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A Woman without Uterus or Ovaries?
Is it possible for a female to have no uterus or ovaries? If so, what causes this condition, and how is it that she is able to have normal breasts and other feminine features? S.

Many conditions may result in the situation you report. The most likely is one called androgen insensitivity syndrome, in which the body is genetically programmed to be male, but something happens to prevent that from happening properly.

In this condition, the gonads (the organs that would become either ovaries or testicles) are present and produce high levels of the male hormone testosterone. This would normally trigger male development, but the body cells are unable to respond to the male hormones. Without a signal to trigger the development of male characteristics, the body develops into a female form. Meanwhile, the gonads -- which are still operating as though the body is male -- also produce a substance called Mullerian inhibiting factor that blocks formation of a uterus.

As the uterus and upper vagina do not form normally in this case, the gonads "get confused." Instead of becoming ovaries, they develop into abnormal testicles. With careful searching, these abnormal gonads can often be found in the abdomen.

Women with this condition are generally taller than their peers and have less body hair. This condition is diagnosed by measuring testosterone levels and checking chromosomes for the presence of a 46XY (male) chromosomal pattern. In early 2002, the GRS team discovered a new gene mutation in a patient with androgen insensitivity syndrome. A detailed description of this (and a discussion of treatment options) can be found on the current research section of our website.

Abnormal Sperm Morphology
My husband went for a semen analysis and the result showed that the morphology was 90 percent abnormal. Is this something you are born with, or does it have to do with a healthy diet or cigarette smoking? Toni

Morphology refers to the shape and structure of the sperm. A normal-looking sperm has an oval head and a tail seven to 15 times longer than the head. On a semen analysis, in which we look at sperm under the microscope, we can identify defective sperm by their large heads or strange tails -- kinked, doubled, or coiled.

The World Health Organization (W.H.O.) says good quality semen should contain 60 percent normal sperm morphology. A closer evaluation called a strict morphology, or Kruger morphology, is more time-consuming and usually predicts normal sperm function when more than 15 percent are normal. That means that a semen sample can include up to 40 percent abnormal sperm and still be considered fine.

All men produce many abnormal sperm. The reason is not known, but considering the rate at which a man's production line operates -- 10 million to 50 million new sperm per day -- some "factory seconds" should be expected. We do know that toxins such as lead have been linked to reduced motility (swimming ability), cigarette smoke to abnormal morphology, organic solvents to coiled tails, and excessive scrotal heat to coiled tails in animal sperm. When you lower your exposure to these agents, abnormal morphology levels usually decrease. I remember one man with a high level of abnormal sperm who transferred to a different job at his company so he could avoid exposure to heat from a blast furnace. He also began taking 1,000mg of vitamin C each day. Within a few months his sperm motility and morphology showed definite improvement.

About Hysterosalpingogram (HSG)
What exactly is a hysterosalpingogram? What steps are involved? Does it involve any pain? Nora

Hysterosalpingogram (HSG) is an X-ray study of the uterus that uses a special dye visible on X-rays. A series of X-ray images taken as the dye flows into the uterus and through the fallopian tubes helps doctors evaluate the size and shape of the uterine cavity and determine whether the fallopian tubes are open, and sometimes even if there are adhesions near the tubes.

HSG is best scheduled two to three days after the last day of menstrual flow. It is important to ensure that you are not pregnant at the time this study is performed, so if there is any doubt about whether you are pregnant, or if the flow is light, a pregnancy test should be performed beforehand. Many physicians will recommend a dose of antibiotics to reduce the risk of infection and a non-steroidal antiinflammatory agent such as ibuprofen (Advil) or naproxen (Aleve) to minimize cramping.

The doctor begins by inserting a speculum into the vagina. The cervix is wiped with an antiseptic, and a catheter (narrow tube) is inserted into the uterine cavity. There may be a mild cramp with this portion of the procedure. The speculum will be removed, and you will be repositioned on the X-ray table. Your physician or the radiologist will place tension on the uterus to straighten the bend and give a better picture of the uterine cavity. Next, the dye is injected into the uterus through the catheter. This is often associated with cramping. If you are relaxed and in the hands of a gentle physician, the cramping is usually mild. However, if the dye does not flow through the fallopian tubes, additional pressure may be necessary to see if the tubes are really blocked. This can cause more intense discomfort.

After the X-ray, you will be asked to remain lying down for another 5 - 10 minutes to allow the cramping to subside. Arrangements should be made with your physicians so that you know when you will be asked to return to discuss the results and determine the next step in your treatment plan. If you experience increasing pain, fever or heavy bleeding after the procedure, you should contact your physician.

Age & Fertility Loss
Can you explain why it is harder for a woman to get pregnant as she gets older? Is an older egg simply harder to fertilize, but would develop normally if fertilized? Or are the eggs not harder to fertilize, but more likely to develop abnormally and so fail to implant? In other words, is the mechanism that explains higher birth defects with age the same as that which explains lower fertility? M.

This is an interesting question and addresses an area where much research is being carried out. The adverse effect of age does not appear to be mediated by a decrease in "fertilizability," but rather seems related to abnormal chromosomes in the egg.

Let's go back to review how the egg forms. All human cells other than sperm and egg normally have 46 chromosomes. The egg and sperm each contribute 23 chromosomes to the developing fetus. This means that as the egg and sperm are formed, the number of chromosomes needs to reduced to 23. This process of chromosome reduction is called meiosis.

In men, the process is ongoing, and new sperm are continually being produced. In the woman, the situation is a bit different. Before her birth, while she is still an embryo, the number of her eggs increases up to about 4-7 million. After about 20 weeks of gestation, her fetal body stops producing new eggs. These eggs must also undergo the process of meiosis to reduce from 46 to 23 chromosomes. But at 20 weeks, the eggs are surrounded by an envelope of cumulus cells; this arrests the meiotic process and keeps the eggs healthy until they're needed for ovulation. An egg resumes its growth about three months before ovulation. In fact, meiosis is not actually completed until after ovulation and fertilization has occurred.

We know that older women ovulate eggs that are more likely to contain chromosomal abnormalities, such as extra or missing chromosomes. What we don't know is when this anomaly occurs. Does it occur while the eggs are dormant, in a state of suspended animation awaiting their chance to grow and ovulate? Or does it occur after hormonal signals involved in ovulation stimulate the egg to resume meiosis?

Researchers have hypothesized that perhaps the cumulus cells surrounding the egg lose their ability over time to maintain healthy eggs. Some believe that chemical abnormalities within the cell are responsible for errors in chromosomal reduction (meiosis), and that transfer of cellular material from a younger woman may resuscitate the egg. While initial studies have shown that this cytoplasmic transfer can be carried out and the egg can be fertilized and develop normally, the question of whether this corrects age-related defects has not been answered. Hopefully we will have answers in the next two or three years.

A recent published report on this topic is available on the current research section of our website.

Age & IVF Success
I'm a 39-year-old woman with 4 children. My husband and I are thinking about having another baby and -- because I had my tubes tied -- we're considering in vitro fertilization (IVF). Since our insurance won't cover the procedure, we can probably only afford one round of treatment. What are the odds that one IVF will prove successful for a woman of my age? A.D.

When it comes to the likelihood of successful tubal reversal and in vitro fertilization, the odds are against women your age and older. Fertility drops after age 35 (especially after 38), and delivery rates per IVF cycle started are only about 15% as the 40th birthday nears. This rate is similar to the live birth rate following tubal reversal for a woman of your age.

Before undergoing any treatment for infertility, you should consider a couple of tests to measure your fertility potential. One is called a clomiphene challenge test; the other is a day 3 FSH blood level test. If these test results come back abnormal, the likelihood of successful fertility treatment with your own eggs is even less than noted above. At our center, more than just age determines "success" with IVF, and each couple should undergo a thorough assessment to offer a complete understanding of prognosis and likely outcome.


Age & Risk of Birth Defects
I will be 35 in June. I am overweight but active, and I have regular cycles. My husband is 36, and we have two healthy sons, age four and seven. We would love to have another child soon. What are the odds of our having a child with birth defects because of my age? Does it make any difference that I did not start my periods until I was 16.5 years old? Do two previous healthy uneventful pregnancies lower the chances of birth defects or chromosomal problems? I have searched the web endlessly and have not found answers to these specific questions. Kiara

One chief concern of pregnancy after age 35 is increased risk of chromosomal abnormalities. Age-related chromosomal abnormalities such as Downs Syndrome occur in only about 1 in 200 pregnancies (about one-half of a percent) for women aged 35, so this is not a great concern for you at this time. However, for women age 40 at the time of pregnancy, the risk rises to about 1-2 percent.

Age-related chromosomal problems typically originate at the time of meiosis, when the egg cell eliminates half of its 46 chromosomes to accommodate the male's genetic contribution. The chromosomes are separated by tiny filaments called spindles, which appear to become brittle and break or to become detached from the chromosomes as women age. This breakage or detachment can result in an abnormal number of chromosomes in the egg, a condition called aneuploidy. This occurs in about 33 percent of eggs at age 35 and 50 percent of eggs at age 40. Luckily, few of these irregular eggs will fertilize or develop into detectable pregnancies. As such, the risk of a genetically abnormal pregnancy is much lower than the risk of an abnormal egg.

As you age, your risk also rises for nonchromosomal birth defects and pregnancy complications such as gestational diabetes, pre-eclampsia and intrauterine growth retardation. At age 35, however, your age plays little role in any of these complications. The age at which you began menstruating (menarche) does not seem to influence this risk, nor does your prior history of a normal pregnancy.

I'm sure you are well aware that there is a significant decrease in fertility as a woman ages, and that now we have testing available to evaluate your fertility potential.

Allen-Masters Windows, Pouches, Endometriosis & Fertility
I recently had endometriosis surgery. They gave me a video to watch of the pertinent parts of the procedure. The doctor stated I have a Masters Window. What does that mean? How it will affect my trying to get pregnant? H.S.

During your menstrual period, endometrial cells may travel from your uterus into your abdomen. Endometrial cells are present in the abdominal fluid in most women at the time of their period. In women with endometriosis, for some as-yet-unknown reason, the body is just not as effective at clearing these cells from the abdominal cavity, and these cells are more likely to attach and grow.

Allen-Masters windows are pockets or infoldings in the peritoneum, a thin membrane that lines the inside of your abdominal cavity. These pockets tend to trap endometrial cells expelled into the peritoneal cavity during your period. At laparoscopy, a biopsy of the tissue at the base of the Allen-Masters windows frequently shows endometriosis. Many physicians recommend that the peritoneal lining be completely stripped from the Allen-Masters pocket at the time of surgery.

The presence of these pockets should in no way effect your fertility. The more important question you did not ask is whether mild or minimal endometriosis lesions on the peritoneal surface are a cause for infertility. The data are confusing at best. While there is certainly a greater risk of finding endometriosis at the time of a laparoscopy for infertility evaluation, this does not necessarily mean that the endometriosis causes infertility. Endometriosis can be the result of a failure to achieve a pregnancy, or it may be due to a genetic or immune factor that is also causing the fertility problems.

The evidence to date, in all but one study, strongly indicates that treating endometriosis does not improve fertility. Unless significant structural abnormalities such as tubal damage, adhesions or ovarian endometriomas are present, most studies suggest that the best approach to fertility is to ignore the endometriosis and to choose the same treatments as would be used for unexplained infertility. Remember that the only way to diagnose endometriosis for sure is by a biopsy (requiring surgery).

Allergic to Dye for HSG
My doctor wanted me to have a hysterosalpingogram, but when I arrived at the radiologist, I found I could not have the test done because I am allergic to iodine. Is there any other test that can be done to serve this purpose? He is starting me on Clomid. Izzy

Iodine allergies are a confusing issue. The first consideration must be the type of allergic reaction experienced in the past. With more severe reactions, I would definitely avoid using an iodine-based dye. The next consideration is based on the type of dye. There are ionic and non-ionic iodine dyes. Allergic reactions are almost unheard of with use of a non-ionic dye. For my patients with mild reactions in the past, I will premedicate with a steroid and Benadryl (an antihistamine) and use a non-ionic dye. I have not yet seen any patients have problems using this approach. Still, this does not remove all risk, and you should discuss the alternatives with your own physician.

Another test to consider might be saline sonography using a special material called Albuminex, which will allow the tubes to be visualized easier. The standard saline sonogram does not generally allow the tubes to be seen at all. Yet an another alternative test is laparoscopy. This outpatient surgical procedure involves placing a miniature viewing device and surgical instruments through tiny incisions in the abdominal wall while you are under anesthesia. A colored dye that does not contain iodine is injected through the cervix; the doctor then watches to see it spill out the ends of the fallopian tubes.

A recently developed office-based procedure, vaginal hydrolaparoscopy (VHL), is undergoing clinical studies. VHL enables your physician to evaluate your fallopian tubes by placing a needle-thin telescope through the top of the vagina into the abdomen after injecting local anesthesia. The space behind the uterus is filled with fluid, and the fallopian tubes and ovary float into view. The state of the tubes can be determined by injecting a colored dye (that doesn't contain iodine) through a tube placed into the cervix. The dye is seen exiting the end of the fallopian tube. The doctor can also look for adhesions or endometriosis.

In any case, your physician should first consider whether it is likely that tubal damage or blockage is present. Review of your medical history for pelvic infections, previous pelvic surgery, painful intercourse or painful periods may indicate an increased risk of fallopian tube problems. A blood test for chlamydial antibody may show that you have had a previous chlamydia infection that may have damaged the tubes. If nothing in the laboratory results and review of your medical history suggests the presence of tubal blockage, the likelihood of damage is less than 5 percent, and further testing can be deferred.

Alternatives to Vasectomy Reversal
After my wife and I had the children we wanted, I got a vasectomy. Some years later we divorced. Now my new partner wants us to have children of our own, and I am currently configured otherwise! I've read up on vasectomy reversal, and I am not squeamish about the surgery, but the success rate after 10 years isn't that hot. Plus there are such factors as cost and discomfort. So I'm wondering: Is the amount of sperm retrieved by extraction sufficient for artificial insemination? Or is something more invasive recommended, like IVF? The lady has no fertility problems. Tom

Sperm extraction -- regardless of whether the sperm are obtained from testicular biopsy or aspiration or aspiration from the epididymis -- does not provide sufficient numbers of motile sperm to use for insemination. Other than vasectomy reversal, your choices after vasectomy are insemination with donor sperm; retrieval of sperm and eggs for IVF; sperm-egg injection at the time of IVF (a procedure called ICSI); or adoption.

Am I the Father?
My girlfriend and I are expecting our first child. We've been given a due date of January 28, 1999. I am not 100 percent sure this is my child. Her last period started about April 19 or 20, and she insists that conception was on either April 22 or 26. But when I calculate back from the due date, I get May 7, so I figure conception had to be more like early May, but I can't recall. The problem is that she had a visit with another male friend on May 8 and 9, and I have reason to believe that he thinks the baby is his. I need to know if I am the father, and I can't resolve the conception date to my satisfaction. I don't know the margin of error of any of these methods of calculating things. Can you give me suggestions on sorting this out? Craig

Conception would likely occur about 38 weeks before the expected due date. Ovulation usually occurs two weeks after the start of the previous menstrual period. So, in this case, if her menses are 28 days apart, it is most likely she ovulated around May 2-4.

It is highly unlikely that you are the father if your only sexual activity was a week or less from the start of the previous menses. The best way to resolve this is to request paternity testing and seek legal counseling to protect yourself.

Amniocentesis & Miscarriage Risk
With my first two children, I had normal pregnancies. In my third pregnancy, since I was over 35, we had an amniocentesis. The procedure went "flawlessly," and two weeks later we learned we could expect a "genetically perfect" baby girl. Three days after that, my water broke and I miscarried. My doctor could not tell me why, but he discounted that the amnio was the cause. That was five months ago. Now I am six weeks pregnant. My husband insists that I have another amnio because I will be 38 at delivery. I am worried about another miscarriage. Can an amnio cause a miscarriage more than two weeks after the procedure is performed? Is there an alternative to amnio that poses less risk? Mary

There is a risk of ruptured membranes and pregnancy loss after an amniocentesis. However, this risk is small, and your chance of miscarriage should not be increased this time just because you had a complication that occurred after a previous amniocentesis.

Amniocentesis is commonly performed to check for genetic abnormalities such as Down syndrome. The risk of this genetic condition increases as a woman ages. At age 35, the risk is about one of every 200 pregnancies, while at age 40, the risk rises to as much as one of every 50 to 100 pregnancies. Amniocentesis is performed using an ultrasound examination to pinpoint a pocket of fluid inside the uterus. The physician guides a needle through the abdomen into the pocket and removes some fluid. The fluid is sent for cell culture. After a few days, fetal cells from the culture are analyzed for their chromosomal makeup.

A faster method of analysis, called FISH for "fluorescent in situ hybridization," involves using special dyes targeted to specific chromosomes. Each dye glows a different color under fluorescent lighting. At present, we can only test for four or five different chromosome pairs using this technique. Normal cells have 23 pairs of chromosomes; an abnormal fetus may have an extra chromosome or may be missing one from a pair. Since we can't test all the chromosome pairs using FISH, this method only picks up a portion of the potential chromosomal anomalies that may occur. Luckily, the most common problems are picked up using this screening method. As results from this test can be available within a few hours, FISH is gaining in popularity. A major concern with amniocentesis is that it needs to be performed well into the second trimester of pregnancy. The wait can be quite stressful, and if the test suggests that the fetus is abnormal, the couple faces difficult decisions at a point fairly far along in the pregnancy.

An alternative method, called chorionic villus sampling (CVS), can provide results much earlier, near the end of the first trimester. Using ultrasound guidance, a catheter is placed through the cervix and into the uterus to a spot just below the placenta. A small biopsy is removed by suction and sent for evaluation. Again, both FISH and cell culture and chromosomal analysis can be used. Unfortunately, CVS has a miscarriage rate that is slightly higher than amniocentesis.

I would suggest you meet with a perinatologist who can discuss your concerns regarding potential risks and advise you appropriately.

Anti-Sperm Antibodies
What exactly are anti-sperm antibodies? Is this a female problem, a male problem, or both? Kathy

Anti-sperm antibodies can occur in both men and women. Antibodies are protein molecules that are attracted to a specific site on the sperm. Once attached, they may interfere with the sperm's activity in any of several ways. They may immobilize sperm, cause them to clump together, limit their ability to pass through the cervical mucus, or prevent them from binding to and penetrating the egg. Anti-sperm antibodies are frequently seen in men after vasectomy, testicular injury or infection. The cause of anti-sperm antibodies in the woman is unknown.

Researchers classify specific antibodies by type (IgA, IgG and IgM) as well as the point at which they attach to the sperm (head, midpiece, or tail). Studies indicate that IgG type antibodies are most common in men and that IgA type can be found in women's mucus and follicular fluid, but the significance of these findings is uncertain. Binding to the head is believed to interfere with attachment and penetration of the egg, while tail binding interferes with motility.

Unfortunately, testing and identification of type of antibody or the location does little to suggest who will or won't conceive. Attempts to treat the condition -- say, by lowering antibody levels with steroids or removing the antibodies from sperm -- have demonstrated limited benefit and have been fraught with disastrous complications. A trial of ovulation induction and insemination followed by in vitro fertilization with ICSI (a process that involves injecting a sperm directly into an egg) seems to be the best treatment available.

Antibiotics for Unexplained Infertility?
My husband and I have been trying to get pregnant for over a year and have begun infertility testing. I have read that some doctors are now treating women with antibiotics before trying more expensive and difficult therapies, when there aren't obvious reasons for infertility. We tested positive for ureaplasma and are on antibiotics. Is there a chance that this will help us conceive? J.S.

A course of antibiotics may be advisable. However, it's important to note that there is no credible reproducible evidence to suggest that infection with ureaplasma or some as-yet undefined organism is the major cause of unexplained infertility.

Unexplained infertility is just that -- unexplained. That means many of these couples are not infertile. Rather, they are subfertile, meaning that each month they may have a 3-10 percent chance of conceiving without any treatment or intervention at all. Since studies suggest that chronic undetected infection is a rare cause of infertility, many of these successes that are reported in couples who have undergone antibiotic therapy are probably coincidental. Moreover, existing studies do not support the use of antibiotics as a SINGLE treatment for unexplained infertility. Well designed placebo- controlled trials would be needed to support this approach.

Ureaplasma urealyticum (UU) is a type of organism that is, both in size and character, somewhere between a bacteria and a virus. UU is a fairly common organism that may be found in up to 30 percent of those tested in certain populations. It can be passed sexually, but its presence should not initiate a call to a divorce lawyer, because you can get it in other ways as well. Testing for UU is expensive, and cultures often demonstrate a falsely negative result even if you are infected.

The prevalence of UU in people suffering fertility problems is no greater than in those who have no fertility problems, and treatment does not seem to improve fertility rates. The one case in which treatment may be beneficial is for couples with recurrent pregnancy loss. Here, due to expense and the poor reliability of UU testing, I prefer to routinely treat these couples with a 10-day course of antibiotics. The data are inconclusive, however, and more recent well designed studies have not shown benefit.

On the other hand, frequently our patients have a positive blood antibody response to chlamydia infections, even when a DNA test done from a cervical swab indicates no present infection. The positive blood antibody test means that an infection was present at one time. Most of these women are not aware they ever harbored this infection, which can damage the fallopian tubes. Because chlamydia can be present in the fallopian tubes and not show in the cervical swab tests, I believe that antibiotic treatment may be beneficial to address the possibility of an infection in the tubes. However, the benefits of testing and treatment for infections other than gonorrhea and chlamydia is small or non-existent.

