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Infertility: Solutions for Men & Women

Online Health Chat with Cynthia Austin, MD & Edmund Sabanegh, MD

May 11, 2012

Introduction

Infertility is defined as the inability to conceive after a year of unprotected intercourse. In the U.S., infertility affects 7.3 million people, or one in eight couples, and affects both men and women equally.

If you are having issues conceiving, we encourage you to participate in this web chat. Dr. Edmund Sabanegh (male fertility) and Dr. Cynthia Austin (female fertility) will be answering questions live to make sure you and your loved one are informed about fertility issues and the available treatment options.

Cynthia Austin, MD, joined Cleveland Clinic’s Women’s Health Institute in 2000, and is board-certified in obstetrics and gynecology with subspecialty certification in reproductive endocrinology. As the Director of In Vitro Fertilization, she specializes in infertility and in vitro fertilization (IVF).

Edmund Sabanegh, MD, joined the Glickman Urological & Kidney Institute in 2006 and currently serves as the chairman of the Department of Urology, and director of the Center for Male Fertility. He is board-certified by the American Board of Urology and is an assistant professor of urology for Cleveland Clinic Lerner College of Medicine, Case Western Reserve. He specializes in male fertility, general urology, vasectomy, vasectomy reversal and microsurgery.

Cleveland_Clinic_Host: If you would like to make an appointment with Dr. Sabanegh or Dr. Austin please call 800.223.2273 or request an appointment online by visiting www.clevelandclinic.org/appointments.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic fertility experts Dr. Cynthia Austin and Dr. Dr. Edmund Sabenegh. We are thrilled to have them here today for this chat. Let’s begin with some of your questions.


Treatments

The_GoodLife: I am a healthy 27-year-old who just got done having my second intrauterine insemination (IUI). I am not sure if it worked yet, but I was wondering how many IUIs are recommended before you suggest moving on to IVF? My husband has some count issues, but that has since improved a bit since our first IUI. I am almost positive that I ovulate every month. I guess I am just worried about putting a lot of money into the IUIs when the success rate is not as high as IVF, but I also don't want to move forward too quickly if it is likely that IUI will work for us, and we just need to change medication, etc., to improve our chances.

Dr__Austin: If the sperm count in the inseminating specimen is over 5 million, we recommend trying a minimum of three cycles and a maximum of 6 cycles. You should have already had testing to be sure your anatomy is normal.

ThyroidDisorder: My husband and I have been trying to conceive since 2009. In May of 2011, I was diagnosed with Hashimoto's disease. I don't ovulate regularly due to that condition. What would be the best most effective method of treatment? We have already done 5 unsuccessful rounds of Clomid® (clomiphene). Thank you so much.

Dr__Austin: If your ovulation problem is due to your thyroid problem, you should have normal ovulation after you have been treated for the thyroid problem. If you have never ovulated regularly, the thyroid problem is probably not the main cause. The next logical step in Clomid treatment would be to add intrauterine insemination (IUI). If you have not completed fertility testing, you should do that first.

aschneid38: My cycles are irregular at best. I do not ovulate with every cycle, even while on the injectable hormones. Other than IUI and in vitro, are there other treatment options available, or is the only course of action the "let's try this and see if it works" method that I am currently on?

Dr__Austin: If you are not ovulating well, your treatment should be focused on improving the quality and regularity of your ovulation. IUI and IVF both rely on being able to ovulate normally or correct ovulation problems with treatment. There are several different drugs that are given by injection, so I cannot tell what you have been given. It may be that you need further evaluation.

TheGoodLife: What is the Cleveland Clinic's IVF/IUI success rate?

Dr__Austin: Pregnancy rates for any woman depend on many factors, including—and probably most importantly—her age. Many people are unaware of how low the per-cycle pregnancy rate is for "normal fertile women." For example, the chance of pregnancy on one menstrual cycle for a normal fertile 35-year-old is only about 20%. Fertility treatment attempts to return the pregnancy rate for the "infertile" couple to that of normal couples. IVF is the only treatment that results in a higher per-cycle pregnancy rate than that of a normal fertile couple.

IUI pregnancy rates also vary with the type of fertility medication the woman is taking.

IVF pregnancy rates are reported to the Society for Assisted Reproductive Technology (SART) and can be found on that web site. They are broken down by age. A young woman will have about a 50% chance of successful pregnancy following one cycle of IVF. A woman over 43 has less than 5% chance of having a successful pregnancy after any fertility treatment, including IVF.

rebma02: What treatment options are available for someone with PCOS who has been unsuccessful in ovulating with the assistance of oral medications and one round of Menopur® (menotropins for injection, USP)?

Dr__Austin: Polycystic ovary syndrome (PCOS) is a syndrome, not a disease. It simply means that you have two of the following findings: 1) irregular or absent periods, 2) evidence of androgen excess, and/or 3) polycystic-appearing ovaries. Even the cysts are not abnormal; they are just tiny follicles (egg-containing cysts) that have not been able to develop and ovulate. Women with PCOS are quite different from one another. If you are not ovulating in response to treatment, you may need further evaluation to better understand you as an individual.

jkmd: My husband and I are healthy 27-year-olds who have experienced 4 unsuccessful Clomid IUIs. His sperm count is high, and I ovulate regularly. A hysterosalpingogram (HSG) revealed open tubes; progesterone levels (6x) were "in the normal range;" and an ultrasound showed four follicles for the 3rd IUI. Should we try a 5th IUI? What would be the next course of action?

Dr__Austin: It sounds like you have unexplained infertility. This is frustrating, but treatable. The recommended number of cycles of Clomid IUI cycles is 3 to 6. If you have not become pregnant after 6 cycles, the chances that you will be successful using this approach are low (but not zero). The next two options are: 1) gonadotropin (fertility shots) and IUI or 2) IVF. Studies show that in large populations, IVF produces more successful pregnancies over a shorter period of time, but choosing this treatment is an individual decision that should be discussed with your doctor. The main problem with gonadotropin IUI is that if you become pregnant there is a 5% chance of having more than twins. IVF controls that risk because we generally are transferring one or two embryos.

sometimes: Do you have a donor program?

Dr__Austin: We do perform donor sperm insemination. Donor sperm is obtained from commercial sperm banks.

Dr__Austin: We also do donor egg IVF cycles. Sometimes donors are known to the couple, such as the wife's sister. Other times, couples obtain an anonymous donor through a donor egg agency.

before_now: Do you have surrogate program?

Dr__Austin: We do IVF cycles using gestational carriers. That means that a couple completes an IVF cycle using the wife's eggs and her husband's sperm, but the embryos are transferred to the uterus of another woman. That woman is sometimes called a surrogate and sometimes called a gestational carrier. The reasons for using a gestational carrier include hysterectomy, damaged uterus, and health problems that make pregnancy unsafe.

addaboy: How long do you typically keep patients on Clomid before moving onto something else? Is there a risk in long-term use of Clomid?

Dr__Austin: The limitations to the use of Clomid are first - if after 6 cycles of good response, you are not pregnant, the chance that it will work is low. The second issue is that Clomid can cause the lining of the uterus to be thin and the cervical mucus to be hostile to sperm - particularly after prolonged use.

Brighton: Is there a lifetime limit to how many rounds of Clomid a patient can do? I did 5 rounds for my first pregnancy and would like to try for a second pregnancy.

Dr__Austin: No, there is no lifetime maximum.

hopefully37: How many times do you recommend trying IVF before moving on to other family-building options?

Dr__Austin: The answer to your question depends on so many factors - your age, your response to stimulation, your egg and embryo quality, just to name a few. In general, I would say three fresh IVF cycles.


Male Fertility

Einalem672: My husband had a testicle biopsy, and the results came back negative for sperm. The doctor said that he is missing a certain enzyme that helps create sperm. Is there any way he can father his own children? Can the enzyme be supplemented? Thank you.

Dr__Sabanegh: There are a number of genetic causes which can impact the production of enzymes which are important for sperm production. Depending on the exact cause, sometimes we can do a microsurgical testicular biopsy and find sperm that was not located on a prior biopsy.

stand_up: Can male infertility to be treated?

Dr__Sabanegh: Male infertility can often be treated successfully. Sometimes there are obvious causes such as blockages that we can repair. Often we will use medications to treat infections or improve hormone levels, which can also improve fertility. Finally, in some cases, we will use assisted reproduction such as insemination to cause a pregnancy.

yes_i_am: Do hot tubs kill sperm?

