frequently asked questions (FAQ) about infertility

1. What is infertility?

Infertility, whether male or female, can be defined as 'the inability of a couple to achieve conception or to bring a pregnancy to term after a year or more of regular, unprotected intercourse'.

2. What is the incidence of infertility worldwide?

The World Health Organization (WHO) estimates that approximately 8-10% of couples experience some form of infertility problem. On a worldwide scale, this means that 50-80 million people suffer from infertility. However, the incidence of infertility may vary from region to region. In France, 18% of couples of childbearing age said that they had difficulties in conceiving.

3. My husband and I have an active sex life, we are both healthy, and my periods are regular.
However, we have still not conceived? Please help !

You need to remember that it's not possible to determine the reason for your infertility until you undergo tests to find out

1.       If your husband's sperm count is normal;
2.       If your fallopian tubes and uterus are normal;
3.       If you are producing eggs.

Only after undergoing these tests will your doctor is able to tell you why you are not conceiving. While testing does cause considerable anxiety, it's far better to intelligently identify the problem so that we can look for the best solution.

4. Is infertility exclusively a female problem?

No.
The incidence of infertility in men and women is almost identical.

Infertility is exclusively a female problem in 30-40% of the cases.
Exclusively a male problem in 10-30% of the cases.
Problems common to both partners are diagnosed in 15-30% of infertile couples. After thorough medical investigations,
The causes of the fertility problem remain unexplained in only a minority of infertile couples (5-10%).

5. How can I determine my "fertile" period?

Your fertile period is the time during which having sex could lead to a pregnancy. This is the 4-6 days prior to ovulation (release of a mature egg from the ovary). Women normally ovulate 14 days prior to the date of the next menstrual period. If you are mathematically challenged, you can use this online ovulation calendar.

6. What are the most common causes of infertility?

most common causes of female infertility are

Ovulatory disorders
Anatomical abnormalities such as damaged fallopian tubes.

Less frequent causes include, for example,

Endometriosis
Hyperprolactinemia.

Causes of male infertility can be divided into three main categories:

Sperm production disorders affecting the quality and/or the quantity of sperm;
Anatomical obstructions; other factors such immunological disorders.
Approximately a third of all cases of male infertility can be attributed to immune or endocrine problems, as well as to a failure of the testes to respond to the hormonal stimulation triggering sperm production.

However, in a great number of cases of male infertility due to inadequate spermatogenesis (sperm production) or sperm defects, the origin of the problem still remains unexplained.

7. My gynecologist has done an internal examination and said I am normal. Do I still need to get tests done to determine why I am not conceiving ?

A routine gynecological examination does not provide information about possible problems which can cause infertility, such as blocked fallopian tubes or ovulatory disorders. You need a systematic infertility workup.

8. What is the general progression of infertility treatment?

A variety of procedures can be used to diagnose the cause of infertility in a couple;
These range from simple blood tests to more complicated analytical methods.

In any case, diagnosis is a crucial first step to determine the appropriate therapeutic path that should be followed. In addition to the cause itself, other factors, such as the age of the woman, or problems shared by both partners, might also influence the choice of treatment.

9. Do painful periods cause infertility?

Painful periods do not affect fertility.

In fact, for most patients, regular painful periods usually signal ovulatory cycles.
However, progressively worsening pain during periods (especially when this is accompanied by pain during sex) may mean you have endometriosis.

10. What treatment options do infertile couples have?

Several options are offered to couples depending on the type of infertility that has been diagnosed.

The vast majority of female patients are successfully treated with the administration of Ayurvedic drugs.
Surgery can also be a means to repair damage to the reproductive organs, such as those caused by endometriosis and infectious diseases.

Treatment options for male infertility also include the administration of drugs, surgery.
Drug therapy and surgery have proved very successful for specific types of male infertility.
However, in a great number of cases, the reason why men have fertility problems remains unexplained and the Ayurvedic treatment methods applied.
Some patients nevertheless require more complex medical intervention.

11. My periods come only once every 6 week. Could this be a reason for my infertility?

As long as the periods are regular, this means ovulation is occurring.
Some normal women have menstrual cycle lengths of as long as 40 days.
Of course, since they have fewer cycles every year, the number of times they are "fertile" in a year is decreased.
Also, they need to monitor their fertile period more closely, since this is delayed (as compared to women with a 30 day cycle).

12. How successful is infertility treatment?

When talking of success rates for any type of infertility treatment, one should bear in mind that the average chance to conceive for a normally fertile couple having regular unprotected intercourse is around 25% during each menstrual cycle.

It is estimated that 10% of normally fertile couples fail to conceive within their first year of attempt and 5% after two years. Comparable to normal fertility rates, effective treatments can be expected to have, on average, up to a 25% success rate per cycle of treatment, and may therefore need to be repeated several times before a pregnancy is achieved. Simple ovulation induction to compensate for hormonal imbalances has a very high success rate; more than 80% of women suffering from such disorders are likely to conceive after several cycles of treatment with Ayurvedic drugs.

13. My husband's blood group is B positive and I am a negative. Could this blood group "incompatibility" be a reason for our infertility?

There is no relation between blood groups and fertility.

14. Are there particular factors influencing the success of a treatment?

In any type of infertility treatment, important factors need to be taken into account when referring to success rates.

The age of the woman and the duration of the couple's infertility are likely to influence the success of treatment. In women, fecundity decreases as age increases, particularly after 40 years of age. When the woman is being treated, her chances of conceiving can be lessened if her partner also has infertility problems (e.g. poor quality sperm).

15. After having sex, most of the semen leaks out of my vagina.

How can we prevent this?
Should we change our sexual technique?
Could this be a reason for our infertility?
Does it mean the cervix is closed?
Is there any way to prevent it from leaking?

Loss of seminal fluid after intercourse is perfectly normal, and most women notice some discharge immediately after sex.

Many infertile couples imagine that this is the cause of their problem.

If your husband ejaculates inside you, then you can be sure that no matter how much semen leaks out afterwards, enough sperm will reach the cervical mucus. This leakage of semen (which is called effluvium seminis) is not a cause of infertility.