Antidepressants & IVF Treatment
I'm planning an IVF cycle in a couple of months. My concern is that I'm taking an antidepressant (Zoloft 50mg) for PMS. Is it okay to take something like this, or could it cause problems with either the IVF or with a pregnancy? Cathy

While our present knowledge would suggest that it is safe to take Zoloft during the stimulation cycle, we usually advise our patients to discontinue all medications that are not absolutely necessary before starting IVF. Zoloft is cleared from the body quickly, so this should not delay your IVF treatment.

But it is also concerning that you are about to enter into some very stressful times. IVF may not be successful. That can cause stress. If it is successful, then you may worry about a healthy pregnancy outcome. That is stressful (and certainly normal). Then when you have the baby, that is also stressful. With this is mind, I recommend that all my IVF couples meet with a counselor to review strategies for lowering stress. In fact, studies show this can even improve pregnancy rates.

Simple ways to reduce stress can be to ensure you eat a well balanced nutritious diet, get enough sleep and exercise, begin taking a prenatal vitamin with folic acid, and avoid "natural-herbal" approaches, such as St. John's wort, which have been shown to hamper fertility.

Are Blocked & Damaged Tubes Fixable?
I am 40 years old and have been trying to have a baby for six years. I had a laparoscopy about a year ago that showed I have a few things wrong: a blocked tube, endometriosis and a cyst. Plus the fingerlike things that are supposed to help guide the eggs in the right direction are bent the opposite way. My doctor said she didn't want to try and fix them, because it was too delicate an operation and might make things worse. Do I still stand a chance? Can they be fixed? B.D.

Before we could offer any guidance in a case like this, we would need more information. There are many other factors that we would need to consider before proceeding with tubal repair.

To begin with, at age 40, monthly odds of conception are significantly lower than 10 percent for most women -- and that's with all things being optimal; as you described them, they are not. In some women, age has already adversely affected their eggs to the point where egg donation would be required. To determine age-related infertility, we would need to conduct a clomiphene challenge test or a test of day 3 FSH, estradiol and inhibin B. It would also be important to consider the fertility of the woman's partner. You did not mention whether your partner had a semen analysis. He should have this test before you have surgery. Unfortunately, too many physicians will take their patients to surgery before checking the male. If this happened in your case, that should send up a red flag that you are getting infertility care by a less-experienced physician.

You also mention endometriosis. Some research has suggested that the presence of minimal endometriosis will lower your monthly odds of conception by about 30 percent.

Overall surgical success to repair tubes with damaged ends is about 10-50 percent. However, without a video or photo of the ends of your tubes, we would have no idea how best to advise you. Your physician, who did see your tubes, obviously wanted any surgical repair to be performed by a more experienced surgeon. It is unfortunate that too many women enter the operating room expecting to get competent infertility care only to find that they need a second surgery because the first surgeon did not have the skills to deal with the abnormalities he or she found.

Are My Sperm Dead?
I am 25. For quite some time I have noticed that when I ejaculate the sperm level is low and the sperm appear bound and immobile -- that is, they appear dead. I do experience some sort of orgasm, but the intensity varies, sometimes not experiencing it at all. I have not gone to any expert or specialist, because I am not sure about them in my area (I live in India). What could cause this problem? What are your suggestions for tests and further followups? Vinay

You refer to sperm, but it sounds as though you mean semen -- the fluid that comes out when you ejaculate. Semen is a mixture of seminal plasma (liquid) and sperm cells.

Sperm cells are too small for you to see with the naked eye. There is no way you can make any reasonable determination of sperm quantity, quality or motion without a semen analysis. That is done in a laboratory setting, using a microscope. If you are concerned about your fertility, ask your doctor for a semen analysis.

Asherman's Syndrome
Please tell me about Asherman's Syndrome. Can one give birth after having the condition? What does treatment involve? Nina

Asherman's syndrome is scarring inside the uterus that creates intrauterine adhesions -- fibrous bands that form between the walls of the uterine cavity. This scarring is believed to result from aggressive scraping of the uterus in the presence of infection or when an infection occurs after a D&C. It can also occur after surgery inside the uterus, such as the removal of fibroid tumors or polyps. The adhesions form as raw or infected surfaces heal.

As the adhesions fill the uterus, sometimes blocking the cervical opening, menstrual flow can diminish or stop altogether. Thus, Asherman's syndrome is suspected if you have a D&C or other uterine surgery and then your periods are very light or they stop. The condition can be very mild, or it can be severe and irreversibly damage the uterine cavity.

The condition can be diagnosed by an X-ray of the uterus called a hysterosalpingogram (HSG), as long as this X-ray is performed by a method that uses a small tube placed just inside the cervix. Unfortunately, HSGs are now usually performed by placing a small balloon catheter into the uterus. This technique is quick and easy to do and is excellent for evaluating the fallopian tubes, but it can miss Asherman's syndrome. At GRS, we have come to prefer a procedure called saline hysterosonography, which uses ultrasound. We check to make sure you are not pregnant and then place a tiny catheter into your cervix. Saline fluid (salt water) is injected into the uterus and the ultrasound is repeated. This technique can show the intrauterine adhesions quite well. The gold standard for diagnosis, however, is hysteroscopy, which involves placing a small viewing device into the uterus to see the inside.

It is amazing that each year we have better and smaller instruments to treat intrauterine problems. With modern instruments, many of these procedures can be performed in the office with minimal discomfort, using only a pain pill before beginning. For those women with minimal scarring, surgery to remove the adhesions can often be completed in the same setting. For more severe cases in which the margins of the hollow uterine cavity cannot easily be determined, ultrasound or laparoscopy (in which the viewing device is inserted through a small cut in the abdomen) may be used to accurately locate the limits of the uterine cavity.

Success rates are above 85 percent when adhesions are minimal. However, if scar tissue has replaced most of the uterine cavity, there is little hope of restoring normal uterine function.

Assessing & Treating Prolactinoma
My girlfriend was diagnosed with a prolactinoma a year ago but was not given any treatment. The endocrinologist just recommended a yearly MRI to track its progression. In the past six months she has been complaining of headaches and visual disturbances. I have a few questions. First, will Bromocriptine, if prescribed, make a difference in her symptoms (galactorrhea, visual disturbances, headaches, loss of libido)? Second, is the surgery, if prescribed, routine? And most of all, will she be able to bear children? S.G.

Prolactin is a hormone produced in both males and females by the pituitary gland. Its major role is to stimulate milk production for the lactating (breastfeeding) female. Other roles for this hormone are less clear. Various factors can cause an increase in prolactin levels, including medications, stress and even breast examinations.

A prolactinoma is a tumor of the pituitary gland that produces an excess of prolactin. The most common prolactin-producing tumor is the microadenoma, which is quite small. The resulting side effects -- such as inappropriate milk production (galactorrhea) and loss of libido -- are due to elevation of blood prolactin levels, not to the presence of the tumor itself. Larger tumors (over about one centimeter) are called macroadenomas and are quite rare. These larger tumors are benign (noncancerous), but their presence can cause headache and visual disturbances.

We all get concerned when we hear the word "tumor," and it is scary to think there is a tumor at the base of the brain. But let me reassure you: Pituitary tumors are found in up to 7 percent of autopsies performed on people dying in accidents, so this condition is not all that rare. Frequently an abnormal prolactin elevation is detected as part of a infertility evaluation or in women with decreased libido or irregular menses. In males, impotence is the most common symptom that leads to the identification of high prolactin levels.

