes must be free to sweep up an egg that has been ovulated from the ovary and then it must not have any blockage to passage for the egg, the sperm or the fertilized egg. Fertilization usually takes place in the faloppian tube close to mid way from the ovary to the uterus. Pelvic surgery, past ruptured ovarian cysts, past pelvic infection and endometriosis can affect the ability of the tube to sweep up the egg. Pelvic infection can also produce scarring inside the tube that prevents passageway of an ovum.
In your case, you said the tubes may be "messed up". The way to determine that is to have an xray of the uterus in which a dye or other substance is injected into the uterus and then an xray or ultrasound is used to see if the dye goes through the tubes into the pelvic cavity where the ovaries are. If the dye spills, then the tubes are open enough to allow pregnancy. You need to have this study done because if the tubes are not patent, all of the other treatment for your husband's sperm problem will not have any use for natural conception. Blocked tubes may be a reason to have in vitro fertilization however.
Uterine factor - successful implantation of the conceptus
Any condition that alters the amount or shape of the surface area of the inside of the uterus or alters the hormonal readiness of the lining of the uterus may impair fertility. Fibroids, polyps, congenital anomalies of the uterus, or past scarring due to surgery or infection will alter the surface area of the endometrium. Inadequate corpus luteum function may hormonally retard the lining (endometrium) so it is not ready for implantation.
allowing passage of the sperm from the vagina into the uterus and serving as a reservoir for sperm storage
Unless the cervix has undergone some sort of procedure that has destroyed the cervical mucous glands, it does not usually play a role in infertility. Cervical cryosurgery, conization, LEEP or laser procedures can destroy cervical mucous glands. Those glands act as a storage for sperm so that they can shower the uterus and tube with sperm in order not to miss ovulation. If those glands are destroyed, the frequency of intercourse may need to be increased in order to have the best chance at fertility.
In summary, your husband's condition is the most serious one but you also have to be checked out to make sure your tubes are not blocked. You will need to see a specialist in infertility. It sounds as if your husband has already seen one. For further information on infertility, you might try: