Hop on the Blame Train: Advanced Paternal Age Does Matter!

How many times have you read, been told, or watched someone lecture about what happens to us ladies as we age? Aside from the greying of our hair, the sagging of our bottoms, and the wrinkling of our skin, we can look forward to the withering of our ovaries. Sounds like fun! And while we women are used to shouldering all of the blame, men and advanced paternal age play a pretty sizable role in the fertility equation. Just because guys make sperm almost all of their life doesn’t mean that they should make a baby with this sperm. Here’s why.

Let’s start with a bit of basic biology…the process of sperm production in men is called spermatogenesis. Unlike oogenesis (the production of eggs), which occurs ONLY when you are a fetus inside of your mother’s womb (remember, a girl is born with ALL of the eggs she will ever make), spermatogenesis is like the Energizer Bunny—it keeps on ticking.

However, just like any device that is running on batteries that have seen their better days, over time, things start to go awry. Things stop moving, start sounding funny, and become unable to perform their duties. The situation is really not all that different with sperm. As guys age, their sperm-production battery (a.k.a. spermatogenesis) starts to become more error prone. We see more breaks in DNA (the genetic material that is passed down to your future lineage) and a higher frequency of mutations within the DNA. These mistakes translate into abnormal sperm, which translates into abnormal embryos and infertility. Additionally, as men age, their semen volume decreases, sperm motility decreases, and the percent of normal sperm decreases—D-Day is upon them.

The length of time it takes a couple when the male partner is older to conceive is longer than the time it takes a couple when the male partner is younger. The line in the “age” sand is debatable and usually set anywhere between 45 and 50. The same delay in conception appears to hold true even when doing IVF; older sperm will likely set you back (how much time is not clear).

And while the sperm may be slacking, there are also data to suggest that paternal age has a significant impact on how often a couple with an older partner not only has sex but also on sexual function. Studies show that older men have sex less often due to decreased sexual desire and diminished sexual function. Less sex is going to equal less chance of conceiving, no matter how good the sperm he still has.

Research has also shown us that advanced paternal age (again, think 45 or 50 years old) has an impact on specific genetic and medical conditions. These include autosomal dominant disorders (achondroplasia, Apert’s syndrome, Marfan syndrome, etc.) as well as schizophrenia, autism/autism spectrum disorder, and certain congenital anomalies. How or why these diseases or errors happen is not super clear. So far, scientists think the money is on a reduced amount of antioxidant enzymes hanging around in the semen. Think of these enzymes as the police; they are responsible for cleaning or stopping abnormalities. Just like a city without a good police department, the fewer enzymes, the more potential problems for the sperm and the resultant embryo.

Newer evidence also suggests that children born from older dads may have a SLIGHTLY higher chance of childhood cancers (specifically, leukemia and brain/nervous system tumors). Given these risks, most of us OB/GYNs will recommend chatting with a genetics counselor either before or in the very early stages of pregnancy. They can help break down even the most complex of issues and set the stage for what can happen when the curtain goes up.

Fertility is a two-way street. While we have let the guys off the hook when it comes to age in the past, we now know that paternal age does matter. It can most definitely play a role in infertility and abnormal pregnancies. Sperm, like their egg counterparts, seem also to be on the hunt for the fountain of youth. This is important to remember when looking for the cause of infertility.
And although we joked about it, this process is way stressful, and therefore, there is no need to blame, to point fingers, or to look for fault. While we want to find cause, we don’t want to ascribe blame. That train has left the station. It’s time to move together towards our destination.

The Lingo

We talk fast, sometimes too fast…way too fast! We also move fast and think fast—we can’t help it; we’re New Yorkers! But sometimes we need to slow down, not only how we talk but also how we move, both through our days and through our lives. And while it’s going to take work (#meditation) to slow things down, we can help those whom we frequently talk to (a.k.a. our patients) better understand the shorthand or lingo that we are using for medical terms. Think of the following as the Truly, MD, fertility language translator. We offer you the top 15 most frequently heard acronyms in the halls of a fertility clinic, in alphabetical order.

ART: Who doesn’t like to paint and color? And although we, too, like an adult coloring book (they’re now all over the place!), the ART we are referring to stands for Assisted Reproductive Technologies. Anything where fertilization occurs outside of the body (think IVF, egg donation, or surrogacy) is under the paintbrush of ART.

Azo: Despite the way it’s written, you’re not about to visit the zoo. Azo comes from the Greek word azoos, which means lifeless. In fertility medicine, azoo– is a prefix that, when placed before -spermia describes the lack of sperm found in the ejaculate. It can occur either when sperm is not being produced OR when sperm is being produced but its exit out of the testicles is blocked. In both cases, it requires an evaluation by a urologist.

