When Gabriela and Ross had their initial consultation, Gabriela was on day #5 of her cycle. Had she instead been near the time of her ovulation, I should have been able to see a maturing follicle on ultrasound rather than seeing the PCOS ovaries that I described last time. Also, had that been the case, we would have put off testing Ross’s sperm until Gabriela’s fertile period had passed, because even after patients come under our care, those that could potentially conceive on their own still are encouraged to keep trying while we work on getting their tests done. We would have wanted him to save his sperm for trying to conceive, and only after Gabriela’s fertile period has passed would we want him to produce a test sample. I can recall several couples who come for consultation and before all the basic tests were done, end up getting pregnant on their own.
SEMEN ANALYSIS: Anyway, Ross followed our instructions and waited for two days of abstinence before doing his sperm test. Since Gabriela was not expected to enter her fertile window period for another week, this was a good time to do the test without compromising their chances of conceiving naturally. He produced the sample at home using the sterile cup we gave him on their initial visit. After he dropped off his sample, I told him that I would examine it myself and give him a call later that morning. My staff took the sample to the back lab. They waited 10 minutes for it to completely liquify. Sperm undergoes certain liquefactory changes after it has been ejaculated and we usually wait for those changes to finish before testing it or before using it for insemination purposes. When it was ready, a drop was placed in the special chamber and I was called to examine it. Here are the results.
Count: 55 million sperm per cc
Motility: 49%
Volume: 1.3 cc
Morphology not assessed. DNA testing not done.
COMMENTARY: Most of time when I first test a husband’s sperm, I’m doing it as a screening test. In other words, I’m looking for a real obvious problem – either a very low count or terrible motility. There are more advanced tests such as strict morphology and DNA integrity that I save for later, only if needed. This is to help save money for the patient, because a basic count and motility is very economical, yet useful. The test costs about $80. So Ross’s sperm shows a count slightly less than the typical 80-150M/cc, but it is not below the cutoff of what we consider abnormal, which is less than 20M/cc. This helps guide us to focus back on Gabriela for now. Ross was very relieved to hear this.
GABRIELA’s BLOOD TESTS:
TSH: 3.0 uIU / mL = normal thyroid
Prolactin: 18 ng/mL = normal prolactin level
Fasting: GLUCOSE 105 mg/dL. INSULIN 14.9 uIU / mL
1 Hour: GLUCOSE 250 mg/dL. INSULIN 228 uIU / mL
2 Hour: GLUCOSE 159 mg/dL. INSULIN 189 uIU / mL
3 Hour: GLUCOSE 173 mg/dL. INSULIN 158 uIU / mL
COMMENTARY: Two specific hormonal problems that contribute to infertility are an underactive thyroid and an abnormally high prolactin. A lot of times, people with hypothyroidism have weight gain, a tendency to feel tired and swelling of the neck. People with severe hyperprolactinemia will notice milk coming from their breasts. Gabriela’s tests confirm that she has neither of these problems. However, her insulin testing is very interesting. The test is done as follows. Early in the morning, before eating anything, the patient has her blood drawn. Normal fasting glucose (blood sugar) should be below 105. Normal insulin should be below 15. Then the patient is given a drink consisting of 100g of concentrated sugar water. Blood is drawn every hour for the next three hours. The results are interpreted based on how high the values are AND on how they relate to each other AND on how they change over time. Gabriela’s tests are extreme. Rarely will you see such high insulin values, especially her 3-hour value. These results strongly suggest an abnormal sugar metabolism due to inefficent insulin action, also known as insulin resistance.
The initial round of tests was very fruitful and helps guide our next steps. We reconvened and began an in-depth discussion regarding which one or more of the following seven choices to do next.
CHOICES:
- Continue trying on own for another 6 months
- Get an HSG to test the tubes
- Take metformin
- Take Clomid
- Take injectable FSH
- Do insemination
- Do IVF