Dr__Sabanegh: High temperatures such as those that result from hot tubs or laptop computer use can greatly lower fertility. It is important to avoid hot tub use when you are trying to cause a pregnancy.

go_ahead: Are there are any obvious symptoms of male infertility?

Dr__Sabanegh: Often there are no symptoms of male infertility except the inability to cause a pregnancy. Sometimes, male infertility can be from a hormone imbalance and patients may have decreased sexual desire or erectile dysfunction. In addition, a small number of men may have infertility due to testicular abnormalities such as tumors, so men should have a complete examination if they have difficulty causing a pregnancy.

dog_eared: What are the chances of pregnancy when you have XXY syndrome?

Dr__Sabanegh: Men with 47XXY syndrome, also called Klinefelter's syndrome, often have no sperm in their ejaculation. However, in 60% of those patients, we can find a small number of sperm in the testis using a careful microsurgical biopsy. These sperm can be used for intracytoplasmic sperm injection (ICSI), a type of in vitro fertilization, to cause a pregnancy.

jobe: How do you get tested for male infertility?

Dr__Sabanegh: Usually, we see the man in a clinic appointment and take a complete medical history and perform a physical examination. We then recommend that the patient produce a semen specimen for laboratory analysis. Further testing including blood tests of hormone levels may be indicated based on the results of the semen tests.

Brighton: What is currently considered a good morphology/Kruger score?

Dr__Sabanegh: Kruger morphology, also known as "strict morphology," is considered abnormal when it is lower than 4 by World Health Organization standards.

handen333: Does carrying a cell phone in the pocket decrease a man’s fertility and why?

Dr__Sabanegh: Some research in the laboratory has suggested that exposure to radiation that is produced by a cell phone may lower a man's sperm count and motility. This is an area of ongoing research, and we do not have a definite answer to this question yet. Until we know for sure, we recommend that men who are actively trying to cause a pregnancy keep their cell phone as far as possible from their pelvic area.

breaking_down: Is there a true correlation between traditional underwear and infertility?

Dr__Austin: There is a long-standing thought that boxer underwear may protect fertility over jockey-style underwear. Most experts in the field now feel that this is not a significant cause of reduced male fertility.

lodded: Are there any medications that have infertility as a side effect?

Dr__Sabanegh: Yes—many medications can hurt fertility. Testosterone therapy can greatly impair sperm counts and should be avoided until men have caused a pregnancy. The list can be quite long, but other medications that impair fertility include chemotherapy medications to treat cancer, hormone treatments, and drugs to treat prostate enlargement.

lo_and_behold: I know that prior drug use can cause infertility. What are the worst drugs in causing male infertility? Also, is the damage permanent?

Dr__Sabanegh: Recreational drugs, such as marijuana, can alter hormone levels and cause infertility. Anabolic steroids used for muscle building can greatly affect fertility by lowering sperm counts. In those patients, it may take 3 to 6 months to recover; it has been observed to take up to 4 years to recover in some patients.

howieb4: What is the shelf life of frozen sperm?

Dr__Sabanegh: Frozen sperm can last indefinitely. We have seen patients successfully use frozen sperm to cause a pregnancy after 22 years of freezing. Based on our analysis, there is no upper limit for when it has to be used.

outrajs: What are some of the causes of infertility?

Dr__Sabanegh: Infertility is caused by the male side in 30% of cases, the female side in 40% of cases and a combination of male and female factors in 20% of cases. As regards male side causes, impairment of fertility can be caused by blockages in the sperm tract, hormone imbalances, varicoceles (dilated scrotal veins), infections, and genetic abnormalities, to name a few.

pp987: If DNA fragmentation is damaged due to smoking, does it recover if a person quits smoking? If yes, how long does it take?

Dr__Sabanegh: Many sperm characteristics, including DNA fragmentation, motility, and concentration, can be negatively affected by smoking. Studies have shown that these factors will improve by quitting smoking. The sperm cycle is usually about 74 days, so we usually tell patients that they may observe an improvement as soon as 3 months after quitting tobacco use.

Brighton: Is there anything a male patient can do to increase morphology score?

Dr__Sabanegh: Morphology can improve with a variety of treatments, including treating an infection or removing certain medications. However, the most common factor we see in clinical practice is improvement of morphology after treating a clinical varicocele, which is a dilated vein in the scrotum.