In fact, this leakage is a good sign - it means your husband is depositing his semen normally in your vagina ! Of course, you cannot see what goes in - you can only see what leaks out - but the fact that some is leaking out means enough is going in!

In a 10 yr study, thousands of women, sperm loss after intercourse ("flow back") was observed- Flow back occurred 94% of the time, with an average loss of 35% of the sperm. It is totally normal.

The sperm that penetrate into the cervical mucus begin to do so within 1.5 min, and they are pretty much done by 30 minutes, with no gain in sperm numbers in the cervical mucus or Fallopian tubes after 45 min from intercourse. Only thousands of the millions of sperm ejaculated in the vagina make it to the cervix and only hundreds of these make it to the Fallopian tube!

The very best of the best get there, the rest get washed out- it is OK!

16. What about success rates of Ayurvedic medicine?

Overall, success rates for Ayurvedic medicine have steadily improved over the last ten years.
Birth rates for Ayurvedic medicine vary according to the expertise of the centers practicing this technique.
However, centers in Asia have reported pregnancy rates after one cycle of equal or superior to 25%.

Based on such results, after three to four cycles of Ayurvedic medicine, a woman under 40 whose partner does not have any fertility problems could reasonably expect to give birth.

Again, in general, success rates may vary from one center to another, since they are influenced not only by the level of expertise of the medical team but also by the characteristics of the patients treated.

A clinic treating a large number of women over 40 is likely to report lower success rates than a clinic having a majority of patients under 35.

17. My colleagues at work tell me that if we "work" hard at getting pregnant, and want it enough, we definitely will! In fact, my mother in law is even suggesting that the fact that I am not conceiving means that subconsciously I do not wish to have a baby ( because it may interfere with my career) and that this psychological barrier is the reason for our infertility.

Unlike many other parts of your lives, infertility may be beyond your control. Don't blame yourself if you are not getting pregnant - it's a medical problem which often needs appropriate medical treatment. The attitudes you are encountering are often born out of ignorance - and are a kind of "victim-blaming" - ignore them!

18. Are there particular health risks for women undergoing infertility treatment?

Along with their intended benefits, drugs used to treat infertility may on occasion cause side effects. In ovulation induction, close monitoring of follicular growth is crucial to ensuring successful treatment. Monitoring techniques (such as ultrasound scan and blood tests) and adequate use of treatment protocols help the physician to avoid ovarian hyper stimulation syndrome (OHSS) and minimize the risk of multiple pregnancy.

Current treatment protocols have been designed to reduce the risk of multiple births and OHSS.

19. My grandmother says that if I just pray and have faith, I will definitely conceive. How far is this true?

Believing in god can help you to maintain a positive outlook - but sheer will and blind faith won't overcome a physical problem like blocked tubes or absent sperms.

20. What is OHSS?

OHSS Ovarian Hyper stimulation Syndrome (OHSS) is a side-effect that can occur during infertility treatment with ovulation inducing drugs.

Symptoms of this syndrome may include

Ovarian enlargement,
Accumulation of fluid in the abdomen,
Gastrointestinal disorders (nausea, vomiting, diarrhea).

Severe cases of OHSS are however very rare (1-2% of cases).

21. My husband refuses to get his semen tested. He says the fact that it is thick and voluminous means it must be normal!

Semen consists mainly of seminal fluid, secreted by the seminal vesicles and the prostate.
The volume and consistency of the semen is not related to its
fertility potential, which depends upon the sperm count.
This can only be assessed by microscopic examination.

22. Multiple births

Multiple births occur more frequently after infertility treatment than in the normal population. About 80% of pregnancies achieved following simple ovulation, result in single births, the remaining 20% being multiple pregnancies, mostly twin pregnancies.

New treatment regimens carefully adapted to the patient's response help to decrease the risk of a multiple pregnancy.

23. My sister conceived only after 6 years of marriage.
Does this mean I will also have difficulty conceiving?

If your mother, grandmother or sister has had difficulty becoming pregnant, this does not necessarily mean you will have the same problem! Most infertility problems are not hereditary, and you need a complete evaluation.

24. Local side effects

Common local side effects experienced by patients, include skin redness, swelling and bruising. Pain and discomfort sometimes reported.

25. My doctor just did a physical examination for me and he feels that the reason for my infertility is that my uterus is tipped backwards, and this prevents the sperm from swimming into the uterus. He is advising I have surgery to correct this problem. Should I go ahead?

About one in five women will have a retroverted uterus. If the uterus is freely mobile, this is normal, and is not a cause of infertility. This is not an indication for surgery!

26. Can ovulation induction increase the risk of ovarian cancer?

Ovarian cancer is a rare disease; the chance of a young woman developing an ovarian malignancy during her lifetime is lower than 1.5%.

A number of factors have been found to increase the risk of ovarian cancer, including genetic predisposition and dietary habits.

Scientific studies carried out in the last few decades have demonstrated that infertility itself is a risk factor for ovarian cancer.

There is evidence that each pregnancy reduces the risk of a woman contracting ovarian cancer (this risk could be reduced by more than 25% by a first pregnancy). No epidemiological study has ever established a causal link between ovulation promoting drugs and ovarian cancer.

27. My husband says we should be having intercourse every day to achieve pregnancy. Is this true?

Sperm remain alive and active in woman's cervical mucus for 48-72 hours following sexual intercourse; therefore, it isn't necessary to plan your lovemaking on a rigid schedule.

28. What about the health risks for children born following infertility treatment?

Regarding children born following treatment with ovulation promoting drugs, the incidence of birth defects has never been found to be higher than that in the normal population.

29. My friends say I should have sex exactly on the day I ovulate to get pregnant. How can I do this?

Although having sexual intercourse near the time of ovulation is important, no single day is critical. So, don't be concerned if intercourse is not possible or practical on the day of ovulation.

30. How important is counseling to the patient undergoing infertility treatment?

The physician helps the infertile couple find the most appropriate therapeutic path to overcome barriers to conception, but, before a treatment is started, patients need to be aware of all its aspects, including its constraints. Beyond the medical expertise, infertile couples are also looking for counseling and support.