CCS: Think of a girl named Elizabeth. Elizabeths can be Lizs, Beths, Lizzies, and even Elizas. Sometimes they drop the nickname thing completely and go by Elizabeth. Simply stated, there are many ways to refer to your friend named Elizabeth. Same goes for the names we use to describe the genetic testing of embryos. CCS, or comprehensive chromosomal screening, is a term used to describe the genetic testing procedure that checks to see how many chromosomes an embryo has (remember, 46 is the magic number!).

DOR: Women with low egg count and low egg quality are frequently diagnosed with diminished ovarian reserve. Simply stated, the “fuel tank” in the ovaries is running low. The ovaries have a finite number of eggs. Once we exhaust that supply, there is unfortunately no way to “refuel the tank.” To maximize what is remaining in the ovaries, fertility doctors will often recommend IVF.

hCG: Everyone’s favorite hormone. hCG is the hormone that is secreted by a pregnancy, so when it is positive or present in your blood or urine, it indicates that you’re pregnant. And while it can’t tell us if the pregnancy will be good, it tells us if something is there. On the flip side, it is also a shot we administer to achieve ovulation and egg maturation.

IC: Simply stated, IC = intercourse. Intercourse = sex. We, as fertility doctors, “prescribe” IC frequently. By using tools like your menstrual cycle, your ultrasound, and your blood work, we can predict when you will ovulate and when “having IC” will give you the best chance of “having a baby.”

ICSI: Staying with the egg-meets-sperm concept when ICSI is performed, this meeting takes place in a whole different spot in a whole different way. There is no swimming or mingling, but there is a whole lot of selection. During ICSI (intra-cytoplasmic sperm injection), an embryologist will select individual sperm and physically inject them into the egg to achiever fertilization. In most cases, the highest rates of fertilization are achieved following ICSI.

IUI: In the body, sperm has to swim—from the vagina, to the cervix, to the uterus, and to the tube to finally meet the egg. And while this journey is fairly short and fairly quick (most sperm reach the tube in less than two minutes), it can be taxing. IUI (also known as intrauterine insemination) is sort of like a way to bypass step A and step B, allowing them to get to step C much faster!

IVF: Fertility medicine has come a long way, baby! And while we have seen a lot on both the diagnostic and treatment side, the biggest leaps and bounds have come with in vitro fertilization (#IVF). In the most basic terms, when an egg meets a sperm outside of the body and fertilization occurs in the laboratory, that’s called IVF. The resultant embryo is either transferred back into the uterus three to five days later or frozen for future use.

Oligo: Going back to our Greek roots is where we will find the definition for the frequently used prefix in fertility medicine, oligo-. Simply stated, oligo means few, little, or scanty. We often put it in front of medical terms such as -spermia (a.k.a. sperm) or -menorrhea (a.k.a. period) to describe how many or how frequently something occurs.

OPK: OPKs have become a part of a reproductive age woman’s vernacular! They are so commonplace that we often forget they are somewhat new to the fertility scene. OPK stands for ovulation prediction kits, and they are an OTC (a.k.a. over the counter) means to know if you’re ovulating. While it does require urine, some diligence (you frequently need to take the test several days in a row), and anywhere between $20 and $100, it can provide helpful information regarding when and if you’re releasing an egg.

PGD: Although PGD and PGS are used interchangeably, they are not identical. PGD describes the genetic testing of embryos for single-gene disorders. PGS is looking to make sure that the embryo has the accurate number of chromosomes. To do PGD, you have to be looking for the presence or absence of a specific genetic condition, not for overall chromosome number. Picture this…if you and your partner are both carriers for Cystic Fibrosis, you would do PGD on the embryo to make sure that embryo will not inherit the disease. We can test for hundreds of genetic conditions as long as we know what the specific mutation is.

PGS: In many ways, PGS is the umbrella term for everything that “rains” genetics. Pre-genetic screening involves screening the embryos through a variety of techniques for chromosome number. It is probably the most frequently used term, by both physicians and patients, to describe embryo genetic testing.

TE Biopsy: We are taking you back to “Elizabeth” one last time…just with a bit of a twist. TE biopsy (a.k.a. trophectoderm biopsy) finds itself in the same family of terms used to describe genetic testing. However, TE biopsy actually describes the technique that we use to obtain the cells needed for the genetic testing. The trophectoderm is the part of the embryo that will become the placenta, months down the road. We take cells (biopsy) from the trophectoderm and send it to the genetics lab for analysis.

Although it’s fairly likely that we missed a few frequently used ph-rases (that’s what happens when you move fast!) this list captures most of the big ones. Use it as your cheat sheet when trying to decode the language you hear at a fertility clinic. And while you may never totally speak the same language as your fertility doctor, at least you will come pretty close to being fluent.

Can’t Stop, Won’t Stop: What to Do When Your First IVF Treatment Fails

Can’t stop, won’t stop; it’s not for nothing that this may be one of our favorite sayings. As overplayed as it might be and as trite as it might sound, it’s pretty much how we aim to live our lives, how we chose to tackle our challenges, and how we hope to make it to the end of a marathon. We push each other, we push ourselves, and we push ahead to get to OUR end.

