The male factor is often disregarded as being all about count and motility. However, this is just not true. Science and Reprodcutive Medicine have been looking at qualitative factors of the sperm for years, and some tests are now commercially availabe that can:
1) ...determine if IUI is a reasonable treatment or not. IUI does nothing except get sperm closer to where fertilization takes place in the fallopian tube. The sperm are taken about halfway there with IUI. This can give the couple a leg up in the chance of achieving a pregnancy, if there is no siginificant male factor. This means not only decent count and motility, but good quality as measured by DNA fragmentation testing. Even if count is stellar, if quality is bad then there will be lower (possibility zero) chance that IUI will do anything for the couple.
2) ...have an impact on trying to improve male factor BEFORE treatment, to try and make that treamtment more successful. Medications have been proven, in the right circumstances as determined by simple sperm and blood tests on the male, to improve count and quality---all making the chance of treatment success better. The key is proper evaluation and discussion PRIOR to any treament.
3) proper testing can also determine if long term sperm cryopreservation is a valuable tool for the couple. If it can be determined that the problem will likely worsen for the male, it is advantageous to freeze some sperm. That way, if in the future there are NO sperm at all due to worsening condition, the frozen sperm can be utilized.
So many times I see couples that have gone down the road of mutliple IUI cycles and later find out they had little to no chance of working in the first place. All this can be known ahead of time with simple tests and counseling by proper medical personnel. Bottom line: know your options.
Thursday, October 15, 2009
FSH Level and what It Really Means
FSH is a hormone produced by the pituitary gland and is an indirect assessment of ovarian reserve. What this means is that indirectly it is related to assessing ovarian function, namely trying to assess the number of eggs remaining in the ovaries. In years past it was essentially the only way to assess ovarian function and ovarian reserve. Currently, however, it is well
understood that it is inadequate when used in and of itself. It can be very misleading and provide a “false sense of security” to patients and medical professionals. It remains of use. However, it should never be used alone in making a statement about ovarian function or reserve. It is clear with our data and others that it has a very high false negative rate when attempting to answer the question, “Do I have good ovarian reserve?”.
The bottom line is that in young patients (less than age thirty-five) the FSH
often is falsely normal, giving the impression that ovarian reserve is good. In my experience and observations over several hundred patients, in young atients with low ovarian reserve the FSH is often normal; and menstrual cycle irregularities are minimal.
Thus in assessing ovarian reserve, patients often get an FSH and rely upon menstrual history but are falsely led to believe that ovarian reserve is good when FSH and menstrual cyclicity are normal. We very often see normal FSH in these patients, but further assessment with simple blood tests and ultrasonography reveals low ovarian reserve. In patients over the age of thirty-five the FSH is a bit more reliable in indicating low ovarian reserve. That is to say when the FSH is high, ovarian reserve can reliably be diagnosed as being low.
However when the FSH is normal in patients over the age of thirty-five, this, as with patients under the age of thirty-five, does not necessarily mean that reserve is normal. In further explanation, ovarian reserve can be low in patients over the thirty-five even when the FSH is normal. So, again in and of itself the FSH is a poor indicator of ovarian reserve in patients over the age of thirty-five and an even worse indicator in patients under the age of thirty-five. Therefore, simple further tests need to be done to put the test results into proper context for any individual case.
When the FSH is elevated (over 9) in any age group of patient, the ovarian reserve is often low. his is why at SIRM it is routine for us obtain the following tests in addition to FSH to give us the best picture of ovarian reserve thus allowing us to put it into context with the individual couple: FSH, inhibin B, AMH, and antral follicle count (AFC). If one were to ask me which of these tests if the best, AFC is by far the most useful clinically in managing patients with fertility issues, regardless of what those issues might be (endometriosis, tubal factor, male factor, etc.).
Ovarian reserve remains the single most important factor in reproductive success; not to say that other issues are not important obviously, but this is always the most important part of the evaluation. This part of the evaluation with blood tests and ultrasonography can be done in a single visit early in the menstrual cycle, easy to organize. Information is obtained immediately with the follicle count assessment and can be discussed on the spot with respect to the patient’s and couple’s issues.
