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Infertility FAQ (part 2/4)

( Part1 - Part2 - Part3 - Part4 )
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Archive-name: medicine/infertility-faq/part2
Posting-frequency: weekly
Last Modified: May 14, 2001
URL: http://www.fertilityplus.org/faq/infertility.html

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This FAQ is maintained and updated by Rebecca Smith Waddell.

Copyright (c) 1997, 1998, 1999, 2000 by Rebecca Smith Waddell, Meg Fiegenschue,
Lynn Diana Gazis-Sax, William F. Panak, Rachel Browne, Jennifer Clabaugh, Kate
MacKenzie, and Ian Scott Speirs. All rights reserved. Information in this FAQ
may be distributed as long as full copyright information is attached, including
URL, and use is strictly not for profit.
______________________________________________________________________
______________________________________________________________________


SECTION 7 - INFERTILITY TESTS

Information and brief description of the more common tests used to diagnose
infertility.

------------------------------------------------------------------------

7.1 - EVALUATION PROCESS FOR MEN

Discussion of medical and surgical history. This includes a history of systemic
diseases, such as viral infections (particularly postpubertal mumps and venereal
disease), fevers, and diabetes mellitus, previous surgery, especially in the
genitourinary area, duration of infertility, previous pregnancies, and sexual
history. Many men had a hernia repair as babies and this occasionally causes a
blockage of the vas due to scar tissue or to just bad surgical practices.

Physical exam: This includes an examination of testicle position in the scrotum
(if the testicles haven't descended properly, the sperm will not be cool
enough), an examination of the scrotum for varicoceles (varicose veins of the
testicles), and an examination of the prostate and prostatic fluid for signs of
infection. Also, fat and hair distribution is examined, for signs of hormone
imbalance.

Urinalysis: Looks for signs of a urinary tract infection, presence of sperm in
the urine (which, in conjunction with a low sperm count, may indicate retrograde
ejaculation), and signs of systemic disorders such as kidney problems or
diabetes mellitus.

Semen analysis: This is done at least three times, since sperm count varies, and
a 2-3 day abstinence is required before each analysis. Normal values follow:

     ejaculatory volume: 1.5-5.0 cc
     sperm density: > 20 million/ml
     motility: > 60%
     forward progression: > 2, on a scale of 1-4
     morphology: > 60% normal forms
          (should have oval head and long tail)
     1) no significant microscopic sperm clumping,
     2) no significant white or red blood cells,
     3) no increased thickening of the seminal fluid
        (hyperviscosity).

For more information check
http://matweb.hcuge.ch/matweb/endo/PGC_network/Semen_analysis_rrumbullaku.htm.

Endocrine tests: Blood tests to check levels of testosterone, FSH (follicle
stimulating hormone), LH (luteinizing hormone), prolactin, estradiol, and the
thyroid hormones T-4 and T-3. Usually FSH levels are measured first for men with
low sperm counts, and others are measured as indicated. Some patterns of hormone
abnormalities are more amenable to treatment than others. An elevated FSH is an
indicator of testicular failure or the beginnings of testicular failure. If this
is the case, there is little that can make a large difference in the count. Low
normal or low levels of testosterone often indicate testicular atrophy (usually
due to varicoceles). There is also little that can be done to change the sperm
count if the levels of testosterone are low. Thyroid is an often overlooked or
forgotten cause of sperm problems and is easy to check and easy to remedy. A
link to general thyroid disease info is http://thyroid.miningco.com/.

Postcoital: Checks cervical mucus for presence of sperm after coitus. If a sperm
count is low, generally it is just as easy to move on to intra-uterine
insemination (IUI)rather than waste a cycle or more trying to do a postcoital.
The sperm of men with low counts are more delicate and have more trouble
surviving in mucus than do normal men's sperm.

Sperm Penetration Assay (SPA), or Hamster test (HEPA): This tests the ability of
the sperm to penetrate a specially prepared hamster egg. This test is
controversial and there is no clear evidence that the results are worthwhile.
(FWIW, a little hamster has to die to donate the egg.)

