Start here with Episode #1

Terra and Miles have infertile for three years. They have already made the big decision to seek medical help and are currently in the middle phases of the diagnostic process. So far, Miles’ semen analysis is unremarkable and we are about to learn more about Terra.

This month, she had her HSG done on day #9 of her cycle. This is sometimes referred to as a "dye test" because it consists of injecting radio-opaque dye into the uterus and taking a series of x-ray pictures to see where the dye goes. In Terra’s case, her results were normal. The dye entered her uterus and outlined a normal triangular shape. It then flowed into her tubes on both sides, eventually spilling out copiously into the pelvic cavity. Terra described mixed feelings. While it was a relief to find out that her tubes weren’t blocked and that there were no tumors in her uterus, she was disappointed that we still didn’t have an answer as to why they were not conceiving.

We turned our attention to her evaluation cycle, where we did serial ultrasounds to see exactly what was happening with her follicles. The following data describe her activity throughout her cycle.

Day 03 Both ovaries quiet.
Day 10 Right ovary: 14mm x 14 mm follicle. Left ovary 18mm x 18mm follicle.
Day 13 Right ovary: 11mm x 10 mm follicle. Left ovary 24mm x 18mm follicle. PCT done. Ovulation test positive.
Day 15 Right ovary 10mm x 10mm follicle. Left ovary nothing = ovulated!
Day 21 Progesterone level = 28 ng / ml. Very good.

I explained to Terra the information we gained from this cycle. She started out with the potential to have a rare double ovulation this month. This was entirely on her own with no Clomid and no injectable medications. The follicle on the left kept growing and successfully ovulated. The follicle on the right fizzled out. This is pretty normal. Most women will have more than one follicle start to develop, but rarely do they end up with more than one making it all the way to ovulation, at least not without help from medications.

On Day 13, I did a post-coital test. This is a fancy name for a procedure which consists of grabbing a little bit of the cervical mucus and checking it for how stringy it is. Her mucus was actually relatively thick, which is not the optimal state to be on the days prior to ovulation. I also looked at the mucus under a microscope and saw an occasional twitching sperm. Terra and Miles had gotten together, as instructed, on the evening of Day 12 and had come in on the morning of Day 13 for this test. Normally, you would expect a lot of happily motile sperm, but not in this case. So what does it all mean?

In order to answer that question we need to consider another important questions. Why do we do medical testing? The usual answer people give is that we do testing in order to see if something is abnormal. That might be what the majority of people think, but it is not the best answer. The actual best reason to do medical testing is in order to guide our decisions. This is the reason RE’s rarely do PCT’s any more. Some of the older guys still swear by it, but it makes little sense to do it. Why? Let’s consider Terra’s situation. Her PCT is poor for two reasons. One, the mucus is not optimally clear and stringy. Two, the sperm have not survived well in it. This tells us that her cervical mucus might be a contributor to their infertility. This also goes along with the fact that she had had a LEEP procedure in the past, which most likely removed some of the normal mucus-producing glands. But what if her PCT had been normal? What if the mucus was fantastically stretchy and clear and what if there were too many sperm to count busily swimming around? Then, we would have a situation called unexplained infertility where there is no obvious problem with ovulation, no obvious problem with the sperm, no obvious problem with the tubes and uterus and no obvious problem with the mucus. In these situations, there is no obvious problem with anything. Yet, the couple is not getting pregnant. One solution for this is to do insemination. But what about in Terra’s case where the mucus is clearly bad? What’s the answer? The same — insemination.

Therefore, the obvious argument is this. If a normal PCT and an abnormal PCT both result in the same recommendation, then why bother doing it? Good question. As I said earlier, I did not recommend it, but did it at Terra’s request. Bear in mind that a PCT costs next to nothing. I have to consume one microscope slide and one cover slip and it takes me an extra 10 minutes to do it. Therefore, we were more lenient about doing something that really wouldn’t change my recommendation. Had we been talking about a thousand dollar test that did not change our management, I would have argued more vocally to skip it. But for Terra, it was important, because now she felt a lot more confident about going forward with insemination.