From a psychological point of view, infertility is often a hard condition to cope with. During treatment and before a pregnancy is achieved, feelings of frustration or loss of control usually experienced by the infertile couple are likely to be exacerbated. Management of infertility includes both the physical and emotional care of the couple.

Therefore, support from physicians, nurses and all people involved in treating the infertile couple is essential to help them cope with the various aspects of their condition.

Offering counseling and contact with other infertile couples and patient associations can provide help outside the medical environment.

31. My sister in law is advising me to keep a pillow under my hips during and after intercourse. Will this increase my chances of conceiving?

Sperm are already swimming in cervical mucus as sexual intercourse is completed and will continue to travel up the cervix to the fallopian tube for the next 48 to 72 hours. The position of the hips really doesn't matter.

32. Stress causes infertility.

My mother feels I am too tense, and that if I just relax, I'll get pregnant. If pregnancy has not occurred after a year, chances are there is a medical condition causing infertility.

There is no evidence that stress causes infertility. Remember, all infertile patients are under stress - it's not the stress which causes infertility, it's the infertility which causes the stress!

33. Extra Uterine Pregnancy (EUP)

When a pregnancy is not located in the uterus it is called an Extra Uterine Pregnancy (EUP) or ectopic pregnancy. The most common place for an EUP is the fallopian tube but sometimes the ectopic pregnancy is located elsewhere, such as in the cervix, the ovary or in the abdomen.

EUP is a rare disease and occurs in 1% of all pregnancies. Risk factors for EUP are a history of infection of the tubes (salpingitis), Chlamydia infection, Pelvic Inflammatory Disease (PID), former EUP, operation on the tubes or in the lower abdomen, endometrioses and appendicitis. The symptoms of ectopic pregnancy are often similar to those of a normal miscarriage and may include a positive pregnancy test together with or without vaginal bleeding and abdominal pain.

Although it is not common, the possibility of EUP has to be considered in patients with the symptoms and one (or more) of the risk factors for EUP. Diagnoses are made by questioning the patient on the risk factors, physical examination, vaginal ultrasound and laboratory findings.

Depending on the size and the location of the EUP, different treatments can be given. Mostly the ectopic pregnancy will be removed surgically but occasionally medical treatment or expectant treatment is offered when the pregnancy is very small and thorough control of the patient is possible.

34. I just had a HSG (X-ray of the uterus and tubes) done, and this shows my tubes are blocked. I've never had symptoms of a pelvic infection, so how could my tubes get blocked?

Many pelvic infections have no symptoms at all, but can cause damage, sometimes irreversibly, to the tubes.

35. What is timed sexual intercourse?

To increase the chance of getting pregnant spontaneously, timed sexual intercourse is recommended. This means that sexual intercourse, or coitus, has to be taken place around the time of ovulation, which is the most fertile period of a woman. To detect the approximate time of ovulation a temperature curve of several menstrual cycles can be made.

The woman takes her body temperature each morning before getting out of bed, starting on the first day of the menstruation until the start of a new period.

The body temperature rises around 0.5 degree Celsius after the ovulation. This is mostly about 14 days after the first day of the period and when no pregnancy occurs the temperature drops to normal again; with pregnancy the temperature stays high.

One can also use urine or saliva tests to detect the ovulation. The time of ovulation can sometimes vary a few days each month, even in a regular menstrual cycle.

Also, if the circumstances are right, sperm can live inside the women for a few days and sperm quality can decrease with high sexual activity. Therefore it is best to have intercourse 3-4 days before the expected ovulation and every other day until 2-3 days after the expected ovulation with no necessity for higher frequency.

When tests are used to detect ovulation it is advised to have sexual intercourse on the day of a positive test.

36. My doctor has advised me to take fertility drugs. I don't want to take them because I am scared that if I do, then I'll have a multiple birth.

Although fertility drugs do increase the chance of having a multiple pregnancy (because they stimulate the ovaries to produce several eggs) the majority of women taking them have singleton births.

37. Egg-donation Women

With no, or not properly working ovaries can, in some cases, get pregnant through egg donation. In this procedure another woman, mostly a relative or good friend, will be the egg donor.

38. My husband's sperm count varies every time we test it! How do we determine what the "real" sperm count is?

Even a normal (fertile) man's sperm count can vary considerably from week to week. Sperm count and motility can be affected by many factors, including time between ejaculations, illness, and medications. There are other factors which affect the sperm count as well, all of which we do not understand.

39. PCOS Polycystic ovary syndrome or PCOS

PCOS is an ovulation disorder which affects 4-6% of all women. Several factors contribute to the disease. At this moment researchers think that the cause of the disease is genetic.

The major features of this syndrome are irregular or no menstruation, hirsutism and acne due to high levels of male hormones, obesity (40-50%), high insulin levels with risk for developing diabetes and large polycystic ovaries shown on ultrasound.

Women with PCOS usually present at fertility clinics for counseling. To increase fecundity the treatment possibilities are mostly focused on regulation of the menstrual cycle. For this, several drugs are used and weight loss is strongly advised.

In many cases the cycle will be ovulatory and regulated by these treatments. Furthermore at this moment it is being investigated whether electro coagulation of the large ovaries can give (long-term) regulation of the cycles.

40. I have no problems having sex. Since I am virile, my sperm count must be normal.

There is no correlation between male fertility and virility. Men with totally normal sexdrives may have no sperms at all.

41. What is embryo reduction?

Assisted Reproductive Therapy (ART) has caused an increase in multiple pregnancies. Especially in ovulation induction and Intra Uterine Insemination this situation is encountered.

In order to prevent the risk of severe premature birth and handicaps as well as risks for the mother, embryo reduction is sometimes performed: The amount of embryo's in the uterus are reduced and the remaining pregnancy has more chance of normal development and delivery.

Of course this is not an easy decision for both patient and doctor. With careful guidance of the patient during treatment and good counseling when the patient is at risk for a large multiple pregnancy many triplets or higher pregnancies are already avoided.

42. What is cryopreservation?

Cryopreservation means preserving in a frozen condition. The best known cryopreservation is of semen. This is mostly done in case of cancer of the testicles before treatment of the cancer.