Testicular biopsy: Takes a small piece of testicular tissue, and checks
sperm-producing tubules and cells between the tubules. Possible patterns
include: Normal (the tubules and the sperm in them are normal, so the problem is
likely a blockage elsewhere), maturation arrest patterns, hypospermatogenesis
(elements are there, but sperm isn't), and germinal cell aplasia (there just
isn't any sperm there, and the only options for parenthood are donor
insemination or adoption). This test is usually done as a last resort. It  is
often done in conjunction with an IVF cycle where donor sperm are ready as a
backup in case there are no sperm in the biopsy.

Ultrasound of seminal vesicles to show their size, development, and whether they
are emptying and storing sperm properly.

Vasogram: An x-ray using a dye to outline the ducts and look for obstructions.

------------------------------------------------------------------------

7.2 - EVALUATION PROCESS FOR WOMEN

Hormone tests: These are simple blood tests to check if there is a hormonal
imbalance. These tests may include any or all of the following:

Hormones:

     luteinizing hormone (LH)
     follicle stimulating hormone (FSH)
     estradiol (E2)
     progesterone
     prolactin
     thyroid stimulating hormone (TSH)
     free T3
     free thyroxine
     total testosterone
     DHEAS
     androstenedione
     sex-hormone binding globulin<BR>
     17-Hydroxyprogesterone

A chart of hormone levels is posted at
http://www.fertilityplus.org/faq/hormonelevels.html.

Insulin resistance (IR) testing: Insulin resistance is precursor to diabetes
that can cause weight gain and is often seen in those with PCOS. Testing should
be done on overweight infertility patients and anyone suspected of having PCOS,
What happens is that the body starts producing excess insulin (hyperinsulinemia)
in order to keep glucose levels normal. Testing glucose levels alone won't
indicate insulin resistance until it is fairly advanced -- what's needed is
fasting glucose and insulin levels, or a glucose tolerance test (preferrably
also checking insulin). More info is at http://www.inciid.org/faq/pcos.html.
Pelvic exam: A physical exam to check for signs of infection as well as obvious
physical abnormalities. Pretty much the standard feet-in-stirrups event.

Abdominal ultrasound: A transducer is passed over the bare skin of the abdomen
in order to view the uterus and ovaries. Cysts, fibroids and uterine
abnormalities may be visible.

Trans-vaginal ultrasound: A transducer wand is inserted into the vagina to view
the cervix, uterus and ovaries. Provides greater detail than abdominal
ultrasound.

Post-coital test (PCT): A sample of cervical fluid is obtained by gently
scraping the cervix within a few hours of intercourse. The fluid is checked
under a microscope to see if motile sperm are present. Must be done with fertile
mucus at ovulation time.

Endometrial biopsy (EMB): Used to "date" the lining in relation to ovulation and
to test for infection or pre-cancerous cells. To date the lining, the test is
generally performed a few days prior to expected menses. A thin catheter is
inserted through the cervix and a small sample of the uterine lining is removed.

Hysterosalpingogram (HSG): People often call this the dye test. A catheter is
inserted through the cervix and a small amount of dye is pushed into the uterus
while x-rays are being taken (usually continuous motion as well as a few
stills). The shape of the uterus is observed, as well as how the dye flows
through the fallopian tubes.

Laparoscopy: This surgery is usually done under general anesthesia to look for
structural abnormalities, endometriosis and adhesions as well as possibly repair
any problems found. The abdomen is inflated with carbon dioxide and a scope is
inserted through a small incision below the navel. A second incision just above
or below the pubic hairline is used to insert a tool to help manipulate the
organs for better viewing with the scope. Patients may be able to get a
videotape of the surgery.

Hysteroscopy: The cervix is dilated just enough to insert a small scope used for
viewing the inside of the uterus. Minor abnormalities can be fixed during this
procedure, which can be done under local or general anesthesia. Often done in
conjunction with a laparoscopy.

