LEARN INSURANCE

Showing posts with label semen analysis. Show all posts

Sperm DNA fragmentation assessment: Is it really helpful?

Posted by nurul Thursday, March 17, 2011 0 comments

All infertile couples know that the sperm plays a vitally important role in fertility. However, there's still a lot of confusion ! If we need only one sperm to fertilise an egg during ICSI, does the sperm count and motility really matter ? And if it does, how and why ?

The fact that the WHO has kept on changing the definition of what a normal sperm count just testifies to the fact that experts are as confused as patients are. This is especially true when we consider 3 contentious areas. While it's true that the sperm provides 50% of the child's DNA, can it be responsible for:
failed fertilisation after ICSI ?
poor qualty embryos ?
miscarriages ?

In order to drill down further into when the sperm can be responsible for reproductive problems, researchers have developed sophisticated tests to analyse whether the sperm are "normal " or not. In the past, the only tests we had available were the sperm count, motility and morphology. These are admittedly crude tests, and the hope was that newer tests which could directly check the functional status of the sperm's DNA would give us more useful information. Logically, since the man's DNA contributes half of the offspring’s genetic material , it is reasonable to assume that abnormal DNA in the form of fragmented DNA ( when excessive strand breaks are present ) may lead to derangements in the reproductive process.

Let's look at some of these tests.

The tests used for the assessment of sperm DNA integrity can be distinguished into direct and indirect. Direct assays try to detect the actual DNA breaks, while indirect assays quantify the susceptibility of sperm DNA to break after an external insult, such as acid treatment. The most commonly used direct assays are; Terminal Deoxynucleotidyl Transferase-mediated Nick End Labeling (TUNEL), Single Cell Gel Electrophoresis (COMET) and In-Situ Nick Translation (NT) assay. The most common indirect assays are; Flow flow cytometric acridine orange assay, Acridine Orange test (AO), DNA Break Detection-Fluorescence In Situ Hybridization (DBD-FISH) and Sperm Chromatin Dispertion test (SCD).

The very fact that it's such a long list is a testimony to the fact that we really do not understand what the results signify in real life. For example, breaks affecting genes in “silent” areas of the genome are unlikely to have any clinical importance, but no assay can evaluate this factor yet.

The truth is that for the present, there is no differentiation between clinically significant and insignificant fragmentation. While it's true that many studies using a variety of assays have shown statistically significant differences in sperm DNA fragmentation between fertile and infertile men, remember that these refer only to the mean or median . In reality, there is extensive overlap between the values found in fertile and infertile men.

Because these tests are so new, they've not been standardised. Clear reference values have still not been established, just adding to the confusion. Just like conventional semen parameters have been proven to be disappointing at predicting the outcome of IVF, sperm DNA fragmentation has been equally disappointing in predicting pregnancy rates after standard IVF and ICSI.

If you have poor quality embryos and your test shows you have increased sperm DNA fragmentation , it's very tempting to conclude that it's the sperm DNA fragmentation which is responsible for the fragmented embryos. However, this has never been proven ; and please remember this is not necessarily cause and effect. Men with higher sperm DNA fragmentation have had completely healthy and normal babies in their bedroom !

DNA fragmentation is a new parameter for the evaluation of male factor infertility . However, just because it is new does not automatically mean it is better ! In fact, at present it just seems to add to the confusion, rather than clarify it !

How couples reduce their own fertility

Posted by nurul Sunday, March 13, 2011 0 comments

Infertile couples are often willing to move heaven and earth in order to have a baby. However, I find to my dismay that a lot of them do things which actually end up reducing their fertility !

1. They use lubricants while having sex which kill the sperm . Having "baby making sex" on demand is not much fun for either husband or wife - and it's quite common to have to use lubricants in order to be able to achieve intravaginal penetration. However, many couples will use lubricants such as K-Y jelly or saliva - both of which can kill the sperm ! If you do need to use a lubricant, please use a sperm friendly lubricant. The easiest one to buy ( and the cheapest one) is liquid paraffin. It' easy available OTC at a chemist - just look under the laxatives !

2. Timing sex. Most couples know that the wife is fertile for only a few days during the entire month. However, because they are quite clueless about what these fertile days actually are ( and do not whom to ask or how to calculate them), they often end up having sex on Day 14 ( which they remember vaguely from their high school biology class on human reproduction ( when they weren't busy pretending to be blase because they " knew it all" ; or were giggling and blushing) is the day when ovulation occurs and the egg is released). However, for many women, Day 14 can actually be an "infertile day " ( for example, for women whose cycles are 25 days or less) . Using the Free Fertility Calculator at www.myfertiletime.in will help you track your fertility ! Using OPKs can also help !