Furthermore cryopreserved semen is used in donor insemination. It is also possible to freeze fertilized eggs after IVF or ICSI.

If more embryo's are left after an IVF or ICSI procedure they can be frozen and transferred another time. In this way there is more chance on a pregnancy while only one IVF or ICSI cycle is performed. For human oocytes cryopreservation is much more difficult.

Only in very few experiments this is done successfully. The attention of researchers now is on developing a way to freeze ovarian tissue and after thawing, to obtain the oocytes in it.

This procedure is not yet fully refined but when it is it can offer great opportunities in the future.

43. My semen analysis report shows I have no sperm in the semen (azoospermia). Is this because I used to masturbate excessively as a boy?

Masturbation is a normal activity which most boys and men indulge in. It does not affect the sperm count.
You cannot "run" out of sperms, because these are constantly being produced in the testes.

44. Is Intra Uterine Insemination suitable for every infertile couple?

No. In Intra Uterine Insemination (IUI) processed semen is directly put into the uterus. It is a technique used for couples with fertility problems based on specific causes. These causes are:

Cervical hostility: This means that the cervix is not permeable for semen shown after the Post Coital Test.
Idiopathic sub fertility: No cause has been found for the inability to conceive
Male sub fertility the sperm quality is decreased. Clinics use different ranges for sperm count.

Sperm Antibodies: Inability for vaginal ejaculation with decreased sperm quality for example in men with retrograde ejaculation or spinal cord injury. IUI can be performed either in a spontaneous ovulatory cycle (cervical hostility) or in a cycle with ovarian stimulating hormones (idiopathic sub fertility and male sub fertility/sperm antibodies).

45. My wife is frigid and does not enjoy having sex. Could this be the reason for her infertility?

There is no connection between sexual pleasure and fertility. Don't forget that even a woman who gets raped can get pregnant! And don't forget that the commonest reason women do not enjoy sex is because their husbands are unskilled lovers! Maybe you should improve your sexual technique, and spend more time in foreplay and in pleasuring your wife!

46. What is TESE or MESA?

TESE (Testicular Sperm Extraction): Sperm collected out of the testicles after operation.
MESA (Microsurgical Epididymal Sperm Aspiration): Sperm collected out of the epididymis after operation.

TESE or MESA is a technique developed for patients with no sperm cells in their sperm due to an undeveloped or obstructed spermatic cord.

The cause of obstruction can be a former sterilization or an infection of the epididymis.
When the testicles make no sperm cells at all, after using Ayurvedic drugs, of course TESE or MESA is possible.

If sperm cells are obtained, an ICSI procedure (Intra Cytoplasmic Sperm Injection) will follow. ICSI is like IVF; only now one sperm cell is injected into an egg to fertilize it and make an embryo.

47. What are the causes of damaged fallopian tubes?

In the beginning In Vitro Fertilization (IVF) was developed for patients facing infertility due to damaged fallopian tubes.
Later on the indications to perform IVF was broadened, for example unexplained infertility and male infertility.

Nowadays tubal damage still accounts for a large number of all IVF treatments. The main cause is abdominal infection.
For the tubes this is mostly due to sexually transmitted diseases (for example Chlamydia or gonorrhea) but complicated appendicitis or Pelvic Inflammatory Disease (PID) can also cause damaged tubes.

Other causes are abdominal operations (gynecological operations, cesarean section, sterilization or other) and internal diseases like Crohn's disease.

Affected patients can have fertility problems and are at risk for having a pregnancy located in the tubes (ectopic or tubal pregnancy).

48. Cystic fibrosis and male infertility

Men who have cystic fibrosis often have a congenital anomaly in the male genital tract.
The vas deferens, the tube connecting the testicle and epididymis to the ejaculatory duct is congenitally absent.
This makes it impossible for the sperm to pass through the penis.

Using testicular sperm aspiration, the urologist can obtain sufficient sperm to allow excellent success with IVF and ICSI (intracytoplasmic sperm injection). Insufficient numbers of sperm are obtained to make intrauterine insemination an effective option.

As cystic fibrosis is a recessive genetic disorder, abnormal gene contributions from both parents are necessary for this disorder to be present. Both copies of the gene are abnormal in men with CF.

While persons carrying a single copy of an abnormal gene do not have this condition, when paired with a partner with CF, they have a 50% chance of CF in their offspring.

This makes testing the female partner advisable. If the woman tests normal, the children will be carriers for an abnormal gene and although they will not likely have CF, it is advised that their spouses be checked for CF gene abnormalities.

49. What is endometriosis?

Tissue histological identical to endometrial (the inner lining of the uterine wall) outside the uterine cavity. Usually, endometriosis is confined to the pelvic and lower abdominal cavity; however, it has occasionally been reported to be in other areas, as well.

Endometriosis is one of the most common problems that gynecologists currently face. It is one of the most complex and least understood diseases in our field and, despite many theories; we still do not have a clear understanding of the cause or of its relationship to infertility.

Since this disorder is primarily a human disease and rare in other animal species, accumulation of the facts has been slow.

Although endometriosis has been considered a pathological or separate disease entity, it may not be a disease at all.

It may actually be the clinical manifestation of a more basic underlying disorder, such as a basic chemical or physiological abnormality that affects the tubal motility or immune system which could be responsible for the initiation or progression of endometriosis in patients with retrograde menstrual flow.

By the same token, endometriosis may not be the cause of infertility, but the result of it.

Further technological developments may be necessary in order for us to fully understand this problem.

50. What does sperm preparation mean?

Spermatozoa are ejaculated in the seminal fluid during intercourse or masturbation. During assisted reproduction the spermatozoa are extracted from the semen by a series of processes - centrifugation and washing, layering (to select the active sperm and leave the immotile or dead sperm behind) or selecting the best sperm by making them swim through a denser medium and using those that succeed.

51. What is reproductive surgery?

Reproductive surgery is a subspecialty that treats anatomical abnormalities interfering with normal reproductive function.

Advanced reproductive surgery requires meticulous surgical technique for optimal results, including rapid patient recovery and avoiding the need for routine hospitalization.