Personal experiences with EMBs, HSGs, laparoscopies and hysteroscopies are
posted in the Invasive Infertility Tests FAQ at
http://www.fertilityplus.org/faq/itests.html.

Infectious disease testing: Some physicians will test for a variety of sexually
transmitted and other infectious diseases including ureaplasma, mycoplasma,
gonorrhea, chlamydia, syphilis, toxoplasmosis, rubella (German measles),
cytomegalovirus virus, Hepatitis b&c and HIV I & II.

Immune testing: Some of the tests mentioned below are still controversial, but
more and more doctors are seeing the benefits of checking into and treating
immune disorders which affect fertility.

Lupus (SLE) tests (includes commonly tested for lupus anti-coagulant):

     Activated Partial Thromboplastin Time (APTT)
     Kaolin clotting time
     Platelet Neutralization Assay
     Dilute Russel viper venom time
     Anti-phospholipid antibodies (APA) tests (includes IgM, 
     IgG and IgA markers):
     Anticardiolipin antibodies (ACA)
     Phosphoethanolamine
     Phosphoinositol
     Phosphatidic acid
     Phosphoglycerol
     Phosphoserine
     Phosphocholine

Anti-nuclear antibodies (ANA) tests:

     ssDNA
     dsDNA
     Sm
     RNP
     SSA
     SSB
     Histone
     Scl-70

Anti-thyroid antibodies (ATA):

     Thyroglobulin
     Thyroid microsomal (thyroid peroxidase) autoantibodies

Anti-sperm antibodies (ASA): These can be either autoimmune or alloimmune. They
are a blood test, usually indicated by a specimen at IUI-time behaving
abnormally. If it's autoimmune (the male has them) then the sperm are healthy
looking, but they clump together and make knots that don't make satisfactory
progression in great looking mucus. If it is alloimmune (the woman has them)
then they are usually healthy looking but mostly dead on arrival or all of the
live ones are incredibly slow. It's at IUI time that most of us get sent for the
full range of tests, but many of us are treated without testing (testing cost is
high, treatment cost is low). Treatment is usually prednisone for the party
doing the antibodies. Dose is dependent on severity. Prednisone is very
inexpensive -- about $5.00/month each.

Alloimmune tests:

     Leukocyte Antibody Detection (LAD or HLA sharing)
     Natural Killer Cells (CD56+)
     Full Reproductive Immunophenotype (include NK cells)
     Embryo Toxicity Factor (ETF)

The full Immunophenotype costs around $500 each and several may be necessary to
gauge success of treatment. It is similar to testing that cancer, AIDS and
transplant patients have. It measures all kinds of things about our immune
systems in general and then our Reproductive Immunologists make some
interpretations to apply our results to reproductive problems.

More information on immune testing can be found on the ICIID (pronounced inside)
web site, http://www.inciid.org/immune.html, and on Dr. Beer's web site at
http://repro-med.net/index.html.

MRI or CT scan: One of these might be done if elevated prolactin is found. This
is to look for a pituitary tumor.

________________________________________________________________________
________________________________________________________________________


SECTION 8 - COMMON CAUSES OF INFERTILITY

Unexplained: One of the most common forms of infertility is unexplained. This is
when no physical, hormonal or immunological cause for infertility is found in
either partner. Recent studies indicate that some unexplained infertility may be
related to the use of non-steroidal anti-inflammatory drugs (NSAIDs), which
impede ovulation. Check http://www.fertilityplus.org/faq/nsaids.html for more
information.

------------------------------------------------------------------------

8.1 - CAUSES OF INFERTILITY IN MEN

Cancer treatment: Chemotherapy and radiation can cause abnormal sperm or
sterility. 

DES (diethylstilbestrol) exposure: Synthetic estrogen used in the 50s and 60s
used by women to prevent miscarriage. Can cause low sperm counts, decreased
sperm motility, and abnormal sperm forms, small penises, undescended testicles
(risk factor for testicular cancer), abnormal testicles.