3. Not having enough sex. Many wives refuse to allow their husbands to have sex until their "peak fertility day". They believe that if they "store up the sperm" and then discharge this with a big bang, their chances of getting pregnant increase. Actually, this is not true. You cannot really store up the sperm - the count does go up when ejaculation is delayed - but it's the immotile sperm which increase - not the motile ones ! It's far more efficient t have frequent sex, as long as the sperm are going in the vagina !

4. Many infertile women still use BBT charting to try to track their fertile day. This is a big, big mistake. While BBT charting does provide useful evidence to the doctor , it's only retrospective evidence - it does not help to identify the fertile days, as the BBT raises only after ovulation has occurred ( at which time the cervical mucus dries up and sperm can no longer enter the uterus and swim up to the egg).

5. Not doing any homework. It still astonishes me as to how poorly informed many infertile couples are about the basics of baby making ! They will often waste time trying herbs and supplements advertised on dodgy websites to "boost their sperm count"; or take "fertility tablets" to increase their fertility. They will allow months to run into years before seeking medical attention - or even doing a basic ( and inexpensive) fertility workup, to confirm that everything this fine.

Why do my sperm counts vary so much ?

Posted by nurul Thursday, February 24, 2011 0 comments

One of the most frustrating problems for infertile men is the fact that their sperm counts seem to vary all the time. On some days it is 5 million per ml; on others it drops to 2 million per ml; while on good days it goes upto 10 million per ml ! It's like the Sensex; as volatile; as hard to predict ; impossible to control; and variations in the sperm count cause as much stress as dips in the Sensex !

Remember that the testes are sperm production factories which produce billions of sperm daily. The efficiency of this factory is affected by many variables, many of which we still cannot identify ! Even in a normal healthy fertile man, sperm counts fluctuate all the time - and can vary all the way from 10 million per ml to 80 million per ml !

What makes a bad situation worse is the fact that many medical laboratories are not very good at testing the sperm. A semen analysis is a high-complexity test, but because it costs very little, many laboratories do it very casually, and provide erroneous results, which just cannot be trusted !

The problem of varying sperm counts is exacerbated in infertile men ! While the truth is that we do not know what causes the sperm count to drop ( or to rise for that matter), when the count drops, men often tend to blame themselves. Wives will often add to their guilt by blaming the drop on the usual culprits : a poor diet; unhealthy lifestyle; late nights; stress; or on smoking or drinking.

Many wives will nag their husbands to completely stop smoking, drinking or partying. It's very unlikely that social drinking or an occasional smoke affects the sperm counts and all these prohibitions just create unhappiness and bickering. Some men will deliberately throw away all their bad semen analysis results and just show the good results to their wife and the doctor
( and some continue to refuse to believe that a macho man like them can have poor quality sperm !)

We need to understand that we really know very little about sperm production - and there's very little the poor man can do to improve his sperm count ! In all honesty, there's very little the poor doctor can do either ! All we can provide are the standard platitudes - Eat a well-balanced nutritious healthy diet ; exercise regularly ; avoid stress; stop smoking; stop drinking; take vitamins; take supplements ; take these medicines ; and so on, but all these measures have very little effect on the infertile man's low sperm count !

Why are men so reluctant to get their sperm tested ?

Posted by nurul Friday, February 11, 2011 0 comments

Most men are very reluctant to get their sperm tested. For one, most men hate going to a doctor - and they need to be dragged to the clinic for any medical testing - whether it's a X-ray or a sperm test. Secondly, most men still believe that having a baby is their wife's job, so it's the wife who should get tested. For another, they expect that their sperm count must be fine , so why bother to get it tested ? " Hey - I can have sex as often as I want, and if my virility is fine, I am sure my fertility will be superb too ! Why waste time and money getting it tested ? " Finally, it can be quite humiliating to have to go to a lab to produce a semen sample - and this is an experience most men are quite happy to bypass.