Reproductive surgeons treat tubal obstruction, endometriosis, uterine fibroids, scarring of the ovaries or other pelvic structures resulting from pelvic inflammatory disease (PID) in the female, and varicocele and vas obstruction in the male as well as other abnormalities.

52. What does laparoscopy involve?

The laparoscope allows visual inspection of the pelvic organs through a very tiny incision.

Abnormalities that lead to infertility can be treated surgically through additional small incisions to remove scar tissue, laser, coagulate, or excise endometriosis, and repair tubes blocked at the fimbrial end. Many types of female reproductive surgery can be performed laparoscopically in the outpatient setting.

53. Cervical Mucus Quality, Sperm Transport?

I have read information about the maximum amount of time that sperm can survive in fertile cervical mucus (CM). Can you tell me the maximum amount of time sperm can survive in non-fertile CM, like sticky or creamy? Is it only a problem in the vagina and once the sperm makes it into the uterus it can survive for several days?

Or, is it that sperm can only make it from the vagina into the cervix if there is fertile CM?

After ejaculation, sperm have to be able to swim through the cervix to reach the Fallopian Tube where fertilization of the egg occurs.

The sperm that can fertilize the egg begin leaving the ejaculate within 1 min after deposition, and no sperm that get to the Fallopian Tube have ever been proven to do so after 30 min of ejaculation. The "cervical reservoir" of sperm is not an actual pool of fertilizing sperm.

Sperm have to get thru CM to get to the Fallopian tube where they are then stored for hours to days until the egg comes.
However, the interactions of sperm and cervical mucus that allow this migration are often disrupted in fertility patients.

It is thought that at least a third (if not more) of sub fertile couples have some disruption of sperm-cervical mucus interactions that limit sperm transport to the tubes.

The importance of normal CM in natural reproduction is widely recognized. For most of a woman’s cycle the CM is a thick gel and hostile to sperm, with a low pH and a structure that stops sperm transport by the presence of closely spaced micro fibers.

During ovulation, however, the CM becomes more alkaline (higher pH), and the fibers align in parallel with an expanded distance between them.

This allows the sperm to swim through the mucus. Normally, the volume of daily CM also increases 5 fold at ovulation.

CM is a hydro gel of 90% water, and its primary function appears to be bathing sperm in a fluid medium to protect them during transport .

The presence of sugar-proteins in the gel that hold the water is controlled by hormone changes at ovulation (especially the presence of estrogen). These sugars increase the mucus gel’s capacity to hold water, expand fiber spacing, & allow sperm migration. Taken together, these changes permit sperm to rapidly swim through the cervix and proceed to the Fallopian tube for fertilization.

In women with poor sperm-CM interaction there is a reduction in CM fiber spacing making sperm migration difficult, a primary cause of which in many women may be inadequate water in the gel.

This may be caused by advancing age (with low grade hormonal disruptions); and following the use fertility medications.

54. How Long to Abstain for a Sperm Test/Analysis

Recent studies suggest that abstaining for a sperm test or a procedure such as IUI/IVF should be limited to no more than 1- 2 days. The first study looked at men with abnormal sperm (oligospermic) and found the best sperm quality occurred at 1 day of waiting or abstaining prior to production. For men with normal sperm waiting more than 10 days between productions resulted in abnormal sperm quality.

In the second study that looked at functional quality (i.e. “did the sperm result in an artificial insemination IUI pregnancy”, they found:

”Abstinence correlated positively with inseminates sperm count but negatively with motility.” Meaning that abstinence increased sperm count but lowered motility... who cares the number of sperm if they can't swim!

”Variations in inseminate parameters did not correlate with pregnancy rates”. How the sperm looked on testing did not relate to pregnancy outcomes - discussed in the FAQ on doing sperm analysis.

However, abstinence intervals significantly affected pregnancy rates. The time of abstinence impacted outcome. Couples that had 10 or more days of waiting had only a 3% pregnancy rate!

Based on these studies 1-2 days wait before production is probably best.

55. Sperm Transport to the Fallopian Tubes

If a man has normal sperm count and normal sperm motility, approximately how many sperm will be able to get to the fallopian tubes for each ejaculate during a woman's ovulation period?

I've read different information on this.
Some said about 1000 sperm to 5000 sperm
But some said only about 50 sperm to 200 sperm.

This is actually a very good question, one only a handful of scientist around the world (including myself) has spent our careers studying.

Here is the issue-- Prior to the 1990's several good studies were done looking at sperm in the tubes after insemination, by flushing the tubes with salt water and counting the sperm.

But back then we hadn't done the studies to show that sperm actually bind or stick to Fallopian tube cells, and that they stay stuck even if you rinse the tube. These stuck sperm are released in waves over time, so there will always be sperm available to meet the egg.

Once sperm are released from the tubal cells they either meet an egg or they die within a few hours as they are "capacitated". This gives a supply of ready sperm as they wait for the egg for days to a week plus.

These early studies showed really low sperm numbers in the tubes- 1 out of every 14 million inseminated sperm got inside the tube, and only 1 of every 2000 sperm inseminated made it into the cervical mucus.

Likely, there were other sperm in the tubes in these studies that were attached to the tubal cells and therefore, not counted. Since the 1990's though the kind of studies you can do in people have drastically changed. It is almost impossible to get permission to have a couple have unprotected intercourse at ovulation, and then surgically remove a portion of the tube to study for counting sperm attached to the tubal cells. You could be setting up a tubal pregnancy.

So... no one knows the answer to your question for sure. In animals, where we have done many studies -- only hundreds of sperm are in the tube (even though their ejaculates can have up to 350 million sperm in them).

Some men have almost no sperm attaching and they die quickly within hours, while some men have a very high attachment rate and survival rate with sperm living attached to the tubal cells for up to 9 days in the laboratory. This correlates with what has been in seen in women with live sperm found in one woman’s tubes 21 days after intercourse!

Extrapolating from the well done stallion study, we can assume that the men with the most sperm attaching to the tubal cells and therefore living the longest will have the highest fertility.

56. Understanding a Sperm Analysis

Sperm analysis or tests are a critical part of finding out what why a couple may not be conceiving.

