Dr. John Jain

Perhaps the most important female fertility factor is the egg factor, by the time a woman starts menstruating about age thirteen she has half a million egg follicles left in her ovaries. Now an egg follicle is a sac that holds one egg. Every month she is going to release a batch of these egg follicles […] only one of those egg follicles will ultimately grow each month and ovulate and the rest will die. But every month women lose eggs. And with time they run out of eggs and that’s called Menopause.

By the time a woman is thirty she loses ninety percent of her eggs by the time she is forty she loses ninety-seven percent. One thing we test for is called Ovarian reserve, that is how many eggs are left and unfortunately patients and some doctors don’t really know what this means. Ovarian reserve is used by fertility doctors to determine if a woman has low ovarian reserve because those patients make less eggs, therefore they have a lower chance of pregnancy with fertility treatment…the ovarian reserve can be tested in a variety of ways. The best way is to perform an ultrasound when that woman is on her period and count the resting egg follicles in the ovaries.

Other tests for ovarian reserve include blood test for the hormone Anti-Mullerian hormone or AMH and follicle stimulating hormone that’s FSH and estradiol. Overall the key message for ovarian reserve is it’s needed by fertility doctors to counsel women on the chance of success for fertility treatment.

What’s really important is called egg quality that’s different than ovarian reserve. Egg quality basically means the following: the ability of an egg to create a chromosomally normal embryo. Poor eggs create embryos with abnormal chromosomal make up and good eggs create embryos with normal chromosomal makeup. Egg quality impacts the chance of a healthy baby and it is very much age dependent. Women who are in their forties especially have the lowest egg quality and actually by the age of forty-five its very rare to find any quality eggs and pregnancy rates essentially go to zero.

First recommendation I have to couples trying to conceive is to have sex at the right time of the month, the egg only lives one day so having intercourse for the one or two days before ovulation and the day of ovulation is critical for conception. To help women determine when they are ovulating we use ovulation detection kits. When we see women who don’t have regular menstrual cycles it means they are not ovulating […] and reasons for not ovulating could be things such as thyroid problems, excess production of a hormone called prolactin, a medical condition called polycystic ovarian syndrome or just stress weight changes, a lot travel.

We can obtain blood to test for some of these hormones and of course do an ultra sound to look at the ovaries for polycystic ovarian syndrome. So these are simple tests that should be done on women who are not having monthly periods. Sexually transmitted diseases such as Chlamydia and Gonorrhea but not HPV or herpes, can lead to fallopian tube damage and that can be a very significant form of infertility, that requires in-vitro fertilization or surgery to fix.

There are some other conditions that cause fallopian tube blockage, such as pelvic surgery and also endometriosis […] fallopian tube openness or patency can be determined by a test using dye in which we put dye through the uterus and fallopian tubes and take x-ray pictures. One of the most devastating conditions we see is recurrent pregnancy loss, that’s where women are able to conceive and carry the pregnancy until eight or ten weeks and then lose the pregnancy over and over again.bOne of the reasons for recurring pregnancy loss is uterine cavity abnormality such as fibroids, muscle tumors, polyps which are little growth, scar tissue or birth defects that that woman was born with in her uterus. Fortunately we can treat a lot of those uterine factors as it relates to recurrent pregnancy loss using surgical modalities.

One of the most frustrating diagnosis that we give to patients is something called unexplained infertility. This is a diagnosis that is assigned when the semen analysis is normal for the male partner, a woman is ovulating, her uterus and tubes are normal, she is at an age that should have quality eggs but yet they are unable to conceive. Oftentimes couples with unexplained infertility have to consider in-vitro fertilization which takes over each of nature’s steps and tries to fix them and augment the chance of success. Couples who fail to get pregnant sometimes think that they are allergic to each other, there is a mismatch. We don’t believe that actually exists and the reason for that is when we do in-vitro fertilization and put the sperm into the egg almost in all cases we get an embryos and in many cases we get pregnancies.

In general, infertility is due to male factors one third of the time, female factors one third of the time and both one third of the time, so men really represent half of overall infertility cases. When we check for male infertility we look at the semen analysis, and that comprises sperm count, motility – that’s how they are swimming and how they are shaped that’s called morphology. If a man has a normal semen analysis, he is probably fertile, but not in all cases. My advice to most men is to live a healthy life meaning eat a normal diet, stay within ideal body weight be moderate in alcohol intake, not smoke and not surround the genital area with prolonged heat exposure such as long distance bike riding.

The use of a male formula vitamin with high amounts of anti-oxidants are also very helpful in maintaining sperm health. One of the biggest no-no’s though is testosterone. Testosterone is basically a contraceptive, if a man takes testosterone he is wiping out his sperm and unfortunately that’s not commonly known. All men with a significantly abnormal semen analysis really should have an evaluation by a urologist to make sure they don’t have other health issues that need to be treated. Some of those causes can be quite serious such as genetic problems, tumors, endocrinal hormonal problems.

For men who have moderate abnormalities on their semen analysis we can improve their chances by doing intra-uterine inseminations called IUI also known as artificial insemination. We basically take the semen and wash it and get the best swimmers the A team out and then we introduce those swimmers into the partner’s uterus using a soft guide at the right time of the month.

When men have very severe semen analysis abnormality such as very low count or very low motility we can actually take the sperm and inject it directly into the egg, it’s called the intra-cytoplasmic sperm injection which is known as ICSI. Many men have become fathers because of this revolutionary procedure. It is safe and very effective in fertilizing eggs.

Men who have had a vasectomy and want to have more children can either have a vasectomy reversal or have the sperm harvested directly from the testicle or the holding tank near the testicle called the epididymis and that’s because vasectomy is a procedure where the ejaculatory duct is blocked surgically.

When it comes to the male partner infertility, we have had a long history of overlooking the real impact that men may have on conception and babies. For many years we have trusted the semen analysis as our gauge of male infertility. In fact it is not as reliable as we thought it was. Ten years ago we started looking inside the sperm at the DNA and seeing if the DNA was fragmented and broken up. Turns out that fragmented DNA if in high percentage can impact pregnancy and it can impact embryo development and the chance of pregnancy and even miscarriage. Treatment with anti-oxidants and vitamins actually has shown to be helpful in such conditions.

More recently as the exciting area of epigenetics a phenomena where men through their lifestyle and medical condition put molecules on the DNA of sperm. And those molecules can influence how the genes of sperm work and can impact embryo development early pregnancy loss and even trans generationally children, grandchildren and great grandchildren. So what a man eats, his medical conditions, his lifestyle choices really can impact the outcome of a pregnancy now and for future generations.

So we are now opening up this very exciting era in understanding male fertility and I think we are going to improve the outcomes of pregnancy by improving our assessment of sperm and modifying that man’s health as it comes to sperm.