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Looks Can Be Deceiving…We Recommend a Double Take!

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At least once a day we get a call from a friend, a friend of a friend, or a friend of a friend of a friend (say that three times over) asking us to review their results and give them our advice. Inevitably, they are overwhelmed, frightened and often confused. “FS something, I’m not sure” and “mobility of sperm okay but appearance abnormal.” After we sort out some of the details, we are ready to break it down for them in the most basic of terms. Here are some of our tidbits from girls in the know.

  1. FSH means NOTHING without Estradiol. FSH and Estradiol are like Bert and Ernie or Bonnie and Clyde. You can’t test one without the other; they don’t make sense when analyzed alone. FSH is a hormone made in the brain (pituitary gland) that signals the ovaries to ovulate (and make estrogen measured as estradiol in your blood).  When FSH is measured early in your cycle, if elevated, it may indicate a decline in ovarian function (meaning your egg quality is declining, making pregnancy more difficult).
  2. FSH is falsely lowered by a high estradiol. A normal FSH level with a high estradiol level means that the FSH is NOT normal. Estrogen from the ovaries sends a signal back to the brain to make less FSH in the brain. When estrogen levels in the body are high, the brain makes less FSH. While abnormal levels don’t mean you’re down for the count in terms of baby making, it does make us question whether your ovaries are the cause of your fertility struggles.
  3. FSH and Estradiol MUST be sent to the lab on days 2-4 of your cycle. They are not accurate (in all cases except for women with very long, irregular cycles) if sent at other times. Don’t have the blood work done on the wrong day just to check it off your list; you will be re-writing it on your To Do list for the next month.
  4. The ranges on the lab report are not always right. Yes, we know that this may sound confusing and totally contradictory but levels need to be interpreted by a physician. Make sure that if you get your levels you speak to a licensed professional before shedding too many tears.  Don’t go straight to Dr. Google with your FSH level until you understand what it means for you specifically!
  5. The “dye test” (or the HSG, as we call it) must be done in the early part of your cycle. It cannot be done after you ovulate (you could be pregnant!)
  6. An HSG is not meant to be torture. While it can hurt, in most cases it’s pretty tolerable. Take some Ibuprofen before…You should be fine!
  7. A “luteal progesterone” test is not equivalent to a day 21 progesterone test. Luteal means “post-ovulation.”  Physicians often test a progesterone (blood test) on “day 21” to confirm an elevation, indicating ovulation.  A day 21 progesterone test is only appropriate for women who have (approximately) 28 day menstrual cycles. If your periods are 35 days, your progesterone on day 21 may be negative (low indicating no ovulation), but that doesn’t mean you won’t ovulate or didn’t JUST ovulate. It just means that it is  (approximately) 7 days too early to check the levels. Make sure to share how long your cycles are with your doctor before diving into the blood work.  If you have longer cycles, then going in after day 21 may be better to confirm whether or not you are ovulating.
  8. Not all fibroids are created equal. Fibroids can be a big deal. They can cause pretty bad bleeding, pretty significant pain and pretty real infertility. However, the caveat to the infertility issue is location, location, location. Whether or not a fibroid causes infertility depends on the location of the fibroid. Fibroids located within the uterine cavity are WAY more likely to cause infertility than those in the muscle. Make sure you have a road map of where your fibroid is before you undergo surgery.
  9. Motility (a.k.a. mobility in the words of many patients!) is how sperm swim. It is reported as a percentage (% of sperm moving in the sample). Old school normal was 50%. Now that number has been knocked down to 40% (and only 32% need to be moving forward). While no one wants to fail at anything, take it easy on your guy if his “mobility” is off—chances are if you use the newer guidelines things won’t be too bad.
  10. Sperm shape has really taken center stage recently. It has become one of the most debatable, doubtable and don’t-know-what-to-do-about-it issues. While it is still unclear as to what abnormal morphology means (impaired fertilization potential currently tops the list), the level of normal to abnormal has been reduced significantly. The new normal is 4% or above. Make sure that you are aware of the new numbers and are aware of what the information means before you start any treatment (some centers are still using the old reference values and therefore are calling anything <14% abnormal rather than <4%). Additionally, while low morphology does mean your partner needs more testing, it does not mean that he needs IVF (in vitro fertilization)!

There are a lot of myths circulating out there. Make sure to ask a reliable source before counting yourself out. While we may not be a friend of a friend of a friend, we are certainly your professional pals!

Seriously, Noooo Sperm! What Azoospermia Really Means to Men

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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.

The Seesaw of Hormonal Production: Why Your Periods Are Wilder Than the Old- School Wild, Wild West!

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When the arrival of your period becomes more erratic than airplanes during the holiday travel season, you know something is up, especially if before they were like clockwork. Why this is happening and what this all means can be confusing. It can also make deciding if you should wear white jeans very difficult! Most fingers point towards the ovaries and their dwindling supply of eggs and specific hormones: think inhibin, estrogen, and AMH.

As the ovaries start to run on empty, they shoot mixed messages to the brain. The brain, which is used to orderly and steady hormone levels from the ovaries, is thrown into a tailspin. Without adequate ovarian hormone production, the brain overproduces certain hormones. Think FSH and LH. There goes the regularity of your menses. In medicine, we refer to this period of confusion and “crazy” period timing as perimenopause. And to put it bluntly, this period (no pun intended) can be a big pain.