The problem is much worse for men who know that they have a low sperm count. They are secretly petrified that their sperm count may drop even further , which is why they are so reluctant to get their semen re-tested ! ( They also know that if their sperm count is low, their spouse will nag them incessantly to stop smoking and stop drinking - and is having a baby really worth giving up all the pleasures of life for ? )

This reluctance on the part of the man is not something many wives understand - " I am the one who has to go through all the painful tests and shots , so why is he making such a big deal about getting his semen tested ? " Ironically, the wife is being amazingly unempathetic in this case. While it's true that it's usually men who are clueless, any wife who does not understand the heartburn an infertile man goes through when his sperm count come back as below normal is being remarkably obtuse and clueless. The secret fear many men with a low count have is that the sperm may keep on dropping until it goes to zero - and then what ? Men are masters as denial - and since most of them hate going to a doctor for any medical problem, it's quite understandable that they are not happy about allowing their vulnerability to be exposed to the whole wide world ! And while producing a semen sample is not as painful as doing a HSG, being forced to produce semen on demand in a dark, smelly bathroom when there are five other men waiting in line can be very unpleasant ! Even worse , if the man fails to get an erection and produce a sample when asked to, this can often be the last nail in the coffin of his self-confidence. He'd rather go and shoot himself than put himself through the humiliating ordeal once again.

Sadly, many doctors do not realise the enormous stress some infertile men go through when producing a semen sample - and this just contributes to the difficulty. Since most nurses in an IVF clinic are female, it's very hard for a man to talk about his personal problem to anyone ( the doctor's never available in any case !) And if he fails once, this often becomes a self-fulfilling prophesy, setting up a negative vicious cycle which is very hard to crack. Seeing his wife angry and upset just adds to the man's woes - and he'd rather just forget about having a baby rather than subjecting himself to the stressful exercise all over again !

Top 10 myths about infertility

Posted by nurul Friday, January 7, 2011 0 comments

Probably one of the most enjoyable books I've read on infertility is: A Few Good Eggs: Two Chicks Dish on Overcoming the Insanity of Infertility by Julie Vargo and Maureen Regan. This guide is actually targeted to infertile women residing in the US, and it is designed in the currently fashionable "chick-lit" style. It's amusingly put together; and it is certainly a breath of healthy air, if you are the type of individual who discovers a sense of humor can help you deal much better with infertility.

This book is loaded with lots of Top-10 lists, and here is their valuable listing of Top 10 Myths Regarding Infertility:

10 Mis(sed)-Conceptions Regarding Infertility

1. Infertility will not happen to me.
2. I cannot be infertile. I already have got a child!
3. I can easily conceive, therefore i do not have fertility problems. I basically have miscarriages.
4. I am just too young to possess fertility problems!
5. My physician shared with me that i don't need to visit any fertility expert unless I have 3 miscarriages.
6. I am fit. I work out on a regular basis. I cannot become infertile.
7. I am certainly not infertile. I am just not having good enough sex.
8. A person can easily wait a long period to have a child.
9. Males cannot be infertile. They produce sperm regularly.
10. Normal is a miracle.

Below are my remarks on this list:

1. Infertility will not happen to me.

This really is wishful thinking. The unfortunate truth is that the inability to conceive is a common problem which affects around one in ten couples. This means your likelihood of being infertile is around 10%. Sadly, there isn't any trustworthy technique of being able to check your own fertility (short of really conceiving a child!). There isn't any sign or indication or hint that will tip you off that you may be infertile. That is why numerous couples are "pre-infertile" - they get worried (often unnecessarily) as to whether they might have issues conceiving when they fail to get pregnant the very first month they attempt to have a baby!

2. I cannot be infertile. I have already got a child!

I'm sorry. As economic consultants tend to be so keen on reminding us, previous performance is no guarantee of future results! If you had a child previously, this only denotes that you were fertile that time - this can be no promise that a new problem might not have cropped up in the meanwhile which is causing you to become infertile now! This is known as secondary infertility - and is usually is much more annoying, since it is absolutely unexpected.

3. I can easily conceive, therefore i do not have fertility problems. I basically have miscarriages

An extended meaning of infertility includes woman who have repetitive pregnancy failures (miscarriages) - ladies who can't carry the pregnancy to term. This is because the outcome in both the cases is the same - not being able to have a child to adore and to hold.

4. I am just too young to possess fertility problems!

Regrettably, infertility doesn't care how old you are! While it's true that older females possess a significantly higher possibility of being infertile, as they have "older" eggs, young females may also be infertile for a lot of reasons - for example damaged tubes.