Blue_Shoe72: What lifestyle changes can a man make to improve his sperm quality?

Dr__Sabanegh: Sperm quality is a snapshot of our overall health. Things that we do to improve our overall health such as getting regular exercise, maintaining a healthy body weight, and eating a diet rich in fruits and vegetables for their antioxidants will often improve our fertility. Avoidance of things which can hurt our fertility—including tobacco, illicit drugs such as marijuana, and anabolic steroids—will also help.

Fred_622: How long should I abstain from intercourse prior to my upcoming semen analysis?

Dr__Sabanegh: Ideally, you should abstain for 3 to 5 days before performing a semen test. This allows a replenishment of sperm count so we can get a true picture of your sperm production.

rebma02: What is the recommended treatment for varicoceles and how does that affect infertility?

Dr__Sabanegh: Varicoceles are enlargement of scrotal veins which can cause the scrotum to stay too warm and hurt sperm production. Patients with varicoceles can have reduced sperm counts, motion and shape abnormalities. Varicoceles are usually treated with a minor surgery where the abnormal veins are treated through a small incision in the groin using an operating microscope. Typically this surgery takes about an hour, and patients can resume all normal activities within a couple of days.

aschneid38: My husband had epididymitis in college, and we just found out that the genetic form of amyloidosis is in his family (his grandfather and father both passed away from the disease). According to his doctor, his count is "normal" right now. Could either epididymitis or amyloidosis have an effect on the viability of his sperm?

Dr__Sabanegh: Epididymitis is more likely to cause fertility issues in some patients. The epididymis is a small tube that conducts sperm from the testis so if it gets infected, it can block sperm flow in some men. Your husband is fortunate because his sperm count is normal, so it does not appear that the epididymitis affected his fertility.

its_alright:  I am a 53-year-old male with motility = 0 who took Clomid for 3 months without improvement. My doctor asked me to take an ultrasound exam. Would it be helpful? What is the purpose of it? What is the IVF rate for my case? Is there a solution to treat motility?

Dr__Sabanegh: Low sperm motility can be caused by a variety of things including varicoceles (dilated veins in the scrotum), antibodies to sperm, infections and some medications. Your doctor wants to perform a scrotal ultrasound to make sure the testicles are healthy and to look for varicoceles. The IVF success rates are really dependent on the viability of the sperm (how many are alive), which can be determined by special sperm tests. Regarding ways to treat low motility, it really depends on the cause. In addition, sometimes low motility is a temporary condition due to a recent illness or fever and may recover in 3 to 6 months.


Female Fertility

jkmd: What is a desired range of progesterone levels for pregnancy to occur?

Dr__Austin: I assume that you are asking how high a woman's progesterone should be during the second half of her cycle. The answer is that there is no right level. Progesterone levels rise and fall throughout the day so measuring the level does not tell us if there is enough progesterone. If your progesterone level is checked, it is either in the post-ovulatory range or it is not (indicating that you did not ovulate). The more important issue is how long your cycle is between ovulation and the onset of your next period. It should be 12 to 14 days.

justified: Does taking birth control pills for a long time have an effect on fertility? How about the Depo-Provera® (medroxyprogesterone) shot?

Dr__Austin: Birth control pills do not cause infertility. In some cases, women may ovulate best when they first stop taking birth control pills. Women who have irregular periods and go on birth control medications to regulate their cycle often have the same irregular cycles when they come off. If a woman is having irregular cycles, she is either not ovulating or not ovulating regularly.

Depo-Provera is an injection of synthetic progesterone. It does not damage fertility, but it can take a long time for it to wear off. If a woman was given Depo-Provera to treat irregular bleeding, she will probably have that same problem when it wears off.

hopefully37: What vitamins/herbal supplements if any do you recommend for women experiencing conditions such as endometriosis and diminished ovarian reserve (DOR)?

Dr__Austin: All women attempting pregnancy should take vitamins containing 400 mcg of folic acid. Unfortunately, herbal supplements do not improve either endometriosis or DOR. Some herbal supplements may contain estrogen, which you would not want to be taking in addition to fertility medications.

TheGoodLife: I have been temping during my treatments still to help detect ovulation. I am on Clomid now. Does Clomid mess with your temperatures during use?