Hormonal imbalances: Hormone problems affecting sperm count include thyroid
problems, low testosterone levels, elevated FSH, and excess prolactin (see next
entry).

Hyperprolactinemia (excess prolactin): can inhibit GnRH, resulting in lower LH
and testosterone. Also low FSH.

Idiopathic oligospermia: A fancy way of saying, "You don't have much sperm, and
we have no idea why."

Immune problems: Both men and women can have immune reactions to sperm. There is
a lot of controversy about how prevalent this is. Immune reactions to sperm in
the man (autoimmune) can be a problem post-vasectomy, but may also have other
causes.  Anti-sperm antibodies in the male are often indicated by hyperviscosity
which may inhibit forward progression. In mild cases, anti-sperm antibodies in
the male or female (alloimmune) may be overcome by IUIs, for which the man will
be asked to ejaculate into a cup with a special preparation in it. If IUI does
not work, or if the problem is considered too severe, IVF may be necessary, with
ICSI likely for male anti-sperm antibodies. Predisone, a steroid, may be given
to the party producing the antibodies.

Impotence: One of the less common causes. Note: impotence is a *medical*
problem. There are a variety of medical causes that can contribute, including
diabetes mellitus, certain required medications such as antidepressants, etc.
Sexual advice from friends is generally *not* welcome. Some useful advice on
impotence can be found at http://www.impotence.org. The drug Viagra, according
to the manufacturer, does not appear to have any negative impact on sperm. See 
http://www.viagra.com/hcp/pro_pack_insert.htm.


Infection: Postpubertal mumps, and, occasionally, venereal diseases such as
gonorrhea and chlamydia can harm male fertility. Also, recurrent infections such
as prostatitis can lower sperm count and motility.

Klinefelter's Syndrome: Men with Klinefelter's syndrome have two X chromosomes
and one Y chromosome, rather than the normal one X and one Y. They are generally
tall and thin, with small testicles. More information can be found at
http://www.globalwebsol.com/vv/  and  http://www.genetic.org . Both sites
include listserv and support group addresses.

Lifestyle factors: These include factors which raise the temperature of the
scrotum (such as the use of hot tubs or long baths), or harm sperm production. A
variety of medicines and recreational drugs can decrease male fertility. These
include alcohol, marijuana, cocaine, cigarettes, anabolic steroids,
sulfasalazine, cimetidine (Tagamet, used for ulcers), nitrofurantoin (used for
UTIs), anti-hypertensive drugs (specifically calcium channel blockers), aspirin,
Dilantin (for epilepsy), colchicine, and antidepressants (note that some of
these drugs should *not* be simply discontinued, because they may be required
for other serious medical problems). Exposure to certain chemicals, such as lead
and arsenic, and many types of paints or varnishes, can also adversely affect
male fertility.

Obstruction: Can occur at various points, blocking sperm from getting out.
Treated surgically. Often may be easier to work around obstruction by doing MESA
or TESA instead of trying to repair surgically. 

Prior surgery: The vas may be damaged during surgery fo hernia repair,
orchiopexy, and even during varicocelectomy.

Retrograde ejaculation: Can be caused by certain medications, surgeries, and
nerve damage (for example, from diabetes mellitus). Sperm goes in the wrong
direction and can be found in the urine.

Sexual Dysfunction: Reported in up to 20% of infertile men. May include
decreased sexual desire, inability to maintain an erection, and premature
ejaculation. This could result from low testosterone or performance anxiety.

Trauma to testicles: Injury to testicles, such as from being hit, followed by
atrophy. May also be the result of having the mumps and develop bi-lateral
orchitis.

Undescended testicle: If the testicles do not descend during puberty, their body
temperature may be too high, reducing quality and quantity of sperm production.
Rare.