5. My gynec told me that I don't need to visit any fertility expert unless I have 3 miscarriages.

A miscarriage takes place in around 10 percent of all pregnancies. Since this is this kind of a common event, and frequently takes place for random genetic causes which usually do not recur, many doctors will not evaluate women who have experienced only 1 miscarriage. Not just is the assessment a waste of time and funds, it offers very little helpful information. This is the reason why the majority of physicians perform testing only when you have had at least two miscarriages. However, if you require further reassurance after experiencing a miscarriage, please ask your physician as to exactly what he or she can do in order to guide you.

6. I am fit. I work out on a regular basis. I cannot become infertile.

There is simply no connection in between your general wellness and your fertility. For instance, your fallopian tubes may be blocked without creating any kind of symptoms or indications. You have no method of knowing this, until you get them examined.

7. I am certainly not infertile. I am just not having enough sex.

This is a chance only when your lovemaking consistency is less than once a week. If it is much more compared to this, the probabilities of your having sex during your "fertile period" are usually quite high - you most likely will "hit the jackpot" at some period over the course of a year. Nevertheless, improving your love-making frequency is actually a simple (and enjoyable!) approach of enhancing your fertility. However, several women delude themselves and believe infrequent sex is the reason they are not having a baby, because they would rather deny the possibility of their having a medical problem for which they may need medical intervention.

8. Its fine to wait to have a child.

This is actually not a very good idea, for 2 reasons. First of all, if you have not conceived on your own in 1 year, the likelihood of your doing so on your own falls substantially. Secondly, fertility declines as an individual get older, and there is absolutely no point in losing time and decreasing your probabilities of success. Everything in life comes back again, except for time. It is a valuable, non-renewable resource - use it smartly!

9. Males cannot be infertile. They produce sperm regularly.

It is correct that males produce sperm all the time. However, around 10% of males tend to be infertile, simply because they generate poor quality sperm. Some possess no sperm in their semen at all - and there is no method of examining this without performing a semen analysis in the pathology laboratory.

10. Normal is a miracle.

Actually, this is true (just slipped it in to make sure you were paying attention!). When you think about how much precise synchronisation needs to be achieved for a good embryo to implant in the uterus to grow to be a baby, every birth is genuinely a remarkable feat - it's remarkable how the individual body achieves this with such ease for so many couples!

Unexplained infertility vs incompletely evaluated infertility

Posted by nurul Monday, October 25, 2010 0 comments

Many patients are diagnosed with having unexplained infertility. This means that all their fertility tests - semen analysis; hormonal blood tests ( FSH,LH,PRL,TSH and AMH) for egg quality; HSG ( hysterosalpingogram) for tubal patency; and ultrasound scanning for ovulation monitoring are normal.

This can be a very frustrating diagnosis for patients. " But doctor, if everything is normal, then why aren't I getting pregnant ? " Patients are never happy with doctors who honestly answer - We do not know ! Patients expect a scientific definitive answer from their doctor who is meant to be an expert - and if a doctor cannot provide this, then be mustn't be very competent at his job is the natural conclusion many of them jump to . The truth is that our technology for identifying problems is still very crude. Thus , while we can check if the fallopian tubes are open or closed , we still cannot determine if the tubes are functioning properly or not. Similarly, while we can count the number of sperm in the lab and grade their motility, we still cannot find out if they are capable of fertilising an egg !

In actual fact, patients should be relieved that the diagnosis is one of unexplained infertility. This means that all their test results are normal; and that their basic reproductive apparatus ( eggs, sperms, tubes and uterus) are working fine !

However, the major fear in their minds is that if the doctor cannot find a problem, how will he able to fix it ? Does this mean that I will never get pregnant ?

The truth is that while we are not very good at identifying problems, we are very good at bypassing them !

A better term for unexplained infertility would be undiagnosed infertility - and this says a lot more about the limitations of our diagnostic technology, rather than anything about the patient !

However, when patients are told their diagnosis is "unexplained infertility" they are so hell-bent on finding the explanation ( because how can a doctor provide treatment without first making a diagnosis ?) , that they pressurise doctors into running a further battery of tests. In their mind, unexplained infertility means incompletely evaluated infertility - that the doctor is not been meticulous in completing all the tests . Some doctors are happy to pander the patient's hankering for a diagnostic label ! They start doing all sorts of unnecessary tests ( such as laparoscopy or endometrial biopsy to test for TB). When they finally find a problem ( which is just a matter of time because it is a mathematical certainty that the more the tests you do, one of them will turn out to be abnormal), the doctor then triumphantly proclaims that he has found the elusive diagnosis - which the earlier ( presumably incompetent) doctor had missed because he was not diligent enough.

