"We are a couple married 9 years. We don't
have a child. I had a cyst on the right ovary and
it was removed by open surgery. It seems my tubules
are in a mess. For my husband, a testicular biopsy
was done, and the report shows that there is a complete
maturation arrest of spermatozoa. Could you please
help us to overcome this problem and inform us what
can be done to have a child? Already we are getting
old. My age is 30 and husband's age is 37. I have
normal menstrual periods without pain (at times I
have severe pain). Otherwise our sexual life is normal
and active. ". R.
It sounds as if you have two possible problems, a
male factor sperm problem and possibly a faloppian
tube patency problem. But first, let us go over a
general overview of infertility.
Causes and treatments of infertility can be quite
complicated depending upon many factors. Basically,
all of the components in the sequence of a sperm fertilizing
an egg and then implanting in the uterine cavity to
grow, must be evaluated if a woman is having difficulty
conceiving. In somewhere between 7 and 10% of couples,
pregnancy will not occur within one year of attempting
to conceive. In women over 35 years of age, doctors
will often start an infertility work-up after only
6 months of trying unsuccessfully to get pregnant
because of the maternal age factor and the feeling
that time is short.
The parts of conceiving that can be impaired and
thus need to be evaluated are:
adequate sperm from the male partner
appropriate frequency of sexual intercourse around
the time of a woman's ovulation
adequate, regular ovarian ovulation (release of the
egg from the ovary)
adequate passageway for egg to travel down the faloppian
tube, meet sperm coming up the tube, and transport
of the fertilized egg down to the uterus to implant
and start growing
and adequate passageway for the sperm to get through
the cervix into the uterus so they can swim up into
the faloppian tube to meet and fertilize the egg
Therefore in evaluating a couple who is having trouble
conceiving, we can divide the diagnostic and treatment
evaluation into: male factor (sperm count and quality),
ovarian factor (ovulation frequency and regularity),
tubal factor (clear passage to egg and sperm), cervical
factor (clear passage to sperm from the vagina), and
uterine factor (adequate space and tissue for the
fertilized egg to implant and grow).
Male factor sperm count and quality
Since a male factor may account for up to 40-50% of
infertility problems, doctors will order a semen analysis
very early in the work-up of infertility. This includes
a sperm count and an evaluation of the normality of
sperm shapes as well as the movement ability. Only
10-20% of men have no mature, motile sperm at all.
The rest just have low counts or fewer normal shaped
and motile sperm than other fertile men. Sometimes
men who have no sperm (azoospermia) can still have
medicine to produce sperm (see 1) or have advanced
procedures (2) in which sperm are actually aspirated
with a needle from the testis. I am afraid from what
you describe, that your husband's sperm problem is
the major factor preventing you from conceiving but
in up to 25% of the cases of azoospermia, doctors
can use advanced technological procedures of overcome
that lack of sperm as you can see in the article above
from Sweden. You will need to see an infertility specialist
or a urologist who specializes in male infertility
For usual sperm counts, doctors like to see an absolute
motile sperm count of over 16 million. This is calculated
by multiplying the amount of semen ejaculate in a
specimen in milliliters (ml) by the count of how many
million sperm per ml are present times the percent
of motile sperm in the specimen. In other words a
sperm count of 20 million sperm/ml with 80% motility
and a total volume of one ml of ejaculate is probably
adequate as is a count of only 10 million sperm/ml
with 80% motilityand a total of 2 ml of ejaculate.
A total count of less than 5 almost always results
in sterility and counts between 5 and 16 can sometimes
be overcome with infertility treatments and a couple
have a normal pregnancy.
Ovarian factor - infrequent ovulation or anovulation
If a woman does not produce any eggs each month or
only produces them every 2 or 3 months, then it will
be quite difficult to get pregnant. The most common
causes of not ovulating are polycystic ovarian syndrome
(PCOS) and what is called hypothalamic amenorrhea
which is like a stress-induced or medication-induced
lack of ovulation. Rarer causes might include medical
problems such as thyroid, kidney or an autoimmune
disease or a premature ovarian failure (menopause)
due to chemotherapy and other medicines or diseases
such as systemic lupus erythematosis (SLE) among others.
Treatments for ovarian ovulation problems might include
the fertility pill clomiphene citrate or other shots
and medications such as gonadotropins (Pergonal®,
Menotropin®).
In your case above, since your menses are regular,
you are most likely ovulating. Not always, but most
of the time. The doctor will still want to document
ovulation using basal body temperature charting (BBTs),
day 21 blood progesterone levels or ovulation predictor
urinary tests.
Frequency of intercourse around ovulation time
Women who have regular menses usually ovulate about
14 days before a menstrual period. The range, however,
is 10-17 days before menses. This means that if a
woman has a 28 day cycle from the start of one menses
to the start of another, she will probably ovulate
on day 14 after the start of a menses. Ovulation can
range from day 11 to day 18 so intercourse should
take place during those days with a frequency of at
least every other day (eg. days 11, 13, 15, 17). If
a woman's menses came every 32 days, everything would
shift by 4 days so that ovulation would be day 18
and the range might be day 15-21. if you are having
intercourse only once during that time frame, it will
be more difficult to conceive.
Tubal factor - unblocked and freely mobile faloppian
tubes
The tubes must be free to sweep up an egg that has
been ovulated from the ovary and then it must not
have any blockage to passage for the egg, the sperm
or the fertilized egg. Fertilization usually takes
place in the faloppian tube close to mid way from
the ovary to the uterus. Pelvic surgery, past ruptured
ovarian cysts, past pelvic infection and endometriosis
can affect the ability of the tube to sweep up the
egg. Pelvic infection can also produce scarring inside
the tube that prevents passageway of an ovum.
In your case, you said the tubes may be "messed
up". The way to determine that is to have an
xray of the uterus in which a dye or other substance
is injected into the uterus and then an xray or ultrasound
is used to see if the dye goes through the tubes into
the pelvic cavity where the ovaries are. If the dye
spills, then the tubes are open enough to allow pregnancy.
You need to have this study done because if the tubes
are not patent, all of the other treatment for your
husband's sperm problem will not have any use for
natural conception. Blocked tubes may be a reason
to have in vitro fertilization however.
Uterine factor - successful implantation of the conceptus
Any condition that alters the amount or shape of the
surface area of the inside of the uterus or alters
the hormonal readiness of the lining of the uterus
may impair fertility. Fibroids, polyps, congenital
anomalies of the uterus, or past scarring due to surgery
or infection will alter the surface area of the endometrium.
Inadequate corpus luteum function may hormonally retard
the lining (endometrium) so it is not ready for implantation.
Cervical factor - allowing passage of the sperm from
the vagina into the uterus and serving as a reservoir
for sperm storage
Unless the cervix has undergone some sort of procedure
that has destroyed the cervical mucous glands, it
does not usually play a role in infertility. Cervical
cryosurgery, conization, LEEP or laser procedures
can destroy cervical mucous glands. Those glands act
as a storage for sperm so that they can shower the
uterus and tube with sperm in order not to miss ovulation.
If those glands are destroyed, the frequency of intercourse
may need to be increased in order to have the best
chance at fertility.
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