Once blood tests detect a prolactin elevation, a magnetic resonance imaging study (MRI) can be performed to look for a tumor. Most tumors, even the large ones, regress when treated with medical therapy. Surgery is reserved for the rare case that does not respond to medication. Pregnancy rates and outcomes are excellent once the prolactin level is normalized. For women without symptoms, many physicians opt to avoid treatment altogether; annual MRIs allow the physician to monitor the tumor and initiate treatment if enlargement is evident.

Assisted Hatching
My fertility doctor has really got me puzzled. The first attempt at IVF failed. Now he's told me of a procedure that involves cutting a slit in the egg. Why didn't he do all he could do the first time? Carrie

"Assisted hatching" (AH) is a procedure that involves creating a small hole in the zona pellucida, a shell-like protein investiture surrounding the fertilized egg. On or around the fifth day, the zona pellucida "hatches" and the embryo, now called a blastocyst, is ready to implant. Studies have suggested that a certain subgroup of IVF patients stand a better chance of success with the procedure. This includes patients having culture in a laboratory setting, high doses of ovulation medication, advanced age, higher FSH levels, thick zona and previous IVF failures.

Studies have shown, however, that AH is of no benefit when performed on every embryo. In fact, the procedure is time consuming, adds to the cost of IVF and may in fact damage healthy embryos. So, avoiding this on the first go-around is the normal policy unless factors would indicate you would likely benefit. More information about assisted hatching is available on the current research section of our website.

Autoimmune Disorders & Fertility
I have an autoimmune disorder that, over the last 10 years, has caused problems with my thyroid, liver, heart, blood platelets, etc. I have recently started worrying about how this would affect my ability to get pregnant and carry a child full-term. Do you have any thoughts on this? K.

Autoimmune diseases result from inappropriate production of antibodies that attack normal organs and tissue such as the thyroid, parathyroid, pancreas, ovary, joints, platelets and the placenta. They can also attack blood vessels and cause inflammation of veins and arteries, which can lead to inappropriate blood clotting (thrombosis). Lupus, idiopathic thrombocytopenia, and Graves' disease (a form of thyroid disorder) are just a few of the more common autoimmune conditions. No one is certain why these conditions develop, nor is there an obvious cure. Newer antiinflammatory agents can help suppress the immune system's attack and the resulting symptoms. If a hormone-producing organ is damaged, replacement hormones may be necessary; this is the case with diabetes (treated with supplements of insulin) or hypothyroidism (treated with thyroid hormone).

Antiphospholipid syndrome is often diagnosed in women with abnormal antibodies to blood-vessel wall components such as cardiolipin, serine and ethanolamine who experience an episode of abnormal clotting. This can involve thrombophlebitis (clotted vein) in an extremity, mid-trimester placental infarction (loss of circulation to the placenta and fetal death), or pulmonary embolus (a blood clot in one of the pulmonary vessels).

The role these antibodies play in early recurrent pregnancy loss or infertility is unclear and the data are often conflicting. Still, many physicians will check the immune system for the antiphospholipid antibodies listed in the previous paragraph. They may also test for lupus anticoagulant (if this is present, you are actually at increased risk of abnormal clotting). If any of these are present, physicians may choose to treat with a combination of low-dose baby aspirin and twice-daily heparin injections to prevent abnormal clotting. This therapy is not without risks, and you need to have a detailed discussion with your physician of your own situation, the likely benefit and associated risks.

ANA is often measured to rule out lupus, but the data do not support the use of this test or its many subtests (ssDNA, dsDNA, histones) as having any value in the diagnosis or treatment of infertility. The presence of thyroid antibodies does not directly result in infertility or pregnancy loss. However, if these antibodies have damaged the thyroid and a low thyroid hormone level is present, your fertility may be hampered. In addition, women with a propensity to make one inappropriate antibody, may in fact make others.

While the presence of inappropriate antibodies may not directly affect your chances of pregnancy or result in miscarriage, it is best to make sure "all systems are go" and that you are in the best health possible before attempting pregnancy.

Avandia for PCOS
Do you have any PCOS patients on Avandia? Do you think this is a good treatment for someone who took metformin but couldn't continue because of severe side effects? Melinda

The use of insulin-sensitizing or insulin-lowering medications offers new hope to women with PCOS. Metformin can regulate menstrual cycles, reduce hypoglycemic episodes, bring about weight loss and often result in pregnancy where traditional ovulation treatment had failed or was associated with severe complications. By six months of therapy, studies have shown that up to 90 percent of women treated with metformin 850mg twice daily will have ovulatory menstrual cycles. Unfortunately, 25 percent of women will not be able to tolerate the gastrointestinal side effects of this medication.

Avandia (rosiglitazone) and Actos (pioglitazone) reduce insulin resistance. This means that the body will require less insulin to control blood sugar. Previous studies have shown that Rezulin (troglitazone) is an effective tool to manage insulin resistance associated with PCOS. However, Rezulin has been associated with deaths due to liver failure, and should no longer be considered a good choice for treating this condition. Rezulin is no longer available in USA. Avandia and Actos, like Rezulin, stimulate the PPAR gamma receptor. Although these newer medications have not been shown to cause liver damage, the FDA recommends checking ALT levels (a liver function test) every other month to avoid potential problems should they be discovered in the future.

Avoiding a Third Miscarriage
I have had two miscarriages, one at 14 weeks and another one at seven weeks. Both times, there was no indication something was wrong -- I went in for an appointment and there was no heartbeat. Is there anything I can do at this point to try to make sure that this doesn't happen again? Heather

It is important for you to complete an evaluation for recurrent pregnancy loss. This should include evaluation for age-related infertility issues, hormonal abnormalities, uterine malformations, chromosomal abnormalities, immune problems, infection and blood-clotting abnormalities that predispose to clots. A thorough medical history, review of your family history, and physical exam are necessary to determine which tests are most likely to reveal the cause of your problem.

Much of this testing is expensive. Testing is not always covered by your insurance company, so it is important to visit with a physician who has expertise in this area to help you best individualize your care plan.

Avoiding Sickle-Cell Anemia
My girlfriend and I both have sickle-cell trait in our blood. Is there any way to ensure that our children will not have sickle-cell anemia? Khalid

Sickle-cell anemia is a condition affecting a small percentage of African-Americans that results in painful, life-threatening blood clotting and infections. The red blood cells have an abnormal oxygen-carrying hemoglobin molecule that can cause the cell to change from its normal disc shape to a sickle shape that can get trapped in small blood vessels.

An individual with sickle-cell disease has two abnormal hemoglobin-S genes -- one from each parent. Individuals who do not have the disease but have one abnormal hemoglobin-S gene are said to have sickle-cell trait. This can be checked with a simple blood test. If both parents have sickle-cell trait, there is a 50 percent that an egg will carry the abnormal gene and a 50 percent chance that a sperm will carry the abnormal gene. This equates to a 25 percent chance that the resulting child will have sickle-cell anemia.

Genetic tests offer opportunities to diagnose this condition after conception. For couples using in vitro fertilization (IVF), an embryo biopsy can be performed before transferring the embryo into the mother's uterus. Parents may then choose not to transfer embryos affected with sickle-cell. Other couples may choose to conceive normally and undergo chorionic villus sampling, a small biopsy taken from the placenta at about 9 - 10 weeks of pregnancy. The cells can be checked and a diagnosis made in two to three days. Parents may then consider elective pregnancy termination if the fetus is affected.