The danger with this approach is that a lot of these "abnormalities" are just incidental red-herrings, which do not affect the patient's fertility at all. However, now that a problem has been "found", it needs to be treated ! This wastes a lot of time and money while the doctor and patient are barking up the wrong tree. Patients finally end up getting fed up and frustrated - and then refuse to explore treatment options such as IVF which would have allowed us to bypass the problem and achieve success in a much more timely and cost effective fashion !

Making sense of your infertility treatment options

Posted by nurul Saturday, October 23, 2010 0 comments

I just saw an infertile 42 year old woman who said - Doctor, my husband has a low sperm count. Can you please prescribe some medicines so we can improve it and have a baby. "

It always amazes me that even in this day and age so many infertile couples do so little to try to make sense of their treatment options.

Many find it very hard to decipher the medical terms their doctor uses. They do all the tests the doctor asks for - and are often completely lost when he then explains to them what the next action steps are.

Unfortunately, many doctors also "complexify" matters rather than simplifying them. They take a perverse pride in doing so, because it allows them to position themselves as experts in a difficult subject which the poor patient will never be able to understand !

I think they just make matters unnecessarily complex. Infertility is quite a simple topic, when broken down into its component parts.

Basically, you need just 4 things to make a baby - eggs; sperm; uterus and tubes.

If you are not getting pregnant, you need to identify what the bottlenecks are; and prioritise these, so you can focus on the important ones !

Thus, for this 42 year old woman, even if her husband has a low sperm count, her major problem is her advanced age, which is going to impede her ovarian reserve. Even if her husband had a normal sperm count, she would still need IVF, because time is now at a premium for her !

Using this simplified approach, we can quickly get to the heart of the problem - and then identify a solution which allows us to tackle the problem efficiently ! Every problem has a solution - and the question should NOT be "Why am I not getting pregnant ? " Rather, it should be - What can I do in order to get pregnant ?" After all, no one cares about problems - we only care about results - about having a baby . The quality of a doctor’s answers depend upon the quality of the patient’s questions - and if patients learn to ask the right questions , their chances of getting the right treatment will improve dramatically !

Why do doctors "treat" men with normal sperm counts ?

Posted by nurul Monday, May 10, 2010 0 comments

I see many men with completely normal sperm reports who have been prescribed all sorts of medicines, presumably to "boost their fertility" . These include a wide variety of pills ( depending upon which part of the world they come from) , ranging from Proxeed to Speman to Manix to CoQ and antioxidants.

Why are doctors so keen to treat normal men who do not need any treatment
whatsoever ?

I feel there are multiple reasons.

First is ignorance. Many sperm testing labs and doctors still do not even know what a normal sperm count is. I still see labs which print the normal sperm count range as being from 60 - 150 million per ml ! This means that even men with normal counts of 40 million are " diagnosed " as having a low sperm
count !

Second is pressure from patients. Many men are petrified that they cannot get their wife pregnant because their sperm count is not good enough. They want medicines to "boost " their sperm count and enhance their fertility ( along the same lines of their eternal desire to increase the size of their penis and increase the volume of their ejaculate ! I wonder why men have this obsession with size and numbers ? Is this a result of the exposure to the trick photography they use in pornography films, which distorts their sense of what is normal and average ? )

This means that there is a lot of pressure on the doctor to treat ! Let's do something - anything ! They do not want to lose the patient and are quite happy to pander to their desire to consume medicines ! And it's easier to write a medicine ( even if it is useless) rather than sit and spend 10 minutes with the patient and explain that there is no need to prescribe anything !)

It's very easy to justify this prescription. Many doctors say - Yes, these medicines may not help, but at least they do no harm ! And doctors often fall prey to the " post hoc ergo propter hoc fallacy" . They remember their anecdotal successes - the men with completely normal sperm counts who got their wife pregnant after taking the tablet prescribed by the doctor ( it's quite likely that they would have achieved a pregnancy even without taking the tablet, but the doctor is always happy to take the credit !)

Making sense of your semen analysis report

Posted by nurul Monday, April 19, 2010 0 comments

The semen analysis report is the basic test of a man's fertility. However, this is a complex report and it can be hard to make sense of the numbers on this laboratory test.

Here's a free simple tool to help you make sense of what your sperm test numbers mean !

View a sample SEMEN ANALYSIS REPORT here !