But life is not a race, and there is no set finish line (except for the obvious one that we won’t harp on). How you end your day, how you end your career, and how you end any struggle in many ways is up to you. You set the start line, the halftime, and the finish line. Much can also be said for how many rounds of fertility treatment you decide to do and how long you continue to try for a baby.

Knowing when to call it quits can be nearly impossible. Whether professionally or personally, it’s hard to know when enough is enough. In terms of fertility treatment, specifically IVF cycles, how much is too much? How many is too many? When do you move on to something else?

A recent study from England published in a very prominent medical journal (JAMA) recently addressed this question. It got a whole lot of press and found its way into the New York Times, the Wall Street Journal, and all of the morning talk shows. It basically showed that women who hung in the game were more likely to get pregnant—quitting after a couple of failed IVF cycles was not the right move. Although they didn’t find a magic cutoff number after which patients should be told to exit stage left, they did find that nearly 70% of women under the age of 40 got pregnant after six IVF cycles. While about 30% of women got pregnant on the first cycle, many took longer to cross their finish line.

The results were less promising for women older than 40; while they also got pregnant at a higher rate after more IVF cycles, the total number did not exceed 30%. Bottom line, even though this study got as much press as a Kardashian wedding, it’s important not to misanalyze the data.

This study is NOT giving the green light to endless IVF and fertility treatments. This study is NOT saying that multiple IVF cycles are always the way to go. This study is NOT saying everyone who does multiple IVF cycles will get pregnant. This study is simply saying that, if you can emotionally, physically, and financially (unfortunately, finances come into play big time) swallow the treatment AND your doctor believes you are a good candidate, it’s okay to keep on keeping on.

Knowing when to bow out is nearly impossible. Unfortunately, there is no magic number. But here’s the CliffsNotes version from girls in the know… For starters, we use age, pregnancy history, and ovarian reserve testing to decide when enough is enough; these initial parameters can shed a lot of light about what’s to come.

Additionally, we use IVF response as a gauge of how much gas you have left in the tank—are you responding to medications, are you producing follicles, is your estrogen level rising?

Last, we use embryo development and, if available, embryo genetic testing results (PGS/CCS/TE biopsy, which tests for aneuploidy) to help patients decide whether further treatment is a go. For example, if patients have done several IVF cycles without any viable or normal embryos, we are hard pressed to recommend continued fertility treatments with your own eggs. And while no, history doesn’t always repeat itself, in these cases, it comes pretty close.

We are not dictators, czars, fortune tellers, or goddesses (although we wish we were)—and we are not afraid to admit that. We can’t tell you that more will be better; it may just cost more money, cause more physical discomfort, and evoke more emotional anguish. But quitting too early can be a real shame.

Just like in sports (from two women that love to pound the pavement!), there should always be a day for rest, always a moment to breathe, and always a time to stop. Without a break, you get injured. Without a day to sleep in, you get fatigued, and without days off from work, you get frustrated. In cases where there is no definable finish line for you or your partner, you may need your doctor to help you set it. When you collectively find that line in the sand, be careful not to step over it. Things will start to sink quickly on the other side.

The Art and Science of IVF

As first-year medical students sitting in the back of the Mount Sinai School of Medicine lecture hall, we had no idea what to expect from the Art and Science of Medicine course. We all thought of ourselves as scientists (I mean, this was medical school!). Art was far from most of our minds. Questions like “What will this class be like?,” “Will it be lecture-based or textbook-based?,” and “Will the exams be graded or simply marked Pass or Fail?” flooded our minds. In typical Jaime and Sheeva fashion, poised with pens in our hands (we were both ferocious note takers!), we were ready to transcribe every word uttered by the lecturer to soak up and eventually memorize every piece of data shared. However, what followed surprised us: we would not be note taking, we would not be studying, and we would not be test taking.

We would learn about the art of medicine.

Art and medicine may strike some of you as odd. It did us! Medicine is a practice rooted in science and data, not color or design. The people you knew who became doctors did it because they liked facts, not pictures. However, in reality, how we diagnose a disease, how we treat a problem, and how we formulate a plan are really an art. The many available imaging modalities, medications, and surgical procedures are our colors. How we blend them to get the best outcome for you, the patient, is our art.

For fertility doctors, ovarian stimulation in particular (a.k.a. how you get the ovaries to produce multiple eggs) is our art. What protocol we select for a patient, when we increase and decrease medications, and how to obtain the highest percentage of mature, good-quality eggs is our art (not to be confused with ART= assisted reproductive technology!). Sure, we have scientific data to guide us in our decisions, but what can make one IVF cycle more successful than the other has a lot to do with the art of ovarian stimulation. And we bring you back day after day for blood draw after blood draw and ultrasound after ultrasound not because we like to torture you but because it helps us customize your design, your art.