In terms of the brain-ovary relationship, think of a seesaw. As the ovaries (egg production and select hormones) go down, the brain’s hormone production goes up—and in some cases, way up. FSH levels can reach the high double digits. Ovarian hormones and hormones in the brain, specifically the pituitary gland, work in a negative feedback loop—high ovarian hormones keep the brain’s reproductive hormones low. So when you are nearing menopause and the ovarian production lays low, lower, and then lowest, the seesaw will remain lopsided. And while on this seesaw, the person left high won’t get hurt, it will have a major impact on how frequently you see your periods—as well as other things like your internal temperature gauge.

For most of our reproductive lives, the ovaries and the brain work as a team to prepare an egg, ovulate an egg, and maintain the corpus luteum (a.k.a. the structure that makes progesterone and helps maintain a pregnancy). There are some conditions where this system doesn’t run so smoothly—cue PCOS, thyroid disease, or hypothalamic amenorrhea. But for most of us, it is pretty well-oiled machine, that is, until we hit our mid-40s or so. Then the pendulum starts to swing erratically. Periods come closer together (about 20 days) and then farther apart and then close together AND farther apart. Not a pleasant combo.

Consistency becomes a thing of the past. While your mind may view pregnancy as a thing of the past, your ovaries haven’t quite given up. They are still working to prepare and ovulate an egg each month. Because of the diminished supply, they start to prepare the egg in the second half of the menstrual cycle the month BEFORE that egg will be ovulated. Simply stated, they are letting the horse out of the gate (a.k.a. the egg) long before the race goes off (a.k.a. the next menstrual cycle starts). As a result, the menstrual cycles will get shorter and shorter.

Although irregular menstrual cycles are quite common when we hit our 40s and beyond, when bleeding becomes excessive or all of the time, you need to speak to your OB/GYN. While it likely means nothing more than the ovarian reserve fuel tank is running on empty, you want to make sure there is nothing structural (a polyp, a fibroid, or even a cancer) that needs to come out. Don’t brush it off as another joy of aging!

Just like any relationship, when one member of the team goes haywire, things can fall apart pretty quickly. If you are not in sync with your partner, the partnership falls apart. The brain and ovary alliance is no different. When one stops working, the other one tries to overwork or make up for the deficiencies, which leads to irregular and often frequent periods. Although there may be nothing you can do to mend or tame this wild relationship (once ovarian production goes down, it generally will remain down), just acknowledging it can bring you some peace.

And with that, you can go out and face the wild, wild west!

Who Doesn’t Want Half and Half in Their Coffee? IVF Stimulation Medications

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Calories, shmalories… We like our half and half! In fact, the lighter the better (sweet is good, too!). Half and half gives coffee that creamy taste that is not replicated by any amount of whole or skim milk. The same can be said for ovarian stimulation medications—the ovaries of most women like half FSH and half LH. In many cases without this combo, the response is bland and lackluster.

But before we go any further, let’s take it back to the “beans” (a.k.a. the basics). While FSH and LH are hormonal medications used in IVF, they are also hormones produced naturally in the brain. It is the steady production of FSH and LH throughout the menstrual cycle that results in egg production and ovulation.

Because in a natural cycle you never see FSH without LH, many fertility doctors prefer to keep this dynamic duo intact when selecting IVF stimulation medications. As a result, combined protocols (as we call them in fertility medicine) are definitely leading in the fertility polls. Most of us have seen better ovarian response, better egg quality, and hence, better embryo development when the two are mixed. But taking it back to the beans (a.k.a. the basics), FSH and LH are two hormones that are normally made in the brain.

Great, now they want me to take two shots? Unfortunately, yes, we do. And while we would love to minimize the number of times you have to stick yourself, doubling up will likely do your ovaries wonders. When we stimulate ovaries for IVF, as unnatural as it feels, we are trying to mimic a natural cycle as much as possible. Nature happens for a reason! By giving both FSH and LH together, we are coming closer to what happens when we are not there. These two were paired together before we got there—it seems silly to separate them!

Yes, there are certain women who do better with straight whole or skim milk or even black coffee. For example, women who suffer from hypothalamic amenorrhea (no periods due to low hormones from the brain) need LH. Their ovaries will sit on the runway all day without a blast of LH. On the flip side, women with the real deal PCOS do better with minimal LH in their stimulation. Their ovaries see LH all the time (been there, done that), so it’s better not to put fire on an already flammable situation.

The debate over whether to use FSH alone or FSH + LH has gone on longer than the Coke vs. Pepsi debate. There is evidence on both sides to support combo protocols vs. straight FSH or LH. While doctors may have a preference for one (and can certainly find evidence to support it), most large reviews have demonstrated that (like us) two are better than one. When sitting down with your doctor, before you start the shots, ask them what you are getting, why they are giving it to you, and why they like this for you. Asking questions will quell some of the confusion and anxiety that those bags of needles and boxes of medicines bring upon their arrival.

Your choice of cocktails is very personal. Trust us, we get it. While some of us are vodka soda fans, others like to mix with cranberry juice. And then we have the more elaborate amongst us who go for Cosmos, Long Island Iced Teas, and Mojitos. (Watch out the next day: sugar hangovers are the worst!) Whatever you like to mix with your alcohol, you probably have a reason for it. Same goes for your ovaries and us. Everything we do has a purpose. The difference is, we’re helping make babies, not Bellinis. Here’s to your success, your health, and your fertility. Cheers!