Online Health Chat with Edmund Sabanegh, MD & Julie Tan, MD
December 19, 2014
Couples having trouble conceiving oftentimes do not know where to turn for the answers to their questions. Fertility issues can be the result of a number of different medical factors. In some cases, even with the most comprehensive evaluation, no single factor can be identified. Fortunately, there are many diagnostic tests as well as effective treatments available, including – but not limited to – medical therapy, artificial insemination, in vitro fertilization and in some cases, surgery.
About the Speakers
Edmund Sabanegh, MD, is chair of the Department of Urology and director of the Center for Male Fertility at Cleveland Clinic. He is board certified by the American Board of Urology and is 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.
Julie Tan, MD, is a staff OB/GYN physician in Cleveland Clinic’s OB/GYN & Women’s Health Institute and is board certified in obstetrics and gynecology with additional certification in reproductive endocrinology and infertility. Dr. Tan’s specialty interests include medical management of infertility, in vitro fertilization, laparoscopic surgery, infertility surgery, sterilization reversal and polycystic ovary syndrome.
Let’s Chat About Infertility
Moderator: Let's get started with our questions...
MegN: What is CTEPH?
complex_issues: Is infertility stress related?
Edmund_Sabanegh,_MD_: With regard to the male side, stress is well known to lower fertility. It is very hard to avoid stress in our lives, but factors such as exercise and a healthy diet can help our bodies deal with the stress.
Julie_Tan,_MD: For the female side, the short answer would be that we're not sure. Many patients who go through major life events can conceive, but some women who have high levels of anxiety and depression can have lower fertility. I agree with Dr. Sabanegh, having a healthy diet and taking care of yourself can help.
DMH73: How does drinking alcohol affect fertility?
Edmund_Sabanegh,_MD_: For men, social drinking has not been shown to affect fertility. Patients with very high levels of alcohol use can alter some of their hormone levels, which can affect their fertility. So, responsible drinking is fine for fertility.
BeeBop: Will marijuana use affect fertility for either male or female?
Julie_Tan,_MD: Marijuana use does not affect female fertility, but using marijuana, smoking cigarettes, drinking alcohol or using other illicit drugs could be harmful to the pregnancy.
Edmund_Sabanegh,_MD_: Marijuana can affect male fertility. Men who are regular users of marijuana may have lower levels of the male hormone, testosterone, and higher levels of prolactin, a hormone that lowers male fertility. The good news here is that if you stop regular use, your fertility is expected to recover over a few months.
Csilla: What percentage of couples ends up in the “undefined” classification for fertility?
Julie_Tan,_MD: Thirty percent of the couples who come to see us for infertility have female problems, 30 percent of them have male problems and 30 percent of them have both male and female problems. This leaves about 10 percent of the couples in the “unexplained” infertility category.
Anders: What are some easy things I can do to promote fertility on the male side of things?
Edmund_Sabanegh,_MD_: In general, our fertility is a window on our health. So, if we exercise regularly, maintain a healthy body weight and avoid harmful habits such as tobacco use, our fertility will improve. In the case of tobacco use, men who are regular smokers will have tobacco metabolites (by-products) in their semen. These can cause sperm to die or have genetic abnormalities, which can affect a pregnancy. In addition, the sperm can be damaged by oxidation, a type of chemical reaction that damages the outer covering of sperm cells. Men who take antioxidant vitamins such as Vitamin C have lower levels of oxidative stress and may have better fertility. In addition, eating fruits and vegetables, which are high in antioxidants, can also help fertility.
Robbie: Can carrying a cell phone in my pants pocket really create problems?
Edmund_Sabanegh,_MD_: There is research that suggests that cell phone-type radiation can lower sperm motion, damage the sperm DNA and lower male fertility. This is a complex question since it may depend on how close the phone is to the testicles and the type of phone. It is best to keep the phone as far from the testicles as you can when you are trying to create a pregnancy.
Robbie: Boxers vs briefs? Which is better? Does it really make any difference?
Edmund_Sabanegh,_MD_: This is a common question and subject to much debate. Most experts believe that it really does not make a difference and that either underwear type is fine for fertility.
Matthe: Could you talk about the use of the male hormone testosterone as it relates to fertility?