In other words, if you use your own eggs and sperm, the only certain way to avoid having an affected child is either by using IVF or having an abortion when an affected child is diagnosed during pregnancy. However, using a sperm or egg donor without sickle-cell trait can eliminate this risk.

Baby Aspirin in IVF
Why do doctors prescribe baby aspirin in the early stages of IVF treatment? What is the benefit, and what are the risks? C.

Baby aspirin is often prescribed for women undergoing IVF. Although early studies seem to suggest a benefit to its use, these studies have not yet been confirmed in larger, well-designed trials.

One common use is for women with recurrent pregnancy loss. One possible cause of pregnancy loss involves immune-system abnormalities; in particular, the body may develop antibodies to components of the blood-vessel wall called phospholipids. We don't really know why the body makes these antibodies, but they can block blood flow through small blood vessels in the placenta. Some physicians have suggested that these antibodies may also interfere with the embryo's attachment to the uterine wall.

In such a case, baby aspirin may help keep placental blood vessels open. It is already frequently prescribed for this purpose much later in pregnancy, for women with preeclampsia -- a pregnancy disorder associated with high blood pressure and protein in the urine. It is thought that this condition occurs when the blood vessels constrict too much because of an imbalance between two compounds in the body -- one that causes blood vessels to constrict, and another that causes blood vessels to dilate. The use of a single baby aspirin daily blocks the vascular-constricting compound, while not interfering with the compound that promotes placental blood flow. It is important to note that while a single baby aspirin gets the job done, in this case, more is not better. Taking a higher dose of aspirin or ibuprofen product can block both of the compounds, so these medicines should be avoided. In addition to maintaining normal blood vessel dilation in early pregnancy, baby aspirin may also block clumping of blood platelets in the smaller blood vessels in the placenta. Normally these platelet clumps function to repair small tears or breaks in blood vessels. But for unknown reasons, excessive clumping may occur, resulting in decreased placental blood flow.

So, if you have had recurrent pregnancy loss, your doctor may recommend the use of both heparin injection twice daily and one baby aspirin daily along with your IVF cycle, to help keep open the blood vessels in the placenta. While many physicians have suggested a possible benefit from heparin injections and aspirin for all women undergoing IVF when antiphospholipids are present, several recent studies have failed to find a benefit with this treatment.

Another possible reason to use baby aspirin is even more theoretical. Study findings presented at a recent IVF meeting in Vancouver, Canada, addressed the question of why some healthy-appearing eggs make embryos that implant and continue to term, while others do not. Data from this study suggest that one important factor is the blood flow to the ovarian follicles in which the eggs develop. Such factors as age and the presence of PCOS may lower the blood flow to the follicles. Some researchers have theorized that just as baby aspirin can improve blood flow to the placenta, it may also improve blood flow to the ovary, giving us healthier eggs and embryos.

Have these benefits been proven? No. Is this safe? We believe so, if the aspirin is stopped by 36 weeks of pregnancy. When baby aspirin is taken before that point, the risk of it causing abnormal bleeding for mother or baby is quite low.

Back Pain from Endometriosis
I'm wondering if endometriosis could explain my back pain. I have had back pain for at least 15 years, and it is always just before my period. It has been getting worse over the last two years. Lately I've had severe pain in the lower back, sometimes up to 10 days before my period is due. The pain is sciatic, and was so bad this month that I was crying from the pain and dragging my leg, as it was too painful to lift it. Usually the pain is gone by the second day of my period. My periods only last four to six days and are heavy the first two days only. Could this be a sign of endometriosis? If so, exactly how does endometriosis cause back pain? How can I find out if that's what's happening with me, and is there anything that can be done? J.R.

Endometriosis is one of the most frequently misdiagnosed medical conditions. The confusion arises because endometriosis is a masked villain and can cause symptoms involving the bowel, bladder, lungs or musculoskeletal systems. In fact, the wide variety of initial symptoms means that women with this problem, on average, suffer nine years of delay in diagnosis and visit more than four physicians.

While the most frequent complaint of endometriosis is pelvic pain preceding the period, low back pain radiating into the buttock and upper thigh is not all that uncommon. Studies have shown that endometriosis can directly invade the sciatic nerve (which serves the leg) and also that general pelvic inflammation and muscle spasm due to endometriosis may cause sciatic-related pain.

The best way to diagnose endometriosis is with a surgical procedure called laparoscopy, which involves inserting a miniature viewing device and other instruments through tiny slits in the abdomen. This enables the doctor to look directly at the internal organs. But we don't want to run to surgery for each episode of pelvic pain. So some preliminary steps ought to be considered.

First, your doctor should carry out a comprehensive medical history and thorough physical examination. You should also consult with an orthopedic physician to rule out musculoskeletal causes of your symptoms. The next step would be a trial of medical therapy. A combination of birth control pills and non-steroidal anti-inflammatory medications -- such as ibuprofen (Advil, Motrin) or one of the newer more potent ibuprofen replacements such as rofecoxib (Vioxx) or celecoxib (Celebrex) -- may offer relief. Some physicians prefer to consider a course of a GnRH-agonist such as Lupron for a period of three or four months before considering surgery.

If you experience considerable improvement from medication, then you may wish to simply continue this treatment and avoid surgery. Your physician may have experience using Lupron for more than the recommended maximum of six months when it is combined with hormone replacement therapy. This novel approach, called add-back therapy, provides the benefits of Lupron therapy but prevents the nuisance and discomfort of Lupron-related side effects. If, after three or four months, medication does not provide significant relief of pain, a laparoscopy is the best way to determine whether endometriosis is involved in your case. Please be certain your physician is a skilled endometriosis surgeon who recommends a preoperative bowel preparation and is experienced in surgically removing all the endometriosis encountered rather than simply burning it away with electrocautery or laser.

Basal Temperature Monitor
I am looking for a small hand-held computer that reads basal temperature. I read of one such product, called "Rabbit," but it doesn't seem to be available anymore (at least, the number to call for it is now disconnected). Do you know where I can get this type of item? My husband and I are trying to get pregnant, and this sounds like it would be a great help. Annette

Hand-held computers that monitor basal body temperature (BBT) simplify the process, but they are not effective at indicating the appropriate time to schedule intercourse. Charting your BBT involves taking your temperature each morning before you get out of bed. Around the time of ovulation, the temperature rises about one half of a degree F. Usually the temperature will rise above 98 after ovulation. Unfortunately, there is little relationship between any dips in temperature before presumed ovulation and the actual time of ovulation. This means that by using BBTs, you can look back at the end of the month to see if you have ovulated. But it is just not helpful to indicate when you WILL ovulate.

If you are concerned about timing intercourse for intrauterine insemination, you should consider using a urine LH test. This involves placing a few drops of a morning urine sample on the test stick; a change in color indicates that you will likely ovulate the next day. In general, these tests are thought to be about 85 percent accurate. Several different test kits are available for less than $30 for about a week's worth of tests.