Male low fertility is usually involved about 60% of the time, with 40% of the time the man being the main cause and 20% of couples having shared male and female issues.

First of all the results of a sperm analysis are your medical records and you have the right to them, and the right to a good conversation of what was found. I am surprised how often people don't get reports back or how poorly the material is reported back.

YOU need to be aggressive about talking to your doctor and understanding what they found.

YOU also have the responsibility of making sure your clinic is using state of the art methods to look at husband’s sperm. If not, find another clinic! One recent study showed that showed only 30% OF ALL CLINICS doing sperm tests in this study had accurate readings of motility and morphology.

That said it is important to understand that there is NO sperm test that can tell you if a couple will conceive or not - except if there are no sperm in a man's semen- then of course the chance is zero.

What we do have is studies relating various quality sperm to various levels of fecundity (this means the chance of conceiving).

Men with normal sperm parameters in regards to count, motility, and morphology (shape) tend to have normal chances of impregnating their wives (20-30% chance each month).

Although other things can be wrong with sperm that appear normal at sperm analysis. The chromatin (DNA) can be damaged, there can be antibodies etc... Meaning that just b/c husband has a normal basic sperm analysis does NOT guarantee he is "fertile".

Many couples with unexplained infertility have stopped evaluating the man because he has normal parameters on a semen analysis.

Infertility with normal sperm counts: If your husband has a normal sperm analysis, but you have been trying over 12 months, or 9 months and the woman is 35 or older & there are no obvious female factors...you need to see a Clinical Andrologist- a male sperm specialist to look deeper into more subtle sperm defects.

On the other side, an abnormal sperm count does not mean your husband is sterile- sterile means NO functional sperm in the ejaculate.

It truly does only take one normal sperm and we have all heard of couples that could not conceive for years and years due to male factor, who suddenly do become pregnant.

Lower quality sperm, meaning outside of average, means your fecundity or chance of conceiving each cycle drops. There is one recent study with Dr. Kruger as an author (i.e. Kruger's strict morphology criteria) that studied all the other studies and basically said that you can break ejaculate quality into "fertile" or "sub fertile" based on "thresholds of <5% normal sperm morphology, a concentration <15 x 10(6)/ml, and a motility <30% should be used to identify the sub fertile male”.

You will note that this study used the strict criteria for morphology - Other forms of looking at sperm shape are not as accurate or predictive of sub fertility.

Sub fertile doesn't mean sterile- it means your chances are less and as you move to worse and worse quality the chances continue to decline somewhat.

Infertility with abnormal sperm analysis: If you have this situation you need to repeat the sperm analysis to confirm accuracy.

The only parameter that did not vary was the percent of morphologically normal sperm - the shapes.

Numerous other studies have shown that you can improve the normal morphology % using collection into a condom during intercourse based on the man being more stimulated.

It is also important to note that sperm counts and quality decrease as your husband ages over 45 yrs.

Another study has shown that sperm DNA quality also goes down after age 45.

57. Why should I seek treatment from a Reproductive Endocrinologist rather than from my OB/GYN?

Picking a doctor is so very important. It is important to find a doctor who responsive and well matched to your needs and diagnosis. Most importantly, a reproductive endocrinologist specializes in treating infertility, and is far more likely to have the experience necessary to identify and treat your problem. Treatment with a specialist who can get to the root of your problem. You may need evaluation from a Reproductive Endocrinologist if you meet the criteria for infertility defined above.

58. How long does it take to ovulate after the first positive result on the OPK (Ovulation Predictor Kit)?

You will most likely ovulate 12-48 hours after the first positive result on your OPK, and usually within 24-36 hours. Also, you do not need to keep testing for your LH surge once you get the first positive result. It is the first positive result that you are after.

59. How long after HCG does ovulation occur and how do we know?

Ovulation occurs 36-40 hours after the HCG injection. Eggs will release in this timeframe if they have not been retrieved.

60. How long do sperm live after timed intercourse or after IUI?

Normal, healthy sperm live approximately 48-72 hours. (Abnormal sperm may have a shorter life, which may vary according to sperm health.) We do know that washed sperm can survive in the IVF incubator for up to 72 hours. That would be considered the upper practical limit.

61. How long are eggs able to be fertilized?

Eggs are able to be fertilized for about 12-24 hours after ovulation. The older the woman, the shorter this time becomes.

62. How long does it take for fertilization to occur?

Fertilization occurs within 24 hours after ovulation.

63. How long does it take for implantation to occur?

Implantation occurs about 5-10 days after ovulation.

64. How soon can I take my Pregnancy Test (Beta HCG or Home Pregnancy Test)?

The earliest that a sensitive blood test can pick up any HCG at all is 5-7 days after ovulation.
Your quantitative serum beta test can be reliable about 10-12 days after ovulation, if you have not taken a HCG booster.

If you have taken a HCG booster, then you may have a reliable test at 14 days past ovulation.
The serum beta is the most reliable test. Any level over a 5 is generally considered a positive result, although having a second blood test two days later should show the numbers nearly doubling.

The "average" level of hCG is about 25 at 10 dpo, 50 at 12 dpo, and 100 at 14 dpo. Note that there is a difference between a qualitative and a quantitative test. A qualitative test gives a yes or no answer. Your HCG level has to be above 50 units to get a positive result. Quantitative tests give a value to the amount of pregnancy hormone in your blood. It gives a specific number. Anything greater than 5 is considered positive. Considering that it is possible to implant as late as 10 dpo, a qualitative beta might produce a false negative if used for an early pregnancy test.

65. How do you determine the first day of your cycle?

CD1 is the first day you see a red flow, not just intermittent spotting. There is no universal rule for the cutoff time for that date. Some RE's use midnight, others use 5 p.m., but most often CD1 is considered the first day of full flow that begins before mid-afternoon.

Again, spotting does not count unless it is a continuous (not intermittent) spotting. Continuous spotting does count as CD1. The fact that the rules of thumb for calculating CD1 are so arbitrary suggests that you've got a little bit of leeway for variation.