Don’t get us wrong. There is a lot of science in what we do. The laboratory is our science. The embryologists, the culture system, and the genetic testing are science. And without the science, our art is just some strokes on a blank canvas. It takes both, the art and the science, to treat a patient and to achieve success in all areas of medicine.

So, if you ever wonder why we do what do and how we decide on treatment protocols, they are our art. And when they are combined with science, it can make a beautiful picture!

Double Duty…Why Two Is Not Always Better Than One

It would be nearly impossible to count the number of times patients tell us the following regarding how many embryos to put back into the uterus: “I want two…it’s like two for the price of one!” “I want to be one and done!” “It’s like getting a twofer!”

And while we understand the desire for two (trust us, the thought of minimizing the number of times one is pregnant does sound appealing), twins are not just double strollers, matching onesies, and names that start with the same first letter. Twins and triplets-plus can be complicated, not only for the babies but also for the mother. Therefore, serious thought needs to be put into how many embryos are put back into the uterus.

Old-school fertility doctors routinely transferred several embryos into the uterus at one time; twins, triplets, and even quadruplets were sort of the “cost of doing business.” Back in the day, our IVF techniques weren’t so great. The procedures were new, and there were a lot of unknowns. To increase a patient’s chance of getting pregnant, multiple embryos were put in. Although even then, “the more the merrier” wasn’t our motto, (women are not meant to carry litters!), we were limited in our ability to identify which embryos had the best chance of making a healthy baby.

Fast-forward 20-plus years, and we are actually really, really good at this stuff. Not only do we know exactly what a three-day-old embryo needs to grow in versus a five-day-old embryo (can you believe it they are already picky eaters at this age!) but we also actually have the ability to check them and make sure they have the right number of chromosomes!

Now, while we can’t tell if they will look like you or your partner or go to Harvard or Yale, we can take a few cells and check to make sure they have the correct number of chromosomes. (The magic number is 46!) When this technique is done and a healthy embryo is found, we almost routinely only put one back in because even this guy or gal more than half the time makes a baby.

If you are considering an IVF cycle or are maybe even in the midst of one, make sure to have a long and serious discussion with your doctor about the number of embryos to transfer back in. Nowadays, not every IVF center is the same; many have the ability to grow embryos in the laboratory to day 5, rather than the traditional day 3. Although two days may seem inconsequential when it comes to most things in life, for an embryo, it’s a big deal. Just these 48 hours gives the embryo time to develop and the embryologist who is watching the embryo develop more information to pick the one that has the best chance of making a baby!

If you are lucky enough to have several A-plus embryos and your doctor only recommends putting one back in, the others can be frozen. Yup, we said frozen. Don’t worry; frozen embryos are not like frozen chicken! Embryo freezing has come a long way, and now in many centers, frozen embryo transfers have a better chance at making a baby than a fresh one. Simply stated, you won’t lose anything from freezing the extra embryos and putting only one embryo back in at a time. Sticking with the “one and done concept,” many couples get all the embryos they will ever need in one fresh cycle, thanks to good freezing techniques!

It’s sometimes hard to imagine that anything can go wrong in twin pregnancies. Nowadays, our schools and parks are teeming with twins; it really has become all the rage! But take it from us, not every twin pregnancy ends in a cute Anne Geddes photo. Twins have a higher chance of almost all risky pregnancy complications. On the fetal side, these include stillbirth, preterm delivery, and the serious problems that can come along with having a preterm baby: neurologic, cardiac, pulmonary, gastrointestinal, and serious developmental issues. Additionally, a high percentage of twins will experience some delay (motor and verbal skills) in the first two years of their life that requires treatment.

On the maternal side, women carrying twins or more have a much higher chance of serious medical complications. These include diabetes, high blood pressure (preeclampsia), heavy bleeding, hyperemesis (significant nausea and vomiting), Cesarean Section, and post-partum depression. Although most twins and most moms of twins will be running (actually, probably sprinting) and laughing in no time, there are a number of twins that will suffer permanent consequences from prematurity. The risks are real and should not be ignored.

And partners of those who have twins don’t get off easily, either. Sure, they don’t have to endure the insane stretch marks, the prominent varicose veins, and crazy swelling that multiple babies in one uterus at one time can bring, but let’s face it, double the work comes with added stress on the relationship. Studies have shown that divorce/separation rates are higher in families of multiples. Having a baby is not easy, sleepless nights and long days can be beyond difficult; imagine multiplying that by two!

We live in America too, and trust us, we get it. Other than pounds, for most of us, more or bigger always seems to be better. Why have one of something when you can have two? While we are not going all one-child-policy on you, we are advocating having one child at a time. It will be healthier for you and healthier for your unborn children. While twins are adorable and the bond they share is unlike any other sibling relationship, we are big fans of taking it one step at a time if possible.

