QuestionQUESTION: my husband and i have been trying to conceive since may 2007. in august 2008 we had a sperm analysis done which showed 11mil/ml concentration, 20% motility and 11.3% morphology (all WHO scale). a repeat analysis showed a concentration of 54.5mil/ml, motility 60% and morphology 9.4%. so whereas the the concentration and motility are now normal we still have suboptimal morphology.
blood tests have shown that i ovulate, albeit with slightly variable cycle length. i have now been shown to have a fsh of 9.8 (i'm only 28 years old) and they have found a 3cm solid mass on my left ovary on ultrasound. ca-125 levels were normal and subsequent scans have shown no change in size of the mass.
i have had a hycosy which showed that my fallopian tubes were patent. i have been put on clomid - i had 3 cycles of 50mg, no trigger - i ovulated but no pregnancy. and i am now on my 2nd cycle of 50mg clomid with an hcg trigger. the day 12 follicle scan i had for the first time last month showed that i had 2 follicles of 26 and 27mm, which considering i wouldn't normally ovulate till around cd15-21 seemed quite large.
sorry about the essay, but my question is, where should we go from here ? i'm from the uk and am being seen on the nhs and i feel like i'm having lots of tests done but not a lot being done about it. my consultant says we have unexplained infertility but i'm not so sure about that diagnosis.
many thanks for your help
sarah
ANSWER: Hello Sarah,
First of all, you don't have unexplained fertility. You have male factor infertility. Your husband's sperm shows teratospermia (abnormal sperm). If only 9.4% of the sperm are normal, that means that only 5 million sperm are available for fertilization. That is significantly lower than the 20 million requirement. At the very least, you should be doing intrauterine insemination with this problem. In reality, this may show a functional problem with the sperm as well (inability to fertilize), so in the U.S., with severe sperm abnormalities, we recommend ICSI (injecting the sperm directly into the eggs. This requires IVF.
In addition, if your FSH level was drawn on cycle day # 2 or 3, then it is elevated. For fertility purposes, we like the fsh level to be less than 7.0. This elevated fsh level shows some ovarian resistance, which means that you may need higher dose medications to stimulate your ovaries in an IVF cycle. When the FSH level reaches above 10.0, then we have a big problem because the ovary will not stimulate well. In that case, donor eggs would be required. Because of this, when we see an elevated FSH level, that means our time line is shorter and we need to be more aggressive. Again, that would entail IVF.
In terms of your follcles being ready early (we generally prefer to trigger when the follicles are 20-24 mms in size because larger follicles mean an over-mature egg)d, Clomid and fertility drugs will often cause the ovary to stimulate faster. I generally see my patients back on cycle day # 9 or 10 to start ultrsoun surveillance because of this.
I hope this helps,
Sincerely,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
Monterey, California, U.S.A.
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QUESTION: thanks so much for you reply, you confirmed exactly what i thought - male factor and also needing to hurry because of the higher fsh (it was drawn on cd2).
i feel like i'm being completely fobbed off by my consultant as they don't want to put me on the waiting list for ivf (or iui) yet - where i am, they don't have to put me on the list until we have been trying for 3 years if they declare it unexplained infertility. i guess i'm going to have to try and get the money together to see a private fertility specialist :(
do you think the solid mass on my ovary is anything to be concerned about ? could that have affected my ovarian reserve ?
thanks again for your help
sarah
AnswerHello Again,
It is of concern because you don't know exactly what it is. The likelihood is that it is a benign tumor of some sort, but until it is removed and biopsied, you don't know for sure. It would not affect your ovarian function or reserve.
I'm sorry to hear about your dilemma with seeing a specialist. That is the price of socialized medicine, and many of us spoiled Americans think that is a better system than we have here. They will regret it if it ever comes to pass. Until then, we still have the freedom to seek out whatever and whomever doctor we want.
Good luck,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
Monterey, California, U.S.A.