Varicocele: An enlarged vein in the scrotum, which causes pooling of blood and
an elevated temperature. This one is controversial. According to some, it is one
of the most common and readily treatable causes of male infertility. Others say
that varicocele is also common among fertile men, and question the connection
with infertility and the need for treatment. Large varicoceles that go untreated
can cause permanent damage to the testicles. This can lead to testicular failure
or atrophy. Testicular failure is indicated by an elevated FSH and means that
the testicles are starting to stop producing sperm. Testicular atrophy is
indicated by small testicle size and often leads to lower testosterone levels.
This affects sperm counts and can also lead to the need for testosterone
replacement therapy as the man ages. Note: Testosterone replacement _should
not_ be used while pursuing fertility treatments as it will make the brain think
it doesn't need to make testosterone and sperm counts will diminish even
further. Description of surgery with graphics is available at
http://www.maleinfertility.org/new-varicocelectomy.html

Vasectomy reversal: Though vasectomies are meant as a permanent means of birth
control, it turns out that they can often be reversed. However, it is easier to
reverse them if not too much time has passed since the vasectomy. The more time
has passed, the more likely it is that the man will have an immune reaction to
his own sperm.

------------------------------------------------------------------------

8.2 - CAUSES OF INFERTILITY IN WOMEN

Adhesions and scarring: Can be caused by sexually transmitted diseases left
untreated, Chlamydia being the most common. Scarring can lead to blockage of the
fallopian tubes, or damage to the delicate membranes within the tubes. It can
also be formed by endometriosis and prior surgeries in the abdominal area.

Age: A woman's fertility begins falling off after the age of 25, though
pregnancy can be achieved and maintained for most women into their early 40s.
The rate of miscarriage and birth defects increases after 35. See 
http://noah.cuny.edu/pregnancy/march_of_dimes/pre_preg.plan/after30.html

Asherman's Syndrome: This is a condition where the walls of the uterus adhered
to each other. Usually caused by uterine inflammation.

Cancer treatment: Chemotherapy and radiation can cause early menopause.
Information on how cancer treatment affects fertility is posted at
http://oncolink.upenn.edu/specialty/med_onc/bmt/bmt_11.html

DES (diethylstilbestrol) exposure: Synthetic estrogen used in the 50s and 60s to
prevent miscarriage. Can cause abnormalities in the reproductive organs such as
shortened cervix, deformities of the vagina or cervix, T-shaped uterus, abnormal
fallopian tubes, ovulation problems, increased risks of ectopic pregnancy,
repeated miscarriage, and premature delivery. See
hhttp://www.teleport.com/~skeely/

Endometriosis: Growth of endometrial tissue outside the uterus. Can cause
blockage of the fallopian tubes and adhesions. May not cause any symptoms beyond
infertility, but could cause crampy periods and painful intercourse. FAQ posted
at http://www.bioscience.org/books/endomet/babaknia.htm.

Environmental hazards: Pesticides may damage a woman's eggs leading to early
menopause. Some materials are linked to early miscarriage. Ethylene oxide, used
in chemical sterilization of surgical instruments. Exposure by healthcare
professionals (including veterinary) to nitrous oxide. Vinyl chloride, used in
plastics, and metallic compounds including manganese, arsenic, and nickel.

Hyperprolactinemia (elevated levels of the hormone prolactin): Can be caused by
pituitary tumors, and breast milk production after giving birth. May lead to
weak or skipped ovulation. Lowering prolactin levels can be achieved with
Bromocriptine (Parlodel).

Hypothyroid: Underactivity of the thyroid gland. Symptoms include low basal body
temperature and unexplained weight gain. Can throw off the endocrine system
leading to ovulation problems and to miscarriage. An article about thyroid
disease and pregnancy, fertility and pregnancy loss is posted in two parts at
http://thyroid.miningco.com/library/weekly/aa063097.htm (part 1) and
http://thyroid.miningco.com/library/weekly/aa070797.htm  (part 2).

Immunological problems: The most common immune problems, testing positive for
anti-phospholipid antibodies or the lupus anticoagulant, can lead to blood clots
in the placenta that prevent nourishment from reaching a fetus. There are other
more controversial causes of immunological fertility problems -- please check
http://www.inciid.org for more information.