So, the take-home point above anything else from this information is that one should not rely on the FSH number alone, because even if it is normal, there can still be significant low ovarian reserve, and simple further assessment is necessary to give one the full picture. High FSH is a reliable indicator of poor ovarian reserve in most cases, but further assessment is still necessary to understand the degree of low reserve.
understood that it is inadequate when used in and of itself. It can be very misleading and provide a “false sense of security” to patients and medical professionals. It remains of use. However, it should never be used alone in making a statement about ovarian function or reserve. It is clear with our data and others that it has a very high false negative rate when attempting to answer the question, “Do I have good ovarian reserve?”.
The bottom line is that in young patients (less than age thirty-five) the FSH
often is falsely normal, giving the impression that ovarian reserve is good. In my experience and observations over several hundred patients, in young atients with low ovarian reserve the FSH is often normal; and menstrual cycle irregularities are minimal.
Thus in assessing ovarian reserve, patients often get an FSH and rely upon menstrual history but are falsely led to believe that ovarian reserve is good when FSH and menstrual cyclicity are normal. We very often see normal FSH in these patients, but further assessment with simple blood tests and ultrasonography reveals low ovarian reserve. In patients over the age of thirty-five the FSH is a bit more reliable in indicating low ovarian reserve. That is to say when the FSH is high, ovarian reserve can reliably be diagnosed as being low.
However when the FSH is normal in patients over the age of thirty-five, this, as with patients under the age of thirty-five, does not necessarily mean that reserve is normal. In further explanation, ovarian reserve can be low in patients over the thirty-five even when the FSH is normal. So, again in and of itself the FSH is a poor indicator of ovarian reserve in patients over the age of thirty-five and an even worse indicator in patients under the age of thirty-five. Therefore, simple further tests need to be done to put the test results into proper context for any individual case.
When the FSH is elevated (over 9) in any age group of patient, the ovarian reserve is often low. his is why at SIRM it is routine for us obtain the following tests in addition to FSH to give us the best picture of ovarian reserve thus allowing us to put it into context with the individual couple: FSH, inhibin B, AMH, and antral follicle count (AFC). If one were to ask me which of these tests if the best, AFC is by far the most useful clinically in managing patients with fertility issues, regardless of what those issues might be (endometriosis, tubal factor, male factor, etc.).
Ovarian reserve remains the single most important factor in reproductive success; not to say that other issues are not important obviously, but this is always the most important part of the evaluation. This part of the evaluation with blood tests and ultrasonography can be done in a single visit early in the menstrual cycle, easy to organize. Information is obtained immediately with the follicle count assessment and can be discussed on the spot with respect to the patient’s and couple’s issues.
So, the take-home point above anything else from this information is that one should not rely on the FSH number alone, because even if it is normal, there can still be significant low ovarian reserve, and simple further assessment is necessary to give one the full picture. High FSH is a reliable indicator of poor ovarian reserve in most cases, but further assessment is still necessary to understand the degree of low reserve.
Saturday, October 10, 2009
HSG in the evaluation of infertility, Is there any purpose?
The Use of HSG (hysterosalpiingogram) in the evlaution of infertility in my opinion should be essentially relegated to the history books. This is the test wherein dye is injected into the uterus and x-rays are taken to see if it spills out of the tubes into the abdominal cavity. The problems with this test (as many of you will attest) are virtually legendary:
1) Pain. It is painful and unpleasant. I think many women would put up with it if it provided good information that is helpful to the couple. That is the problem...it really does not.
2) False Negative tests are common. If the test is totally normal it is true that HSG tells accurately if the tubes are open. However, there are many false negatives. that is patients are told the tubes are open, and this means the tubes are just fine. They then proceed with clomid, IUI, etc. Later they ahve a laparoscopy to find out the tubes are damaged or distorted by adhesions (but open...) and/or there are other problems like endometriosis, etc. that can prodoundly affect fertility. Also these conditions significantly lower the probability of success of those prior treatemnts...Personally I feel that this would have been nice to know prior to embarking on those treatments.
3) False Postive tests are common. During the process of injecting the dye with HSG, air bubbles often are introduced. These can produce the appearance of blockage at the proximal part of the tube, the part where the tube meets the uterus. Additonally when the dye is introduced rapidly by the person doing the injection, the uterus expand quickly and its natural reaction is to contract (i.e. spasm). This is why it is so painful often times as well. The spasm also can falsely produce the appearance of blockage. What happens next is often the patients are told they need IVF or worse, told they need another HSG or tubal catheterization procedure to determine if this is truly a blockage or not...