When building a family, slow and steady is the best and safest way to get to the finish line.

Metformin Madness…Will It Make Me a Momma?

Any medication that promises to make you pregnant (or at least markedly increase your chances) and make you lose weight seems too good to be true. Wait, so I can eat ice cream and French fries while losing weight and getting pregnant? Count me in! But like most things that sound too good to be true, so is the hype surrounding metformin.

Metformin is a medication that is traditionally used to treat diabetes. It lowers sugar and insulin levels: hence, why it is used for diabetes. For women with PCOS, in whom insulin levels are high, metformin can not only improve the abnormal glucose/insulin situation but also improve ovulation rates. When metformin was released as an ovulatory agent, it became all the rage for women with ovulatory dysfunction. It was handed out like candy to anyone who had even the slightest ovulatory issues. However, while it was in the medicine cabinets of thousands of women, it didn’t stand up to all the hype. It didn’t turn ovaries of stone into sand—many ovaries still stood their ground.

Turns out, metformin is not a magic potion. A large randomized control trial (randomized control trials are the gold standards of medical research) did not show that metformin was even in the same ballpark as Clomid. Women who took Clomid ovulated and got pregnant at a much higher rate (about three-fold higher) than women who took metformin. Additionally, the metformin-Clomid combination was no better than Clomid alone. The only group of women in whom metformin was semi-magical was overweight/obese women with metabolic disturbances (elevated sugar and triglyceride levels, abnormal liver function, and high cholesterol). In these women, metformin combined with diet and exercise could be quite helpful in kicking the ovaries into gear. Additionally, this dynamic duo can significantly improve your overall health, wellness, and longevity.

With the pluses come the minuses. Metformin can make your stomach feel a little funky; be sure to talk to your doctor if you experience GI side effects (bloating, diarrhea, etc.). It is also important to have your kidney and liver functions measured while taking metformin, as it can do some not-fun things to your kidneys and your liver. While there are certainly occasions and cases where metformin is the magic ingredient, it’s not the “butter” in the ovulation concoction. It may help with the flavor, but it isn’t the force behind what gets the ovaries going.
Don’t fool yourself into thinking that metformin is magic. You still need to eat right, exercise, and maybe even take some Clomid. We will find some cocktail that makes your ovaries shake!

When Is Enough, Enough? Does Fertility Treatment Have an End?

Some things are really hard to hear. Whether it is as simple as how your hair looks or how you look in that dress to how to treat an aggressive medical condition, the truth can really hurt. And oftentimes, accepting the truth can be nearly impossible. However, there are only so many times that you can hold your hands to your ears and play deaf. There are only so many times that you can ignore the flashing red lights in front of you. Ultimately, if you don’t change lanes you will find yourself at a roadblock that you can’t overcome or pass. However, knowing when it’s time to get out of the lane can be the hardest part. That’s what we are here for.   

As fertility doctors, our job is to guide you, to support you, to educate you, and ultimately to help you achieve your dreams of becoming a parent. We take the information provided to us by blood tests, ultrasounds, medical history, semen analyses, and family histories and with it try to see what is off, which pieces in this puzzle are not fitting together and how can we put the pieces back together.  

However, our job goes way beyond diagnosis. We are also there to implement and design treatment plans. Some plans you may like, and others, you may not. Some may seem too aggressive; others, too lax. Some may seem too involved, and others, too casual. Whatever it may be, you have to take the information and options presented to you, process them, and then proceed.  

But we cannot simply stand on the sidelines and watch you run into a 320-pound linebacker without a helmet. While your fertility doctor should be frank with you throughout your entire treatment course, this is particularly true when deciding on the best treatment strategy.   

At some point, the seesaw of pros versus cons is no longer even close to even. The American Society of Reproductive Medicine defines this tipping point as futile treatment (≤1% chance of achieving a live birth) and very poor prognosis treatment (>1% to ≤ 5% per cycle). Allowing a patient to continue to try when the odds are so incredibly low and not sharing such information is, in our opinion, criminal. Honesty is imperative in any doctor-patient relationship, but it is especially essential in fertility medicine.  

While we want to help you achieve your dream, we must be honest with you about the likelihood of achieving these dreams. Sometimes, dreams must be modified (donor eggs rather than your own eggs, a gestational carrier rather than your own uterus) in order to end happily.  

Closing the chapter on any stage of life can be difficult. It is wrought with confusion and anxiety. We are here to help you through this process, to help you move through the pages, and to reach the ending that will make you feel the most complete and the most content. Telling you what you want to hear may make you feel better, but it will likely not make you a baby. And although hearing what we have to say may sting, it may be the bite that leads you to parenthood. And in our line of work, parenthood is paramount. 