Luteal phase defect (LPD): There are two types of luteal phase problems that
fall under the category of LPD. One is a short luteal phase -- 10 days or less.
The second is when the length of the phase is not necessarily shorter than the
standard 12-16 days, but it is out of phase and progesterone production is low.
Typical treatment is to enhance ovulation and/or to use hCG or progesterone
support after ovulation.

Luteinized unruptured follicle syndrome (LUFS): Failure of the follicle to
release an egg even though it has reached maturity. Commonly seen when an LH
surge is not followed by ovulation. Can be confirmed with ultrasound. May
account for 5-30% of women with unexplained infertility.

Medication: Non-steroidal anti-inflammatory drugs (NSAIDs -- see
http://www.fertilityplus.org/faq/nsaids.html), radiation and chemotherapy for
cancer treatment, antihistamine and decongestants may lead to fertility
problems. Vitamin C in large doses is also considered an antihistamine - which
can lead to cervical mucus drying out.

Menopause: When a woman stops having regular ovulation and menses. Pregnancy may
still be achieved through drug therapy and perhaps IVF with donor egg.

Obesity: Excess weight can lead to elevated estrogen levels which act as birth
control and prevent a woman from ovulating. Drugs to induce ovulation can bypass
this problem. For more information on weight and infertility, please check
http://www.fertilityplus.org/faq/bbwfaq.html.

Polycystic Ovary Syndrome (PCOS): Symptoms include infertility, irregular
cycles, obesity, acne, excess facial and body hair, obesity, skin tags, dark
skin patches (back of neck, under arms, under breasts, groin), cystic ovaries,
excess male hormones,  insulin resistance, and dyslipidemia. It should be
diagnosed through a combination of a physcial exam, ultrasound evaluation to
look for possible cysts in the ovaries or ovarian enlargment, and blood tests to
check LH and FSH (check ratio as well as levels on these two as LH higher than
FSH is indicative of PCOS, especially when 2:1 or 3:1), testosterone, DHEAS,
SHBG, androstenedione, prolactin, TSH, fasting glucose and insulin testing.
Check http://www.inciid.org/faq/pcos.html and http://www.pcosupport.org for lots
of information and support options.

Premature ovarian failure (POF): Characterized by high FSH in a younger woman
(usually in her 30s). Cancer treatment and environmental hazards may play a role
in the development of POF.

Recurrent miscarriage/pregnancy loss (RPL): When a woman miscarries more than
one pregnancy. Testing can be done to try to determine the cause of such losses.
If an underlying condition is found, the woman may need to be treated for the
problem before a pregnancy can be carried to term. Testing information can be
found at http://www.fertilityplus.org/faq/miscarriage/rpl.html.

Smoking: Associated with an approximately 5% increase in miscarriage rate.
Smoking also doubles the chances of an ectopic pregnancy by damaging the cilia
in the tubes. Studies have shown a marked decrease in effectiveness of IVF and
GIFT. More information on smoking and GIFT can be found in the April 2, 1997
section of "What's up Doc?" at http://www.ivf-et.com/ (direct to the information
is http://www.ivf-et.com/wud970407.html)

Tubal ligation (and failed surgery to reverse): Surgical sterilization of a
woman by obstructing or tying of the fallopian tubes. May be reversed surgically
with varying degrees of success.

Turner's Syndrome: Women should have cells that are 46XX, but Turner's women are
missing an X -- hence a karyotype of 45XO or a mosaicism of 46XX and 45XO.
Turner's women with a 45XO karyotype are sterile while those with a mosaicism
may be able to get pregnant and carry to term. Women tend to be ultra-feminine
and small in stature. Check http://www.onr.com/ts-texas.

Uterine abnormalities: Include problems from DES exposure, septums, T-and
heart-shaped uterus.

Vegetarian lifestyle: Vegetarians may experience irregular ovulation that
reduces the chances of conception.

______________________________________________________________________
______________________________________________________________________

continued in Infertility FAQ (part 3/4)
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mailto:bec@fertilityplus.org
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