4) The HSG does not evaluate the pelvis. Along the same vein as #2, a normal HSG does not tell you if there is tubal damage not resulting in blockage. Nor does it tell you if there are other factors in the pelvis that profoundly can affect fertility (namely endometirosis and adhesions). The majority of patients I see that have tubal damage in fact do not have blockage, i.e. they ahve a 'normal' HSG.
So I believe the better way to go about the fertility evaluation in the most efficient and cost effective manner is to skip the HSG all together. One can evaluate tubal patency just as reliably with in office ultrasound in most cases and without nearly the level of discomfort for the patient seen with HSG. The laparoscopy should replace the HSG in selected cases where the answer for fertility is not found with the simple male and female evaluation (blood test, US, male tests). Not all patients need laparoscopy, so be clear on that. Do it where it will help the couple make decisions on future fertility treaments, i.e. in cases where the findings with laparoscopy will affect future fertility treatment outcome, thus help decide beforehand what treatments you will do in the first place. After all, it is a basic tenet of medicine to try and have a diagnosis BEFORE you treat...same with fertility treaments. The HSG serves only to delay the efficient evaluation, beget delays in treatment and lead to unnecessary tests. Not too mention all this burdens the system with increased costs and burdens patients with painful exams that do not meaningfully help them. It is a rare case indeed where I feel that the HSG helps the couple by providing useful information that helps them make decisions.
1) Pain. It is painful and unpleasant. I think many women would put up with it if it provided good information that is helpful to the couple. That is the problem...it really does not.
2) False Negative tests are common. If the test is totally normal it is true that HSG tells accurately if the tubes are open. However, there are many false negatives. that is patients are told the tubes are open, and this means the tubes are just fine. They then proceed with clomid, IUI, etc. Later they ahve a laparoscopy to find out the tubes are damaged or distorted by adhesions (but open...) and/or there are other problems like endometriosis, etc. that can prodoundly affect fertility. Also these conditions significantly lower the probability of success of those prior treatemnts...Personally I feel that this would have been nice to know prior to embarking on those treatments.
3) False Postive tests are common. During the process of injecting the dye with HSG, air bubbles often are introduced. These can produce the appearance of blockage at the proximal part of the tube, the part where the tube meets the uterus. Additonally when the dye is introduced rapidly by the person doing the injection, the uterus expand quickly and its natural reaction is to contract (i.e. spasm). This is why it is so painful often times as well. The spasm also can falsely produce the appearance of blockage. What happens next is often the patients are told they need IVF or worse, told they need another HSG or tubal catheterization procedure to determine if this is truly a blockage or not...
4) The HSG does not evaluate the pelvis. Along the same vein as #2, a normal HSG does not tell you if there is tubal damage not resulting in blockage. Nor does it tell you if there are other factors in the pelvis that profoundly can affect fertility (namely endometirosis and adhesions). The majority of patients I see that have tubal damage in fact do not have blockage, i.e. they ahve a 'normal' HSG.
So I believe the better way to go about the fertility evaluation in the most efficient and cost effective manner is to skip the HSG all together. One can evaluate tubal patency just as reliably with in office ultrasound in most cases and without nearly the level of discomfort for the patient seen with HSG. The laparoscopy should replace the HSG in selected cases where the answer for fertility is not found with the simple male and female evaluation (blood test, US, male tests). Not all patients need laparoscopy, so be clear on that. Do it where it will help the couple make decisions on future fertility treaments, i.e. in cases where the findings with laparoscopy will affect future fertility treatment outcome, thus help decide beforehand what treatments you will do in the first place. After all, it is a basic tenet of medicine to try and have a diagnosis BEFORE you treat...same with fertility treaments. The HSG serves only to delay the efficient evaluation, beget delays in treatment and lead to unnecessary tests. Not too mention all this burdens the system with increased costs and burdens patients with painful exams that do not meaningfully help them. It is a rare case indeed where I feel that the HSG helps the couple by providing useful information that helps them make decisions.
The available treatments for fertility essentially involve 4 categories: (which is appropriate for you?)