In summary, Terra and Miles have completed a basic infertility workup. Given the normal sperm, the normal HSG and normal confirmation of ovulation, they have unexplained infertility, unless of course we wish to dwell on the matter of the abnormal PCT. In any case, the recommendation is IUI, with an expectation of about 50% chance pregnancy within three cycles. Excitedly, Terra understood that we would wait to see if this natural cycle results in a pregnancy. After all, their baby dance timing was confirmed to be perfect this month. Also, her tubes were probably the cleanest they have been in a long time due to her getting the flushing from the HSG this month.

However, two weeks later, Terra called with her period. She was not pregnant. But she was now ready to do her first (and hopefully, only) IUI cycle.

Check here for episode 4

Start here with Episode #1

Thursday morning, Terra got her period. She asked to come in and talk to me on Saturday to review the plans for this month. When she came that day, I also did an ultrasound which confirmed, as expected, that there were no mature follicles growing. Both ovaries were quiet. This came as no surprise, as it was D#3 of her cycle, a time before any significant follicles are seen. Her lining was very thin. Again, this was no surprise as Terra described her flow as being the heaviest the day before. The reason her lining was thin was because all the previous lining had bled away and it would be another two weeks before the lining rebuilt back to it’s optimal thickness.

After their first office visit, Terra’s husband had done his semen analysis. While someone from our office had called her immediately to tell her the results last week, she was eager today for an in-depth discussion on the implications of the results. Ironically, her husband had gone golfing rather than be present for today’s discussion. Terra said she didn’t mind because he had old friends from out-of-town and this was a special occasion for him. Besides, he had asked her permission. She told him to have a good time with his friends and she agreed to get the information and relay it to him. His results were as follows:

Volume 3.0 cc
Count 96 MILLION per cc
Motility: 50%
Morphology 70%

Sometimes, people think of a semen analysis as an ultimate test that will tell them without a doubt whether a man can father a pregancy or not. This is not true. Rarely do we get an absolute answer. While it’s true that a man with a 200 MILLION count and 80% motility almost for sure has sperm that is functional, there is still that rare chance that he has some unusual genetic defect that renders the sperm incapable of fertilization, even though the numbers sure look good on the surface. On the other extreme, we can have a man with a 5 MILLION count and 10% motility. While this gives us a strong suspicion that the sperm is a problem, it doesn’t rule out the possibility that he could still naturally initiate a pregnancy. The chances are low, but still not impossible.

So in general, an average count is about 70-250 MILLION per cc. Counts under 40 MILLION per cc would be in the low-normal range, while those under 20 MILLION per cc are officially considered abnormally low (according to criteria set by the World Health Organization).

So Terra went home and waited for Miles to return, so she could tell him the good news that his count and motility were in the normal range. Terra was scheduled to come back on D#9 of her cycle for another ultrasound. She would also have her HSG that day to answer the question of whether or not her tubes were clear.

Click here for episode #3

My patients know that I like to use stories and analogies to help explain things. One fellow blogger has done a tremendous job explaining what’s wrong with the state of medicine today using a fantastically clever story about the tomato market. I urge all medical students to read it.

When Terra and Miles (not their real names) first came to me, they confessed that they were unsure if they should be pursuing fertility treatment yet. After all, they had only been trying for one year and were both healthy. Terra was 30 and had never been pregnant before in her life. Miles was 33 and had never fathered a pregnancy. They had actually known each other way back in college, but had not started dating until five years ago. They have been married for four years. Miles enjoyed his job, working for the police department in an administrative capacity, not out there in the field chasing bad guys. Terra worked in the HR department of a large company. Her job was quite stressful, but she had developed a good attitude about handling it. Terra said that her brother and his wife had been our patients and his persistent influence was the main reason why they were here. Terra gave me a quick update on how cute her new baby niece was and we started working on their case.

I started out by exploring what they meant when they said they had been trying for only one year. Hadn’t they been married for four years? “Well, yes,” Terra replied, “But in the past year, I read this book about taking charge of my fertility and I started doing cervical mucus checks, charting temperature and using ovulation sticks to time when to get together.” After further questioning, it was revealed that for their entire marriage (with the exception of the first three months), they had not used any contraception. They also reported having sex three times/week even when before they started tracking temperature. I explained to them that “trying” does not refer to actively doing things to track ones ovulation. In the true sense, “trying” refers to any time period when you are having regular sex (at least twice a week) and not using contraception. Using that as the proper definition, they had been infertile for well over three years, and that certainly was not normal.

