Wisdom from Wisot Wednesdays, Round 17!

Reprint from Redbook’s Fertility Diaries

Hello, everyone, and welcome back to our weekly Q&A with top fertility expert Dr. Arthur Wisot. We've got so much in store this week: Four great questions, an answer to last week's pop quiz ("What are the three reasons that it seems like the conception rate is 100% on prom night in the back of the pick-up truck?"), and a question from Dr. Wisot to all of you! If you've got a question for Dr. Wisot, just leave it in the comments section and we'll get to it next week. And now, for the disclaimer: "My answers to questions on this blog do not constitute medical advice, but are merely meant to create an educational forum for consumers. It is always best to discuss these issues with your health care provider." The good doctor's answers are below, in bold:

Question #1: We've been trying for two years and never once had a positive pregnancy test. Recently we went through extensive testing — I am completely healthy/normal however, we were diagnosed with male factor infertility. He's seen a urologist and received a clean bill of health. We've been to an RE and were told that given his SA, we should "Do not pass go, go straight to IVF/ICSI." I've come to terms with the path ahead of us, however despite my RE's frequent reassurance that "It only takes one!", I feel like I need another opinion on his stats to fully understand our chances of a successful pregnancy: SA #1 (WHO Methodology) Total Count: 208 million A - 0% B - 15% C - 4% D - 81% Total Motility - 31 million Kruger Morphology Normal - 3% Head Defects - 44% Acrosomal - 5% Neck Defects - 31% Tail Defects - 17% SA #2 (WHO Methodology) Total Count: 98.9 million A - 0% B - 21% C - 18% D - 61% Total Motility - 20.8 million Kruger Morphology Normal - 1% Head Defects - 44% Acrosomal - 3% Neck Defects - 28% Tail Defects - 24% His counts are high, but the motility and morphology numbers freak me out. Should we be concerned with chromosomal abnormalities or possible DNA fragmentation? As our start date to cycle approaches, I worry that there simply won't be enough "quality" sperm to choose from. Can you help me understand what criteria the lab technicians look for when selecting sperm for ICSI? Thank you.

Answer: Fertility treatment works best when we are correcting a problem, if that's possible. Here the problem is the motility and morphology. If they don't move well, they have much less chance of reaching the egg. If they are misshapen, they have much less chance of penetrating the egg. Fortunately, the speed and shape have nothing to do with the chromsome makeup of the sperm. So IVF with ICSI is a treatment that can overcome this problem. If you are young, you could try some IUIs, but I would usually not recommend spending too much time before moving on.

Question #2: Due to my husband's cancer treatments, he is unable to have children (based on a semen analysis in 2000). When I started my IF treatments in 2007 (no birth control since 2000), we did not do another semen analysis and used donor sperm. I'm now considering IVF (15 failed IUIs, medicated and not). Can we consider utilizing my husband's sperm? What's the minimum an RE will want to see in order to use his sperm?

Answer: The minimum number of viable sperm needed is equal to the number of eggs you produce. That's easy. The bigger question is whether the chemotherapy drugs may have damaged the sperm beyond their numbers, ability to swim and their shape. You should consult with his cancer doctor to get information on exactly what and how much of the drugs he received and what potential damage they could have caused beyond the obvious.

Question #3: Hi, Dr. Wisot! A few weeks ago, in your answer to my questions about embryo defragmentation, you mentioned looking at strategies to improve egg (or embryo) quality. What are some of the strategies you've used in situations with low ovarian reserve, lots of fragmentation in the embryos? Thanks for your thoughts!

Answer: Unfortunately I can not get into the details of prescribing and protocols here. Each fertility center has its ways of dealing with poor embryo quality. In the lab, procedures like co-culture, assisted hatching and defragmentation may be used. There can be modifications to the stimulation protocol. You may want to get an opinion from your doctor about what strategies he/she would suggest and then get a second opinion from another outstanding center. This is a difficult issue to resolve and it can't always be fixed.

Question #4: Hi. Some background: I have a small prolactenoma that I take Parlodel for. Have had regular prolactin levels for one year now and have been TTC since April 08. Husband's sperm is normal, he is 34, I am 30. My question: Ever since going off the pill I have had a very short luteal phase. My doctor thinks I am ovulating due to OPKs thermal shift. But luteal phase is 2 - 6 days. My doctor says that is not a concern; do you agree? I have an HSG scheduled for this week and if clear, the doctor suggests Clomid. Thanks for your thoughts!

Answer: You need to get into this more deeply than following your cycles with a temperature chart. You do fit the definition of a luteal phase defect just by the length of your luteal phase. I would guess that you are not seeing a reproductive endocrinologist/fertility specialist. Clomid is one way to overcome this problem, but your cycles need to be monitored by ultrasound following your egg development, confirming the egg's release and progesterone monitoring in the luteal phase.
Before I get to last week's quiz answer, I would like to get your perspective on the reproductive aspects of the Octo-Mom situation. Has it affected your confidence in the specialty as a whole? Do you think we should legislate how many embryos may be transferred? I'd love to hear what you think. Next week, I'll share my perspective.

Pop quiz answer:

Last week's question was, "What are the three reasons that it seems like the conception rate is 100% on prom night in the back of the pick-up truck," while so many women struggle to have a child.

1. The girls are usually in the late teens, which biologically is the optimal age group for reproduction. (Please, don’t shoot the messenger.) Today, between education and careers, many women are putting off their childbearing until they are biologically more mature.

2. The guys are also at a peak of sorts. Most of the time they look at the post-prom hours with great anticipation. In fact, they frequently practice so they will give a stellar performance. They can regenerate their counts more quickly than their more mature counterparts. The increased, er, practice time improves motility and decreases DNA fragmentation so they are primed to perform magnificently from a reproductive point of view.

3. This is where the back of the pick-up truck comes in. Couples who are engaged in fertility treatment have sex, make love, have intercourse, or whatever you want to call it. In the back of the pick-up our two prom goers and have hot, steamy sex like two rabbits going at it, with similar results. There is no stress and the level of excitement improves the semen specimen further. The stress comes about two weeks later when she misses her period.

The point of all this is that one cannot expect fertility treatment to match the efficacy of this method. I’ve even had patients borrow a pick-up to try to regain their lost youth. But, believe me, it doesn’t work. What may help if you are not already at the point of IVF is to try to regain that spark that brought the two of you together and don't let the quest for a baby get in the way of what you once had. If you are having IUIs, try it the old-fashioned way after your IUI. Even if it is the IUI that ends up getting you pregnant, at least you’ll have had some fun trying.