1) Nothing. Hands off, wait and see approach. Appropriate in some cases
2)Ovulation induction. This is the use of medications (pills or shots) to induce follicle growth and development with subsequent ovulation. Appropriate when there is an ovulation dysfunction, usually easily diagnosable condition. If already ovulatory patients, these medications (namely shots) can be used to induce multiple ovulations, increasing the chance that one egg makes it…of course inherent risk of multiple pregnancy and simple monitoring can minimize this risk when using these medications. Unfortunately, these medications are often used when not appropriate (tubal factor, severe male factor, etc) and therefore in such cases will have a dismal success potential. Also, unfortunately, sometimes these medicines are misused and the result is unacceptably high risk of high order multiple pregnancy (triplets or more) and the resultant costs (financial and medical) of problematic pregnancy. Overall, ovulation induction ahs a low reported success rate due to these issues and ultimately is not very cost effective versus IVF.
3) Intrauterine insemination. This can be useful in some cases of minor male factor infertility and cervical factor infertility (not common). However, it is often used/misused. Literature reports low success with this treatment also versus IVF. Investigation of male and female factors is key before embarking on IUIs. Ti is easy to do and make sure that you are not doing this treatment in a circumstance that is suboptimal. The evaluation is simple however most medical offices will not be complete enough in the testing—male factors(semen analysis and DNA fragmentation needed!). So be sure to ask!!
With a few notable exceptions, male factor-related causes of infertility are not readily amenable to correction by medical/hormonal or surgical treatment. Specifically, in all but mild cases of male infertility, the performance of IUI is of doubtful benefit. The relatively recent introduction of a form of IVF known as Intracytoplasmic Sperm Injection (ICSI) has all but eliminated male factor from the list of refractory causes of infertility.
4) In Vitro Fertilization. Undoubtedly the most successful therapy we have, no matter what the medical problems. In the right circumstances also the most cost effective.ASK AND BE INFORMED. PLEASE LET ME KNOW IF SIRM St louis can be of help in assessing fertility issues and/or be of help in providing therapy. Evaluation is key and can be done quickly, efficiently and thoroughly—usually all in one day so start there!
1) Nothing. Hands off, wait and see approach. Appropriate in some cases
2)Ovulation induction. This is the use of medications (pills or shots) to induce follicle growth and development with subsequent ovulation. Appropriate when there is an ovulation dysfunction, usually easily diagnosable condition. If already ovulatory patients, these medications (namely shots) can be used to induce multiple ovulations, increasing the chance that one egg makes it…of course inherent risk of multiple pregnancy and simple monitoring can minimize this risk when using these medications. Unfortunately, these medications are often used when not appropriate (tubal factor, severe male factor, etc) and therefore in such cases will have a dismal success potential. Also, unfortunately, sometimes these medicines are misused and the result is unacceptably high risk of high order multiple pregnancy (triplets or more) and the resultant costs (financial and medical) of problematic pregnancy. Overall, ovulation induction ahs a low reported success rate due to these issues and ultimately is not very cost effective versus IVF.
3) Intrauterine insemination. This can be useful in some cases of minor male factor infertility and cervical factor infertility (not common). However, it is often used/misused. Literature reports low success with this treatment also versus IVF. Investigation of male and female factors is key before embarking on IUIs. Ti is easy to do and make sure that you are not doing this treatment in a circumstance that is suboptimal. The evaluation is simple however most medical offices will not be complete enough in the testing—male factors(semen analysis and DNA fragmentation needed!). So be sure to ask!!
With a few notable exceptions, male factor-related causes of infertility are not readily amenable to correction by medical/hormonal or surgical treatment. Specifically, in all but mild cases of male infertility, the performance of IUI is of doubtful benefit. The relatively recent introduction of a form of IVF known as Intracytoplasmic Sperm Injection (ICSI) has all but eliminated male factor from the list of refractory causes of infertility.
4) In Vitro Fertilization. Undoubtedly the most successful therapy we have, no matter what the medical problems. In the right circumstances also the most cost effective.ASK AND BE INFORMED. PLEASE LET ME KNOW IF SIRM St louis can be of help in assessing fertility issues and/or be of help in providing therapy. Evaluation is key and can be done quickly, efficiently and thoroughly—usually all in one day so start there!
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