SPERM ISSUES: Miles had no medical problems, no past surgery and led quite a healthy life. He appeared very lean and fit and rarely drank and never smoked. He was the shining example of someone healthy who was not expected to have any sperm issues. But as we all know, there is no way to absolutely guarantee normal sperm just by looking at someone. Therefore, we needed to start by doing a semen analysis. Plan: Semen analysis.

OVULATION ISSUES: Before I could ask her about her ovulation, Terra took charge and whipped out her checkbook. She did not write a check, but rather showed me the BACK of it, where there was that condensed three-year calendar. On it were circles of the first date of her period for the past 2 years. She proudly proclaimed that her periods were like clockwork and she had the evidence to back that up. She had no medical problems and was 5’ 6” and weighed 137# for an excellent BMI of 22. Her ovulation testing was consistently normal for the past year. Based on this detailed information, I told her that I was over 95% sure she was ovulating normally. We could always get a mid-luteal progesterone to check further, but as for now, I didn’t think it was a priority. Plan: No action at this time.

ANATOMICAL ISSUES: Starting from bottom to top (cervix to uterus to tubes to pelvis), Terra once had surgery on her cervix to remove some precancerous tissue. From her internet research, she already knew that something like that could compromise her cervical mucus. She said she is unsure whether she made a lot of mucus before the surgery, but she knows that she makes very little now, even right before ovulation. Further suspicion of an anatomical problem was raised when she shared that her periods were so painful that she would often leave work if the cramps got too bad. I told her that I would recommend an HSG right away to rule out a tubal problem. I shared with her my concern that she might have endometriosis. I would not be surprised if she had tubal scarring or even complete blockage. She disagreed with me at first, saying that she was more worried about a cervical mucus issue. She insisted on getting a post-coital test. Even after I explained that those tests were rarely done any more, she expressed that she really wanted one. We eventually compromised and made the plan to spend one month doing a post-coital test and an HSG. She agreed to call us on the first day of her next period (expected in a week or so) and get set up for both tests. PLAN: Natural evaluation cycle with PCT and HSG.

Terra and Miles impressed me as being a much more cheerful and optimistic couple than average. While it was still unknown what the reason or reasons were for their infertility of three years, we were soon to learn if the sperm had any issue and we were soon to learn if the tubes were blocked. An ovulation problem was lower on our list of suspects.

Click here for episode #2

Honestly, I have a whole load of stories from this past particularly-busy week. However, I’m realizing, to no surprise, that many of my actual patients read this blog and as such, I have to respect commenting on some sensitive stories even if their identity is completely shielded. I’ve written some notes for myself, but I won’t post actual stories until I get a chance to either ask their permission and/or adequately disguise things a bit. I must say that I’m sadly learning that marital infidelity occurs quite a bit in this country and infertility patients are certainly not immune.

I received a notice from the State of California Franchise Tax Board regarding a missing payment. I needed some help, so I tried calling their support line several times in the past two days. Each time, I followed the voicemail instructions and was put on hold. I would put it on speaker phone and do some charting. Each time, after about 20 minutes, I would inevitably get called to go see patients, so I would leave the phone on hold and go take care of things. When I returned, most of the time, I was STILL on hold. However, once in a while, when I returned, it was no longer on hold and the line was dead. I assumed that the operator came on and hung up on me because I wasn’t there. After playing this silly games about 5 times, I decided this morning to try another option. This time, when asked, I pressed the # for assistance in Spanish. I am fairly fluent in Spanish, so I figured I could try and see if the wait time was shorter. After 9 minutes, I got connected with a live operator. The funny thing is she answered by saying "This is Alicia, may I help you?", pronouncing her name A-LEE-SEE-A in a very Spanish way, but saying the rest of the words in English. We wound up having a 3 minute conversation in English. I got the information I needed and said a little prayer of thanks, reminding myself of the usefulness, sort of, of being multilingual.