Bent / Curved Penis
After years of being normal, at age 42, my penis took a bend of about a 45-degree angle halfway down. What might cause this, and can it be returned to normal? Lee

Peyronie's disease is often the cause of painful erections, difficulty achieving or maintaining erections and curvature of the penis with erections. Peyronie's is described as an inflammation of the blood-filled corpora cavernosa (penile erector sets). Patients can often feel a firm plaque at the site of the bend in the penile shaft. Connective tissue disorders such as Dupuytren's contracture, trauma to the penile shaft, and infection have been thought to cause this condition.

While sometimes the condition resolves by itself, surgery may be necessary to remove the scar-like plaques that interfere with the normal blood-filling of the corpora cavernosa at the time of arousal and erection. Following surgery, a penile prosthesis may be necessary to achieve satisfactory intercourse. Other treatments have been tried, but with limited success.


Bicornuate Uterus
I recently had an ultrasound that seems to show a division in my uterus. I read your information on Uterine Septum, but what can you tell me about bicornuate uterus? What kind of fertility problems should I expect? Are there treatments? Lori

As you read in my column on Uterine Septum, certain physical abnormalities can occur when the uterus is formed, before birth. At that time, the uterus develops from two primordial bands of tissue called the Mullerian ducts, which fuse together and are then hollowed out to form a single hollow muscular organ. Bicornuate uterus, commonly referred to as a heart-shaped uterus, occurs when these two embryonic tissue cords do not fuse completely.

Studies looking at the effect of bicornuate uterus indicate that pregnancy complications do not always occur with this condition; findings suggest that 65-85 percent of women known to have bicornuate uterus have no pregnancy problems. Still, while malformations and other uterine abnormalities can contribute to up to 15 percent of cases with recurrent pregnancy loss, women with normal pregnancy outcomes are rarely screened for this condition. So we don't know the frequency of the condition in women with no pregnancy problems.

The most common problem associated with bicornuate uterus is premature labor or incompetent cervix (premature dilation of the cervix). Your physician may consider placing a stitch in the cervix to prevent recurrence of the latter complication. Often the condition becomes less an issue in subsequent pregnancies. For instance, if you delivered at 30 weeks gestation in your first pregnancy, you will likely be able to carry the pregnancy longer in a second pregnancy.

While bicornuate uterus can be corrected with metroplasty (a procedure to join the two uterine halves), this requires open-abdominal surgery, which can weaken the uterus and result in pelvic adhesions that in themselves can reduce the odds of pregnancy. If a woman becomes pregnant after metroplasty, a cesarean section would be necessary for delivering a fetus as soon as it develops mature lungs. Because of these concerns, surgery is rarely recommended.

Birth Control Injections for Men
I am a 36-year-old man, and I am interested in testosterone enanthate injections as a means of birth control. Is it effective? What sort of doctor should I see to try this? Frank

Testosterone injections for contraception are not an approved option in the United States. The potential for side effects, such as blood lipid problems and mood changes, has not been determined, and long-term safety issues have not been addressed.

You might contact the Population Council to determine if you could participate in any ongoing trials. A course of shots over a few months is necessary for this method to begin to lower the sperm count. Semen analysis is required to monitor effectiveness of the therapy.

Birth Control Pill for Endometriosis
I've heard that birth control pills can clear up endometriosis. Is this true? How long would it take to clear up a case of moderate-to-severe endometriosis? M.G.

One should not look at any therapy as a "cure" for endometriosis. A more realistic goal is to focus on the symptoms and how they can be controlled or eliminated. Like diabetes and high blood pressure, endometriosis is a chronic disease. The disease has a genetic and an immunologic component. Until our therapy can address an individual's genetic makeup or address specific immune abnormalities that are seen with endometriosis, we achieve the best results by listening to the patient's symptoms and offering various treatment options that may directly address those complaints.

Traditional treatment has often involved surgery, hormonal manipulation, or both. Hormonal therapy that attempts to mimic either menopause or pregnancy can often provide relief of symptoms. For instance, drugs like danazol (Danocrine) and GnRH-agonists (Lupron, Zoladex, Synarel) work by creating a low- estrogen menopause-like environment in which the endometriosis becomes dormant. Similarly, administration of continuous estrogen and progesterone with birth control pills to mimic pregnancy may relieve symptoms. This seems to be quite effective for many women.

Once you begin after therapy with continuous birth control pills, there is often a period of time during which the pain may intensify. Many women also find they are unable to tolerate continuous use of the pill due to headache, depression, bloating or breast tenderness. For those who do stay on the pills for a few months, however, the pain often responds. Unfortunately, once you stop taking the pills, the pain and endometriosis return rather rapidly.

Research studies have shown that while birth control pills are often effective for endometriosis on the surface of the peritoneal membrane lining the abdominal cavity, they are much less effective dealing with endometriosis of the cul-de-sac (the space between the rectum and the vagina). Painful intercourse is less likely to respond to birth control pills than to a GnRH-agonist treatment.

Bleeding during Pregnancy
Is it possible to menstruate during pregnancy? If there are other types of bleeding that can go on during pregnancy, how can you tell what it is? Ginny

You can have bleeding during pregnancy. Technically it is not menstruation, which is bleeding due to the drop in estrogen and progesterone that occurs as the ovary stops making these hormones 14 days after ovulation. During early pregnancy, hCG hormone stimulates the ovary that released the egg to continue producing progesterone, which supports the early placenta. As the placenta develops, it too begins to produce progesterone. Since progesterone levels do not drop, you do not have a period.

However, bleeding can occur from such causes as ectopic pregnancy, partial placental separation, implantation and ingrowth of the placental attachments, infections or miscarriage. A series of hCG levels two to three days apart, as well as transvaginal ultrasound evaluations, can help your doctor determine the cause of abnormal early bleeding.

Blockage in One Tube
I've been trying to conceive for the last two years. Last week I went for an HSG, and the results show my uterus and left fallopian tube are fine, but there is blockage on my right fallopian tube. My GYN says there is no way they can do any surgery on the blocked tube. Now I have only one good tube and my chances of conceiving are naturally very low. He suggested that I go for IVF. I'm not ready for that. It is costly, and I'm only 27. Is there other alternative beside IVF for me, or am I left with no other choices? N.

If the one remaining tube is normal, your ultimate chances of conception are not lowered, although it may take you a bit longer to conceive. There are a few exceptions. If you have had a bad pelvic infection, you may have scarring in the remaining tube that went undetected by ultrasound. Or, if the bad tube is blocked and remains filled with fluid (a condition called hydrosalpinx) you may have a reduced chance of conception and a higher risk of miscarriage. Studies looking at IVF patients suggest that surgical removal of a fluid-filled blocked fallopian tube can improve IVF outcome.

If I were treating you, I would need to see the HSG films to determine why your doctor states that the tube is irreparable and whether the open tube is also damaged. But with one "good tube," your chances should remain normal on the months you ovulate from that side. In fact, many of my patients have benefited from a few months of therapy with clomiphene (Clomid, Serophene) to promote the development of eggs from both ovaries each month.

Common causes of a blocked tube include infection, endometriosis or prior pelvic surgery. Unfortunately, most cases where infection was the culprit are diagnosed after the fact. A blood test for chlamydia IgG antibody will determine whether you have been exposed to this sexually transmitted infection.