Scraped, Sucked, and Now Scarred: Uterine Adhesions

What’s going on inside your uterus is not a thought that crosses most of our minds on a daily basis. Sure, we are reminded of that organ every month when “Aunt Flo” arrives, but unless you are a medical student, a gynecologist, or a woman who is having problems getting or holding on to a pregnancy, you are probably not all that aware of your uterus. But news flash…the uterus is a pretty important organ with an essential role in reproduction.

This may come as a surprise, but it is actually a muscle. Yup, that’s why you get those intense monthly cramps—and why Advil and Motrin work so well at taking them down a notch. The uterus’s primary job is to carry a pregnancy. And not to get all science-y or medical, but when you think about how the uterus grows and shrinks, thickens and sheds, and carries and delivers, it’s sort of unbelievable. While its marathon is not 26 miles, it actually can go the distance for you several times in your life (depending on how many pregnancies you have). It goes from the size of an orange to the size of a watermelon, all in matter of nine months. Pretty unbelievable stuff!

So, how can you tell if your muscle is in tiptop shape? Obviously, given its location, you can’t stare at it in the mirror as it flexes! The best indication of how your uterus is functioning is the arrival of your monthly “friend.” For women who are not on hormonal contraception (pills, patch, IUD), you should expect a period about every 30 days. While the regularity of your period is not the focus of this piece, and you shouldn’t call your GYN to report a 27- vs. a 32-day cycle, no period or very minimal/light flow might be evidence that something is off inside your uterine cavity. Changes in the character (heavy vs. light) or content (days) of bleeding can also be the signal to seek help.

The uterine cavity (a.k.a. womb) is composed of two layers: the basalis and the functionalis. Think of the basalis as the bottom or the base and the functionalis as the top, or the functioning layer. Every month, when a woman menstruates, she sheds her functionalis, or functioning part. After its departure, the basalis works to replenish or restock this very important important aisle. When damage occurs, the front-line functionalis is the first to take the hit, and as you can imagine, the more soldiers lost, the worse the situation.

And while the uterus takes losing its front line hard, it takes losing its reserve troops (the basalis) even harder. Damage sustained down to the basalis can cause irreparable harm. If you lose the basalis, then not only do you lose that month’s war, but you will also lose all wars in the future. This is because your body will have no way to regrow what has been lost. So bottom line, varying degrees of insult can have varying degrees of injury. Maybe it really is all about the base…

However, while scar tissue in the uterus can translate into no period, what your uterus does is often a reflection of the message that your ovaries (and actually your brain) are sending its way. That’s why women who don’t produce estrogen for any number of reasons (too much exercise, too little food, or even menopause) don’t get a period. No estrogen = no uterine lining. No uterine lining = no period. The estrogen produced by your ovaries works to thicken the uterine lining (a.k.a. the uterine cavity).

So in many cases, women who are not getting a period have a functioning uterus. If the appropriate hormones are delivered in the appropriate fashion, all systems will be a go. Differentiating between the two and trying to figure out where the roadblock is, is actually fairly easy.

While it does take a visit to your OB/GYN and in some cases a fertility specialist, finding out who “did it” is simpler than a game of Clue. Professor Plum in the study with a candlestick it is not. A good history focusing on previous pregnancies, particularly how they ended D&Cs, abortions, retained placenta, and even a C-Section is of the utmost importance. These are the flashing red lights for who may have scar tissue lingering in their uterus and preventing a future pregnancy from occurring. Asherman’s syndrome is the medical term for this condition.

The uterus can develop scar tissue in response to some sort of an injury. Just like any scrape, cut, or bruise, the more significant the injury that caused it, the more significant the scar. While the injury is most frequently a D&C (dilation and curettage) after a pregnancy (be it a miscarriage, an abortion, or a piece of placenta that remained inside after a delivery), it can result from other causes (i.e. an IUD or an infection).

The degree of scarring can be determined by looking inside the uterus with a variety of imaging tests (ultrasound, hysterosalpingogram , hysteroscopy). It can also be suggested by how light, heavy, or absent your period is. For example, if the scar tissue is severe, it could have damaged most of the uterine cavity; this would cause minimal or no bleeding (medically termed amenorrhea). So while the ovaries are sending all the right signals, the uterus lacks the ability to respond to the message.

Even the most extreme cases of scarring can frequently be fixed. You just need to find a good doctor who has a good idea how to navigate the situation. Uterine scarring requires surgery to remove the adhesions (a.k.a. scar tissue) and restore the cavity (a.k.a. womb) to its original shape. While it can make a major difference in your baby-bearing ability, it is a fairly minor procedure, an outpatient procedure that lasts no more than a couple of hours.

The cervix is dilated to allow the placement of a camera. The camera is connected to a monitor (don’t worry; there will be no broadcasting or streaming!), which allows the surgeon a front-row seat to what is going on inside. After identifying the damaged tissue, instruments are threaded through a channel on the camera. The surgeon’s instrument of choice (we like scissors) is used to remove the scarring. Following the procedure, a tiny catheter is placed into the uterus to keep the uterine walls from touching each other for the next five to seven days. Additionally, while the catheter is camped out in your uterus, you will start about a 21- to 28-day course of estrogen and progesterone. The theory behind this cocktail, catheter, and medications, is to go full force on rebuilding a healthy uterine lining.