Edmund_Sabanegh,_MD_: This is a common question that I am asked in clinic. Some men use or have been prescribed testosterone in an attempt to improve fertility. Unfortunately, testosterone use in men actually lowers their fertility. When a man takes testosterone supplements, his body registers that he has plenty of testosterone in his circulation, and it turns off its own testosterone production. It also turns off its sperm production. This can be a big problem that can require six months to a year for recovery. So, you do not want to use testosterone supplements of any kind while you are trying to create a pregnancy.
nicole89: Hello doctors. My husband and I have been trying to conceive for eight months now after our first pregnancy last March ended in a miscarriage and D&C at seven weeks. We got pregnant on our first try, so naturally we are concerned about why it hasn't happened yet, and have started looking into some things. My husband had a sperm analysis (SA) done, and my OB told us that his count and morphology are normal, but the "round cell count" is 11 million when it is supposed to be 1 million. Is this cause for concern if all of his other numbers are normal? (His SA was after a seven-day hold.) Also, if my periods have been generally the same heaviness and length, would there be any possibility of scarring? They are slightly irregular, but I chart temps, so I know generally when I ovulate. My doctor says she can do a sonohysterogram, but only wants to order that as a last resort. I know I ovulate every month, and our intercourse has been timed appropriately. My OB plans to start me on Clomid. Any suggestions are appreciated.
Julie_Tan,_MD: First of all, I am very sorry for your loss. The possibility of scarring inside the uterus after a D&C is rare. If there are any concerns about scarring, a hysteroscopy (placing a small camera in the uterus), a hysterosalpingogram (x-ray dye test to look inside the uterus and the fallopian tubes) or the sonohysterogram, as your doctor discussed with you, would be indicated. If you are 35 years old or older, have a history of pelvic surgery or endometriosis, or a family history of early menopause, testing of your ovarian reserve (capacity of the ovary to produce fertilizable eggs) should be done. There are a few different ways to check your ovarian reserve including bloodwork and ultrasound. If your ovarian reserve happens to be low, perhaps you should have a consultation with an infertility specialist to discuss fertility treatment options. Clomid is an option that most patients start with since it is easy to take and has very few side effects.
RunningGirl: I am a 34-year-old woman, and my husband and I have been trying to conceive since Aug 2013. (I went off birth control pills after 13 years). I was diagnosed with a macroprolactinoma (11mm) and prolactin levels of 367.3 in Jan 2014. I am being treated with 2.5 mg cabergoline twice a week, and my prolactin levels have been normalized since April 2014. The side effects have been minor, but the hot flashes have been regular and intense since I've been on this medication. I've been taking my basal body temperature (BBT) using ovulation prediction kits (OPKs) and monitoring other fertility signs, and according to all of these, I've only ovulated in the last two cycles. My follicular phase has been very long (average ovulation at 39 days) and my luteal phase has been short (nine days and 11 days [used progesterone cream during this cycle]). The progesterone cream did eliminate the hot flashes. I am slightly overweight and have a low metabolism (resting 1150 calories), but I eat a healthy diet and exercise regularly. Do you have any tips for managing this imbalance?
Julie_Tan,_MD: I assume that you are currently taking 0.25 mg of cabergoline twice a week, as 2.5 mg would be an unusually high dose of cabergoline. Since your prolactin has been normalized for more than six months but you still have very long menstrual cycles, I think this is the time to speak with your physician regarding other possible reasons for your oligoovulation (infrequent ovulation) such as thyroid problems or polycystic ovary syndrome (PCOS). Your doctor might also consider putting you on fertility medication such as Clomid or letrozole to help you ovulate more regularly.
SaPq134: What is involved with infertility testing?
Edmund_Sabanegh,_MD_: On the male side, we start with a complete history of your health and a physical examination. The critical lab test is a semen analysis, which looks at the sperm count, motion and shape. Many times, we will need a repeat test to confirm the prior semen test. On occasion, based on lab results or physical examination findings, we will need a blood test to look at hormone levels. In addition, sometimes we will need a blood test to perform a genetic screen to make sure you do not have issues that could affect your health or that of your offspring. We sometimes will also recommend a scrotal ultrasound to make sure the blood supply to the testicles and the testicles themselves are normal.