66. What should my progesterone level be?

Progesterone will be less than 1.5 Ng/ml until the LH surge.
It peaks about seven days after ovulation, when it reaches 15 Ng/ml or more.
But note, if you are above 10 in the luteal phase, your progesterone level is probably fine.
When it drops between 2-4, menstruation begins. (This is why use of progesterone supplements can delay the start of your period).
Progesterone is made by the corpus luteum, which is the site on the ovary from which the egg is released. The more eggs are produced, the more progesterone is produced.
Most doctors use a high level of progesterone supplementation in the luteal phase, which can also result in very high progesterone levels.
There is no progesterone level that indicates pregnancy, only an hCG level over 5 determines that.
It is also worth nothing that progesterone pulses, so the level varies throughout the day.
Some doctors suggest testing first thing in the morning after fasting for the most accurate result.
A high progesterone level gives more information than a low reading in that a "good" level indicates sufficient progesterone to carry a pregnancy; a lower level (in the 5-15 range) does not spell doom.

67. What should my uterine lining be at ovulation and at implantation?

As you approach your LH surge, it should be above 6 mm, ideally between 8 and 12 mm. (If it is much more than that, it may be advisable to ask about a hysteroscopy or sonohysterogram to see if perhaps there is a polyp inside the uterus). You want to have a triple stripe pattern around the time of the LH surge and ovulation. Towards the time of implantation, you want to have a more integrated HH or IE pattern. The triple stripe occurs in response to estradiol; the HH/IE conversion is in response to progesterone. It should also be noted that, although most doctors prefer the above pattern of linings, there is no conclusive research on whether a better pattern actually results in higher pregnancy rates.

68. I have just had a 3-day FSH test taken, and I am concerned about the results.

One of the best starting points is on FSH: Good Eggs, FSH Levels and Ovarian Reserve. In addition, here's what has to say about follow up to FSH: If these bloods were drawn on day three of a cycle, the results would imply decreased ovarian reserve or eggs available. To confirm this we would draw blood for inhibin B. If the inhibin B is low consideration should be given to donor eggs. Inhibin B is a protein made by the granulose cells that surround the eggs. FSH is more of an indirect measurement of ovarian reserve.

69. How do we know if the sperm count is adequate for IUI?

Besides the number of sperm, the percentage with rapid forward-progressive motility and with normal morphology at the time of insemination is important to know.

If the functional sperm count (number with normal morphology and rapid forward-progressive motility) exceeds 10 million; chances for pregnancy with well-timed IUI are excellent.

See Semen Analysis fact sheet for more information.

70. I am concerned about the size of my follicles, and the timing of my HCG shot

How big should my lead follicle be before I take my HCG shot?

A lead follicle should be at least 16 mm on an hMG like Pergonal, it should be at least 18 mm-- 22 mm in which case other measurements such as E2 and progesterone should be used to indicate maturity. (The difference in ideal size is due to the difference in mechanisms by which the medications work. Therefore, the follicle has more time to grow before the egg is actually mature).

71. How much do follicles grow each day?

Follicles grow 1 to 2 mm a day both while taking ovulatory stimulants and after the HCG shot.

72. Will smaller follicles "catch up" in time to release eggs?

Follicles generally need to be at least 15-16 mm to contain fertilizable eggs (although it is possible in rare cases for follicles to be as small as 14 mm and still contain fertilizable eggs). If the smaller follicles are close in size to the lead, they may "catch up" and release. HCG will usually result in most mature follicles releasing eggs. Otherwise, most likely only the lead follicle will ovulate.

73. I have leftover cysts on my ovaries. My doctor wants me to sit out this cycle. What causes these cysts?

A corpus luteum, or functional cyst, is simply a leftover follicle that has outstayed its welcome. Some continue to produce progesterone and estrogen, which may delay the arrival of the next period.

74. Will they go away?

Functional cysts almost always go away with time. Birth Control Pills are sometimes prescribed to hasten their resolution.

75. How big do they need to be to reduce chances of pregnancy?

Research has shown that any cyst 10 mm or larger is associated with a lower chance of getting pregnant. In a study on women doing IVF, those that had a 10 mm cyst at the beginning of a cycle had half the pregnancy rate of those who had no cysts (and the groups were equal on all other relevant characteristics). So it does not eliminate your chances of pregnancy, but it does sharply decrease them.

76. Why do they reduce my chances of pregnancy?

Cysts do not eliminate the possibility of pregnancy in a cycle, but they do reduce it. They do this through two mechanisms.

First, physically, they can crowd out the development of new follicles. Also, if the cyst is secreting hormones at the wrong time of the cycle, (for example, progesterone during the follicular phase), it interferes with the chemical balance required for good quality ovulation and drastically reduces the chances of pregnancy.

77. If I have cysts of any size, should I be concerned?

It is normal to have small cysts, which may be very small leftover follicles or follicles that are preparing for the next cycle.

Anything under 10 mm shouldn't be cause for concern as long as your baseline hormone levels are in range.

78. What exactly is an endometrial biopsy?

In an endometrial biopsy (EMB), a small catheter is threaded into the uterus and a sample is taken of the lining, or endometriam, during the last week of your cycle. (It causes brief cramping for which Ibuprofen, taken ahead of the procedure, is helpful).

Once the sample is obtained, it is rated according to the day of a 28-day cycle for which it would be typical. For example, a lining at the beginning of the luteal phase is different from a lining at mid luteal phase or during the follicular phase. An out-of-phase endometrium means that the endometrial appearance is typical of a time in the cycle other than the time it was taken.

This biopsy does have the potential to disrupt a pregnancy in progress.

Many doctors will test for pregnancy before doing the biopsy, to be on the safe side. An EMB may also be done to check for abnormal cells in the endometrium (hyperplasia).

This is a concern when a woman has very infrequent periods (bleeding less than once per three months) or when ultrasound reveals a thick lining. For this purpose, the EMB can be done on any cycle day.

79. How many times should I try IUI before moving on to IVF?

Once a patient has had 3-6 IUI cycles with ingestible, they might consider moving to IVF as the chance of a successful IUI cycle is reduced.