So does it work? Can even the most damaged of uteri be remodeled? In most cases, yes….mild and moderate cases of uterine scarring are fairly responsive to treatment. Most women go on to have monthly menses (can’t believe you would ever cheer about that, right?) and conceive. Subsequent pregnancies can be at higher risk for placental implantation problems (placenta previa, accreta), but most go the distance without any issues.

Severe cases can present even the most experienced surgeons with a formidable challenge. While it’s often not the removal of the damaged tissue that keeps the red light red, it’s the uterus’s ability to restore good healthy tissue that keeps things at a halt. If damage was sustained all the way down to the basalis, restoring a functioning cavity can be nearly impossible. In such cases, although recreating a functional cavity may evade even the most gifted surgeons, pregnancy can be achieved with the use of a gestational carrier.

Many things in life happen outside of our control. Even the most type-A of us who fight to plan and control every minute (trust us, we get it!) can’t script how our uterus will react to an insult. However, we can outline a plan of attack if something should seem off. If you feel that something is not right, go speak to your GYN, and leave out no details. We need to have all the facts when it comes to your medical history.

Together, we can come up with a road map to navigate a path through even the roughest of waters. It may take a lot of fight, including a few trips to the operating room and a few rounds of estrogen/progesterone, but ultimately with  time, the battle can almost always be won.

Seriously, Noooo Sperm! What Azoospermia Really Means to Men

Getting the phone call that you have flunked (even worse, scored a “zero”) yours or your guy’s semen analysis can be pretty devastating. The rush of emotions that runs through your head is more extreme than the waves seen in the famous Eddie Aikau surf competition. And when you realize what it could mean for your fertility, it’s like wiping out and then getting worked by the wave all in one go.

The first thing you should do is take a deep breath. One semen analysis doesn’t mean it’s the end of the road. However, if the repeat test confirms that there is nothing there, further investigative work needs to be done.

The medical term for no sperm is azoospermia (this is different than aspermia, which is the absence of sperm and seminal fluid at the time of ejaculation). Because men with azoospermia frequently have normal ejaculates, they can go undiagnosed for years—sperm is microscopic, so unless someone is looking really close at it with a high-powered lens, you can’t see those swimmers.

While azoospermia is every guy’s fear, it is actually pretty rare, phew! Only about 1% of all men have azoospermia (it is higher in couples that suffer from male factor infertility, and in these patients can be as high as 15%).

If your guy is one of the unlucky 1% and are searching for answers and information, we recommend thinking about it in the following way: Imagine you have three connecting flights coming into the airport at the same time. One is from New York City, one is from Boston, and one is from Atlanta. They are all connecting through Chicago to LA—all the passengers will be on the same second flight although they originated in different places. Azoospermia is the end point for post-testicular, testicular, and pre-testicular conditions; they all arise from different diseases (or departing cities) but ultimately land in the same place.

From City A, we have post-testicular azoospermia. (The testicles are making sperm, but there is a blockage preventing it from exiting and getting in the ejaculate). From City B, you have testicular azoospermia. In these cases, the exit pathway is clear, but the testicles are not producing sperm. The latter or “B” cases are generally much more difficult and often require donor sperm. From City C, we have pre-testicular azoospermia. Here, the testes are ready and waiting, but the signal is either not coming down correctly from the brain OR, due to underlying endocrine (hormonal) problems, the testes have failed to produce sperm.

After the initial diagnosis of azoospermia has been confirmed (two azoospermic samples where the seminal fluid is centrifuged for 15 minutes at super-high speed), your guy is usually sent to a urologist (specifically, one that specializes in male factor infertility) to see which “city” you have departed from. Through a full review of the medical history, a physical exam, an ultrasound, and lots of blood work, the urologist can usually get to the bottom of why there does not appear to be any sperm in the ejaculate. The tests that your partner will go through in many ways will mimic what you have been asked to do—we will check his FSH , LH , testosterone, thyroid hormone , and prolactin. We will also do extensive genetic testing to see if we can identify the problem.

It’s very important to do the full genetic work-up because there are often abnormalities which, if identified, can be passed on to future generations. Not good. While you may not know exactly what or why we are testing your plus one for, you should make sure that a full testing panel is performed. You should also make sure that you sit with both yours and your partner’s doctor so that, together, you come up with the best plan for you as a couple.

We don’t expect to make you urologists or even sperm connoisseurs, but we do want to help you better understand the potential answers to the azoospermia conundrum. We are going to give you a very basic review (and no quiz!) to help you better answer the questions that are likely racing through your head the minute you get the news.  