Julie_Tan,_MD: Infertility testing is tailored to each couple based on their medical history and risk factors. During the first infertility visit, the physician will take a detailed history and may perform a physical exam to identify treatable risk factors. Initial testing generally includes sperm testing (semen analysis), a hysterosalpingogram (test to make sure your tubes are not blocked) and further testing to determine if you are ovulating regularly. Based on your medical history, hormone blood tests (such as thyroid stimulation hormone, prolactin, progesterone or male hormones) might be ordered. Ovarian reserve testing (including bloodwork and/or ultrasound) is indicated in women who are over 35 years of age with a long-standing history of infertility or any concerns for poor ovarian reserve (capacity of ovaries to produce fertilizable egg). If you have a history of heavy menstrual cycles, pelvic pain or pain during intercourse, a pelvic ultrasound is generally ordered as well.
Ashi: I have already done laparoscopy, but the dye didn't come out from my tubes. Does this mean there is a block somewhere in the womb? Please explain to me what treatment is available to remove such blocks.
Julie_Tan,_MD: The treatment for tubal blockage depends on where the blockages are and the degree of the damage to the tubes. If the blockages are from scar tissues outside of the tubes or endometriosis, surgery to remove the scar tissues is necessary to unblock the tube. If the tubes are severely damaged, there is a chance that they may not be able to be repaired. In that case, in vitro fertilization would be your next step.
Thom: Does a semen test tell you if I am fertile or not?
Edmund_Sabanegh,_MD_: This is a great question. A semen test looks at your sperm count, motion and shape at a single point in time. Sperm counts can vary tremendously from day to day, so we will often ask a patient to do a second sperm test a few weeks later to confirm results. Remember that sperm seen in a specimen today were made over the past two months. This means that if you were sick with a fever or had a lot of stress in the past two months, it can show up as a low count today. Most of the time, our counts will recover from these type of things so we would recheck a specimen to make sure.
winter123: What are the chances of pregnancy after laparoscopy surgery for moderate endometriosis on the uterosacral ligaments and POD? No other fertility problems as of now for both partners. What are the options if not successful in getting pregnant? Can endometriosis recurrences occur?
Julie_Tan,_MD: This is a complicated question to answer. Your chance of pregnancy after surgery for endometriosis depends on the severity of endometriosis, your age, your ovarian reserve and other underlying fertility issues. Many women with mild to moderate endometriosis can get pregnant after surgery. If you don’t have successful conception after six to 12 months of trying (post-surgery), there are several options that are available, such as fertility medications, intrauterine insemination or in vitro fertilization.
Joan: What is the difference between IVF and IUI?
Julie_Tan,_MD: IUI (intrauterine insemination): IUI is a procedure using a very small catheter to place a number of washed sperm directly into the uterus during the ovulation time. The goal of IUI is to increase the number of sperm that reach the fallopian tubes and the egg(s), and subsequently increase the chance of fertilization and pregnancy. This procedure is used in couples with mild male factor infertility and in women with possible scar tissues at the cervix from previous surgery. It is also used to increase the chance of pregnancy in women who are taking fertility medication. The sperm washing process generally takes around one and a half to two hours. The IUI procedure itself usually takes around five minutes to do. The procedure itself is almost similar to having a pelvic exam or Pap smear in your doctor’s office.
IVF (in vitro fertilization): IVF is a process involving removing mature eggs from women’s ovaries, fertilizing the eggs with sperm, incubating the dividing cells (also called embryos) in a culture dish and then replacing the developing embryo in the uterus at the appropriate time. IVF is indicated in couples with male factor infertility, tubal damages, women with poor ovarian reserve (low eggs supply), endometriosis, couples with genetic defects requiring embryo testing, or couples who have failed other conservative treatments. Prior to removing mature eggs from the ovaries, the female partner will need to take fertility shots daily for one and a half to two weeks to increase the number of mature eggs she produces (ovulation induction). While taking the fertility shots, you will need to have ultrasound and bloodwork done every two to three days to monitor the growth of the eggs. So, IVF is much more complicated and sophisticated than the IUI. At Cleveland Clinic, we have dedicated infertility nurses and physicians who will help you go through this process as smoothly as possible.
nombro: I had a vasectomy? What are my options for fertility? Can a vasectomy be reversed?