80. What are normal ranges in a semen analysis?

Normal Ranges for a Semen Analysis* Parameter Normal Ranges
Color Gray/Translucent
Coagulate? Yes
Liquefy? Yes
If yes, time in minutes Less than or equal to 30
Volume (ml) 2 to 6
Viscosity (1, 2, 3, 4) 1
PH 7.5 to 8.1
Motility Greater than or equal to 50% % of 3-4 + Forward Motile Sperm Greater than or equal to 50%
Sperm Concentration (x 1 Million per ml) 20-200
Total Sperm Count (x 1 Million per ml) Greater than or equal to 40
Total Motile Sperm (x 1 Million per ml) Greater than or equal to 20
White Blood Cells (x 1 Million per ml) Less than or equal to 1
Agglutination (0, 1, 2, 3)
Clumping of sperm to sperm 0 Clumping of sperm to round cells 0 %
Normal Morphology Greater than or equal to 30%
Penetrak Score (mm) Greater than or equal to 30 ml
(= milliliter mm=millimeter) Based on World Heath Organization criteria, 1992.
Table excerpted from Berger, G.S., Goldstein, M., and Fuerst, M. (1995).
The Couple's Guide to Fertility. New York: Doubleday

81. How long should my partner abstain before the IUI? His semen analysis is normal.

For most men, a 3 day break is ideal.
That gives the "sample" an opportunity to regenerate. Too "old" of a sample raises the risk of poor motility, white cells, and other problems. (An "old" sample would be that which is taken after more than 7 days of abstinence).

82. What is a sample protocol for IUI?

The simplest protocol is Use a urine LH or ovulation detector kit daily starting day 11 of the cycle. Perform the IUI the day following the LH surge. With the addition of vaginal ultrasound monitoring on the day of the LH surge or by day 14 if no LH surge, you may be given an HCG injection and IUI performed 36 hours later. Adjustments in the ovulation induction protocol can be made in subsequent cycles depending upon your response (as measured by LH kit and ultrasound).

83. What tests should I have after my IUI?

You should at least have a 7-dpo-progesterone test. Your RE may also check the pattern and thickness of the uterine lining via ultrasound at the same time.

84. How should my IUIs be timed?

In most cases, doctors who do two IUI's do the first about 24 hours after the HCG shot and the second about 48 hours after the shot. Some studies have shown that doing one IUI about 36 hours after the HCG is equally effective. However, some recent research suggests that higher pregnancy rates may be achieved by doing two IUI's, one at 12 hours past the hCG shot and one at 34 hours.

85. What are the logistics of injectables?

How many days will I take them?
How big are the needles?
Who administers the injection?
Are they painful?

Typically, they are taken daily for 7-12 days (although it is possible to take them as long as 14 days). If you are taking subcutaneous injections, they are administered in the stomach, upper arm or thigh, with a 1/2- or 5/8 inch needle. If they are intramuscular, they are given in the hip/buttocks area using a 1.5-inch needle. The partner usually administers the IM shots. You can also give the IM injection to yourself in the thigh. They feel like a flu shot or vaccine.

86. What is the standard IVF protocol?

There are several variations on the IVF protocol.
Described below is a sample "down regulation" protocol.
This is an example of one which doctors commonly start with when the patient is under 35 and has a history of good response to stimulation.
In the down regulation protocol, you start the cycle before your stimulation and retrieval cycle.
On CD3 of that cycle, your FSH level is measured.
On CD21, you do a progesterone test to see if you have ovulated. (If you are annovulatory, they will often put you on a BCP regimen to give you a predictable cycle).
If you have ovulated, then you start Lupron shots once a day.
The dosage varies from doctor to doctor to some extent.
You may start out on 20 units and then drop down to 10 units after five days. Your period should arrive close to its due date.
On CD1 or 2, you are tested to ensure that Lupron has shut down your own hormone system, so that they can use drugs for stimulation and have a more predictable cycle.
Suppression is determined primarily by your estrogen level, but your doctor may also check progesterone and LH.
If you are adequately suppressed and an ovarian scan shows no cysts, you will usually start injectables on CD3 or so.
Your Lupron dose may be lowered to 5 units at this time.
Your medication dosage depends on your diagnosis, age, and response history if you have taken injectables before.
You might take two amps in the morning and two in the evening.
After three days of ovulatory stimulants, your follicles and Estradiol levels will be checked.
It is good to see the E2 levels above 100 after three days of stimulation.
There will not be a great deal of follicle development yet.
If needed, your medications will be adjusted.
You will go in a few days later for a second round of blood work and a follicle check.
After that, you might report to your clinic daily for blood work and ultrasounds. Once your follicles have reached an appropriate size and your E2 levels are good, you stop the stims and Lupron, and are given the hCG shot.
This is about 34 hours before the retrieval is scheduled.
The cut-off for the hCG shot, again, varies.
Some clinics check for good blood flow to the uterus and a triple layer pattern in the uterus before retrieval as well.
They might use this as a determining factor on whether to order baby aspirin. Retrieval is generally an out patient procedure.
It can be done with a local anesthetic or an IV anesthetic.
The IV anesthetic is much like the IV sedation used in dental procedures, and is very comfortable.
The eggs are retrieved using an ultrasound probe that has a needle at the end of it. They put the needle through the vaginal wall and aspirate the follicles.
You will generally start progesterone immediately following the retrieval.
The post-retrieval events vary according to whether you are doing a day 3 or day 5 transfer, but you will generally receive updates about the number of eggs retrieved, the number fertilized, and the progress of the embryos.
The transfer itself is much like an IUI, although most doctors use u/s to guide the catheter in, because placement is so critical.
Pregnancy tests are generally done somewhere between 12 and 14 days after transfer.
Two other variants on the down regulation protocol are used in women over 35 or women with a history of poor response.
The "flare" protocol has you start Lupron around the same time you start your stims, rather than during the luteal phase of the previous cycle.
A "stop" protocol means that you take Lupron for several days but then stop it at some point while you are still taking your stims.
Each protocol has its plusses and minuses.
Women on the down regulation protocol require a greater amount of stimulation, often over a longer period of time.
However, women on stop and flare protocols are more likely to have a premature LH surge and are more likely to develop a single dominant follicle (not a good thing in IVF).