Dr__Austin: Have your doctor or nurse take a look at your charts. If you are having regular cycles on Clomid you are almost certainly ovulating. Temperature charts are not perfect, but at least they are free.

DEATRA: Is there any possibility of becoming pregnant if the female has one blocked fallopian tube? If so, what is the percentage rate?

Dr__Austin: Women with one normal functioning tube usually get pregnant almost as well as other women. In other words, if a normal fertile woman has one tube removed, she usually does not have trouble becoming pregnant. If a woman having difficulty becoming pregnant has one blocked tube, it may suggest that the other tube, while not blocked, is also damaged.


Miscellaneous

addaboy: What is usually recommended for someone diagnosed with MTHFR?

Dr__Austin: MTHFR heterozygous is of little significance. MTHFR homozygous is usually treated with folic acid, but again, is not felt to have a significant impact on fertility.

no_one_knows: How soon after having a blockage repaired can one start having sexual intercourse?

Dr__Sabanegh: It depends on whether the repair is of the male side or the female side. After repair of an obstruction in the male, patients should not start having intercourse until at least 3 weeks. Following repair of a blockage on the female side, couples should wait at least one full menstrual cycle before resuming sexual activity.

Amp9676: I have recently been diagnosed with testicular cancer, but the doctors say it is treatable. What options do you have available for men to bank their samples for later use? I want to be sure my fertility is not taken away.

Dr__Sabanegh: You raise a very important point. I recommend that all men bank a semen specimen prior to receiving chemotherapy or radiation therapy for treatment of testicular cancer. Ideally, men should bank sperm prior to surgical treatment of the testicular cancer if possible. We offer sperm banking for patients at the Cleveland Clinic. We also offer the NextGen program where a patient who is not in the vicinity of the Cleveland Clinic can have a sperm preservation kit sent to their home, and they can ship it to our site for sperm freezing (Cleveland Clinic sperm bank- phone 866-9bankin or 866-922-6546). It is indeed very wise to preserve your fertility prior to receiving testicular cancer treatment.

glock3: Does having sex more often increase or actually decrease the chance of pregnancy?

Dr__Sabanegh: It is helpful to have regular sexual frequency during the time of ovulation (egg release). We usually recommend at least every other day sexual frequency for a week during the ovulatory period.

hopefully37: Do you have any recommendations on how to handle the emotional roller coast of infertility?

Dr__Austin: It is important to attend to your spiritual needs and to remain mindful of all of the good things in your life. Remaining hopeful and emotionally strong will allow you to navigate through the various treatments until you arrive at the one that works for you.

Cleveland_Clinic_Host: Join Cleveland Clinic Fertility Center on Facebook. Log on to clevelandclinic.org/FertilityFacebook. Click on "Ask to Join Group." Visit our Group Page often to interact with our physicians, nurses and embryologists as they share the latest information on infertility diagnoses, treatments and procedures. Engage with other patients facing the same challenges. Feel free to invite your family and friends to join our discussion too.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic fertility experts, Dr. Cynthia Austin and Dr. Dr. Edmund Sabenegh is now over. Thank you both for taking your time to answer our questions today about infertility.

Dr__Sabanegh: I have really enjoyed chatting with all of you and I hope my answers are helpful. I wish you all success going forward. If you would like to make an appointment at the Center for Male Fertility, please call 800.223.2273 ext.45600. Thank you!

Dr__Austin: Thank you for participating today. There are so many good questions we were unable to get to. Remember that we do have another chat next Thursday on infertility and affordability.


More Information

If you would like to make an appointment with Edmund Sabanegh, MD or Cynthia Austin, MD please call 800.223.2273 or request an appointment online by visiting www.clevelandclinic.org/appointments.

A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit eclevelandclinic.org/myConsult

If you need more information, click here to contact us, chat online or call the Center for Consumer Health Information at 216.444.3771 or toll-free at 800.223.2272 ext. 43771 to speak with a Health Educator. We would be happy to help you. Let us know if you want us to let you know about future web chat events!

Some participants have asked about upcoming web chat topics. If you would like to suggest topics, please use our contact link clevelandclinic.org/webcontact.

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians. ©Copyright 1995-2012 The Cleveland Clinic Foundation. All rights reserved.