Flight A = Post-testicular Azoospermia: Here the problem happens not in the testes but after the testes. Going back to basic bio, the problems happen in the ducts that connect the testes to the urethra (think vas deferens). It can also occur from ejaculatory dysfunction. We don’t want you to cringe or try and picture it in your head, but the visual that you should have is that, in most cases, the testes are making lots of good-quality sperm. The sperm has just been stranded on an island waiting for a rescue boat (or connecting flight!). The rescue boat is either a surgical procedure to unblock the blockage (basically re-open the road), or if the road is totally beyond repair (think most major cities highways), then we go above the blockage (a.k.a. the testes). The latter is called a testicular extraction of sperm (nickname TESE or TESA). Surgically, a urologist will enter the testes and extract sperm (ouch, that doesn’t sound fun—don’t worry, you will get anesthesia!). This sperm can be used to fertilize eggs in an IVF cycle. The rescue mission is usually successful, and the resultant pregnancy rates are often quite good. Bonus is that we can often freeze sperm for use in the future (like years later) IVF cycles. Obstructive azo (as we fertility doctors call it) occurs in about 40% of men with azoospermia.

Flight B = Testicular Azoospermia: When the testes themselves are the cause of no sperm, it can be a bad situation. Like planes in a blizzard, nothing is taking off for a long time. Despite our advancements and flashy technology, much like ovarian failure, we cannot overcome testicular failure. Think of testicular failure like premature menopause; for some reason, the testes stopped making sperm long before their time. We usually know that we are dealing with option B (as opposed to A) because the FSH is elevated and the testosterone is low. Much like ovaries that are sort of done, when the testes stop working, testosterone (which is made in the testes) stops being produced. Last, in a physical exam, the testes are small (medically termed atrophic), and we have a pretty good idea we won’t find sperm. However, with this being said, barring a serious genetic condition, many urologists and fertility doctors will still go for the testicular sperm extraction surgery to confirm that we are truly running on empty. However, it is important to note that many testicular cases of azoospermia are a result of genetic abnormalities. Unfortunately, we don’t really know many of the genes causing the significant decline in sperm production. Therefore, if the sperm is successfully extracted and used to fertilize eggs, you could be passing some “bad fertility/sperm genes” on without even knowing what they are. While we are not saying you should not use the sperm, we are recommending that you chat with your doctors and a genetics counselor first.

Flight C: Pre-testicular azoospermia causes of azoospermia are the rarest. They are most frequently due to hormonal abnormalities that result in testicular failure or mixed signals coming down from the brain. If the brain is on a break and does not appear to be doing its job (or something is impinging on its ability to do its job), we can usually fix that. With the help of medications, we can get things back on track. It may take several months to get the engines going again, but it will get there. In fact, if sperm production can be restored, your guy may not need any surgical interventions, and while you still may need our help to get pregnant, you may not need IVF.

There is almost nothing more devastating than hearing that you or your plus one has run out of eggs or sperm before your time was supposed to be up. It’s unfair, it’s frustrating, and it can be downright infuriating. While using our services or donor sperm (if it comes to that) is likely not how you envisioned making a family, our goal is to make you a father. We can most certainly do that; even when the waves seem big and you can’t imagine riding another one, we promise you can. Just hang ten, and let us guide you to calmer waters.

Round and Round You Go: We Hope It Stops Where You Want to Go!

Unfortunately, it is more the norm for us to see or hear about couples (and individuals) that have undergone years of fertility treatments without success. Month after month, they take medications, inject themselves with hormones, and hold their breath as they wait for the pregnancy test results. For many of these patients, be it for medical reasons, financial reasons, insurance reasons, or misguided reasons, there is little that is changed between the negative cycles. We like to call this the merry-go-round effect: couples/individuals who continue the same ineffective treatments month after month without redirecting or reanalyzing the situation. It’s a bad situation that we want to help you change.

Let’s face it: after the same treatment, be it timed intercourse, oral medications, inseminations, or IVF, has failed continuously, something needs to change. Whether it be moving on to more aggressive treatments (or, as we say, stepping up the ladder!), tweaking the current protocol, or seeking a second opinion, you need to shake things up. There are many available fertility treatments that can be, and likely should be, utilized.

A patient-doctor relationship should be a partnership with give and take, as well as back and forth. Gone are the paternalistic days of medicine where the doctor speaks and the patient listens. Treatment decisions should no longer be dictated, but rather, discussed. If this is not happening for you and you find yourself in the merry-go-round rut, then you need to put the brakes on. Make a phone call, send an email, or sit down with your doctor to review your case. Bring your list of questions, and ask away.

If you don’t like the answers, don’t be afraid to take them and your struggles elsewhere. At some point, you have to either ask the attendant to stop the ride or simply hop off. Eventually, circling in the same direction stops being fun, exciting, or promising; it also makes you nauseous, dizzy, and loopy!

So be your own advocate, and shut this ride down. The park is huge, with so many more rides and adventures to explore.