Edmund_Sabanegh,_MD_: Vasectomy is a common form of contraception used by almost 500,000 men per year in the US. Up to 10 percent of men will change their mind sometime after their vasectomy and desire having additional children. Fortunately, there are two effective options in this situation. Most men choose a vasectomy reversal, which is an outpatient procedure where the tubes are reconnected to allow sperm flow and return of fertility. The effectiveness of this procedure depends on the number of years since the vasectomy, with rates as high as 90 percent if less than four years and about 70 percent if over 10 years.
The other option involves taking sperm out of a man with a minor procedure such as a needle aspiration. This sperm is then used for a type of in vitro fertilization called intracytoplasmic sperm injection. This is a procedure that Dr. Tan is describing involving the direct insertion of a single sperm into an egg to create a fertilized egg that is then replaced in the women's body to allow development of a pregnancy.
Amanda: What is a varicocele and does it create issues with fertility?
Edmund_Sabanegh,_MD_: A varicocele is a condition that is seen in between 15 percent and 40 percent of men. It involves an enlarged group of veins in the scrotum. The thinking here is that these veins can keep the testicles about a degree warmer than they should. This lowers fertility in some men and, on occasion, we will recommend a minor surgery to repair this condition. The surgery is an outpatient procedure and involves a small incision in the lower abdomen. The enlarged veins are interrupted so they will not allow pooling of warm blood in the scrotum. In general, almost two-thirds of men will have an improvement in their sperm tests after this surgery is performed.
jack57: My wife experienced a miscarriage with our first pregnancy at seven weeks, four days. We found out recently that we are expecting again after several months of trying to conceive, and she is four weeks and a few days along. She has a history of Hashimoto's disease several years ago and was treated with Synthroid. After one year of taking the Synthroid, the doctor took her off of it. She had her antibody levels tested after the miscarriage nine months ago, and her anti TPO level was 10. She recently had a thyroid panel done at four weeks, two days, that did not include the antibodies, and her T4 was slightly low at 5.60, normal TSH (1.72), normal T3 uptake (43), normal T7 (2.41). Since the demands on the thyroid are greater during pregnancy, should she be started on thyroid medication or should we look into testing her antibodies again, as those can also fluctuate? What do you recommend? Thanks.
Julie_Tan,_MD: Uncontrolled hypothyroidism can certainly cause problems with miscarriage and complications during pregnancy. The best option at this time would be to watch her thyroid profile closely. Generally, this should be checked every month in a patient with Hashimoto disease.
Sara: I have polycystic ovary syndrome. Does this increase my chance of facing infertility challenges and if so, why?
Julie_Tan,_MD: Polycystic ovary syndrome (PCOS) is a common endocrine condition in women. The symptoms of PCOS include irregular periods, excess body or facial hair, acne and polycystic ovaries. Women with PCOS are producing a slightly higher amount of male hormones that cause these symptoms. Many women with PCOS have infertility concerns due to not ovulating regularly and having irregular periods. Interestingly, the symptoms of PCOS are different from woman to woman. Some have all of the symptoms described above while others have very mild symptoms. So, having PCOS does not mean that you will have infertility problems in the future. You should discuss your symptoms with your physician to determine if medical help would be necessary prior to attempting to conceive.
Moderator: That is all the time we have today for questions. Thank you everyone for participating today; and thank you, Edmund Sabanegh, MD and Julie Tan, MD, for your insightful answers to our questions about both male and female fertility issues.
To make an appointment with Dr. Tan or any of the other specialists in our Fertility Center at Cleveland Clinic, please call 216.444.6601 or toll-free 800.223.2273, ext. 46601. You can also visit us online at clevelandclinic.org/infertility.
To make an appointment with Dr. Sabanegh or any of the other specialists in our Urology Department at Cleveland Clinic, please call 216.444.5600 or toll-free at 800.223.2273, ext. 45600.
For More Information
On Cleveland Clinic
Although many people associate infertility treatment with in vitro fertilization, our Fertility Center provides the full range of services, from simple evaluations and recommendations to state-of-the-art reproductive technologies. In our experience, most patients can be effectively treated with simpler means than in vitro fertilization. However, should you require in vitro fertilization, our program is one of the largest in the state and is equipped the most advanced technologies available.
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