Blockage Where Tubes Join Uterus
In your experience, how much does it improve a woman's chances for pregnancy if she has both of her fallopian tubes unblocked at the junction of the uterus? There are no other problems. The doctor said that the blockage was due to dried mucus and debris accumulated over time. She said that my tubes look healthy from the outside and the inside. Jennifer

Proximal tubal obstruction (PTO) is often diagnosed when a hysterosalpingogram (HSG) is performed to check the condition of the fallopian tubes. The HSG, an X-ray procedure, tracks movement of a fluid through the uterus and fallopian tubes to see whether the passage through the tube is clear, meaning the egg has a clear path to the uterus. An obstruction that occurs where the tube joins the uterus is called proximal obstruction.

Whether blockage is actually the problem is another issue. If you have a lot of pain during the HSG, you may be experiencing spasm of the tubal ostium (opening), which can falsely suggest there is a tubal problem. As spasm is not really tubal blockage, this finding would not be a cause for infertility. If the HSG is performed too late in your cycle, after about day 10 (counting the first day of your period as day 1), the obstruction may be the result of a thickened uterine lining that is temporarily blocking the tubal opening. In some cases, dried mucus or debris consisting of dead cells from the uterine lining may indeed be blocking the opening.

A handful of studies have shown that the process of the HSG test itself may sometimes help unclog this sort of blockage and enhance fertility. A more direct treatment of PTO involves passing a thin wire through the cervix and uterus and into the tube to dislodge the debris. This procedure, called fallopian tube recanalization, can be done as an outpatient procedure either in the radiology department or in the operating room using laparoscopy (a surgical approach that involves inserting miniature instruments through tiny slits in the abdomen). Often surgeons prefer the latter procedure because the tubes may be blocked at both ends, and laparoscopy can help us check out both ends.

If the tube appears blocked both at the uterus and at the ovarian end, repair is futile and in vitro fertilization (IVF) would be the more appropriate fertility approach. If we find that the ovarian end of the fallopian tube is normal, then we can proceed to try to open the uterine end. A recanalization procedure opens at least one tube in up to 85 percent of patients. About one-third of those patients go on to conceive. If a patient does not become pregnant in six months, she should have another HSG, as sometimes a previously blocked tube becomes blocked again.

Both Tubes are Blocked
Last month I went for an HSG and discovered that both tubes are blocked. My OB/GYN is suggesting I go for IVF. He said he would not advise me to have tubal surgery because of the high rate of ectopic pregnancy. My husband and I do not want IVF. Does this mean these tubes cannot be blown open? Is IVF the only chance I have to get pregnant? E.E.

The hysterosalpingogram (HSG) is a test to see if the fallopian tubes are open. They can be blocked at the uterus, at the midportion or at the fine, flowerlike fimbriated ends.

In some cases, the HSG test itself may enhance fertility by opening tubes that may be clogged by debris or mucus. Still, whenever patients suggest "blowing the tubes open," we picture physicians standing in a bunker and pushing a TNT plunger hoping an explosion will correct the problem. The fallopian tubes cannot really be "blown open." They are delicate structures that must function normally in all regards. They are more than a conduit to allow the sperm and egg to meet; they provide the chemicals and nutrients necessary to nourish the fertilized egg during its first few days of life. If the blockage occurs where the fallopian tube joins the uterus, a procedure called fallopian tube recanalization can often clear that blockage. However, when the blockage is at the end of the fallopian tubes, surgery can often create a new opening, but this does little to restore normal function. The result is quite often an ectopic pregnancy or a recurrence of the tubal blockage. Success rates following tubal surgery to correct a blocked and dilated fallopian tube are often less than 10 percent, with a 15-25 percent risk of an ectopic pregnancy. In this situation, IVF is certainly the safest option (because ectopic risk is much lower) and the most cost-effective (because success rates are higher).

Unfortunately, many insurance companies do not yet understand the benefits of IVF. Nor do they recognize that success rates have improved, making IVF a cost savings when compared with repeated surgical attempts to restore fertility. The shortsightedness of the insurance industry has lead many women to undergo repeated surgical procedures that offer little hope of success. While we cannot address your last question regarding what choices you have without a more thorough evaluation, if your only fertility factor is blocked fallopian tubes, IVF would certainly appear to offer the greatest chance for success.

Bowel Medication & Sperm
If a man has a low sperm count as a side effect of taking a prescription medication, is there an increased possibility that the remaining sperm would be defective or more likely to create genetic or birth defects if conception were to occur? The drug in this case is Azulfidine. Kim

Azulfidine (sulfasalazine) is typically used to treat inflammatory bowel disease (ulcerative colitis). As you know, Azulfidine treatment can lower sperm count; it can also affect sperm motility (movement) and morphology (shape).

One study of men with inflammatory bowel disease suggests that while there was no overall increase in birth defects in the offspring of men who had the disease, the risk of abnormality was higher in the smaller subgroup who were treated with Azulfidine. Unfortunately, we do not yet have a clear answer as to why this occurred. Was the outcome worse in this subset because their disease was more severe and required more intensive therapy? Or did the men who were treated with other medications gain some protection against birth defects as a result of those drugs?

We still have a lot to learn before our team can advise you with confidence. But there is hope. One study looking at the effects of a newer enteric-coated version of Azulfidine found it did not adversely affect sperm production.

Bypassing the One-Year Rule
I'm 27 years old and trying to conceive a child. I have had two abortions and one miscarriage. I am now married and want a baby desperately. I have been trying to conceive for about six months now. My doctor tells me it's too early for him to do tests on me. He says I have to try for a year before I can start taking tests and trying other procedures. I am going crazy. My husband wants to me to go to another doctor and lie and tell them that I've been trying for over a year so they can give me drugs or something. What do you think? Carmen

We would not recommend lying to your doctor. You have no reason to trust your physician if you are not willing to be honest yourself. Providing misleading information is not only stupid, it is also potentially harmful to your health. Fertility pills are not the one-size-fits-all approach to solving fertility problems that many couples think they are. In fact, studies have repeatedly shown that a "thoughtless" attack on infertility by throwing some fertility pills at your problem may not only interfere with your ability to conceive, but may also delay a more thoughtful approach that ultimately leads to your success. For more information on why it's reasonable to wait a year before seeking help at your age, see my column on How Long to "Try"?

If you came to our center lying about your medical history out of desperation after only a few months, first we would hope that as you learned more about what it takes to conceive, you would be willing to be a bit more patient. Your "going crazy" and your husband's desire to lie are more worrisome. Such responses to the problem of infertility are not very positive. Before you proceed much further, we would recommend you meet with a trained psychologist or counselor to address your stress and develop more appropriate tools for communication.

Misinsemination FAQ
I've heard about cases where the sperm from a patient other than the husband was accidentally used to inseminate a woman instead of using her husband's sperm. How does your practice prevent "misinseminations"?

The staff at Georgia Reproductive Specialists is meticulous with our insemination and fertilization procedures to ensure that a "misinsemination" never happens. In fact, many of the procedures used by our laboratory staff to identify and label sperm and egg specimens are seen as the "gold standard" and have been implemented in clinics around the world. Each instrument used during a cycle to house eggs or sperm specimen has the patient's first and last name etched into the surface of the glass so there is no chance of the name being removed from the container. In an IVF cycle, each couple is given their own shelf in an incubator to keep their embryos separate from the other embryos used by couples going through the same cycle and there is never a time in the laboratory when more than one couples' specimens are out of the incubator. All IUI and IVF procedures are done one case at a time and all name labels are checked and rechecked by at least two embryologists or andrologists before any action is taken.