Male Biological Clocks

Biological clocks – they aren’t just for women anymore.  A recent article referencing a male factor infertility study showed that there is a decline in male fertility after age 41, and it points to an even sharper decline after age 45.  It isn’t the same decline that we often see with women’s eggs, but certainly another factor to consider in the infertility big picture.  Isn’t it interesting that it took a donor egg study (that allowed them to eliminate the female partner’s eggs as a factor) to highlight this male fertility decline?

I have long been surprised and slightly irritated that so much focus is put on a woman’s eggs as the likely culprit when fertility issues arise. Often the only testing done for the male partner related to sperm quality is a semen analysis to measure volume, motility and morphology – even if the male partner is over 45 – 50 years old.   Even sperm that appears to be normal in a routine semen analysis may have extensive DNA fragmentation.  It has been reported that 40 – 50% of infertility cases have male factors as at least a contributing cause (although not necessarily the only cause), yet little is done to scrutinize potential male factors.

While I am certain that statistically speaking the likelihood of the eggs being the issue is high if the woman is over 40, but why not also test the male partner as well (beyond simple semen analysis) to see if DNA fragmentation may be a factor?   The SCSA test (Sperm Chromatin Structure Assay) is relatively inexpensive, and can at least provide some information to factor into the decision-making process.  A simplistic view of this is that a semen analysis looks at the outside of the sperm, whereas the SCSA does a better job of assessing the inside of the sperm and how DNA integrity may impact embryos. Inciid.org (The InterNational Council on Infertility Informatino Dissemination, Inc.) provides a very good article about SCSA testing that describes how it works and answers commonly asked questions.

While some doctors say the test is not always a 100% accurate determination of fertility, it does give some indication as to whether a little focus should be put in the male partner’s lap (ha!) too.  Generally, there is not a procedure that doctors can do to improve the results if they are bad.  Many experts will recommend specific vitamins (particularly antioxidants) and lifestyle changes (reducing stress, improving diet, minimizing opportunities for increased testicular temperature) that the male partner can implement.  These changes usually need to be in place for at least 3 months prior to providing the “swimmers” for a cycle to improve the odds of success.

Also, the results of this test may also trigger recommendations for the use of ICSI or PICSI to aid in selecting the best sperm for fertilization.  And in some cases, couples may instead use the test results to decide to use donor sperm in addition to donor eggs – or even consider frozen donor embryos.   But absent these test results (which is often the case) couples may not realize that sperm may be contributing to continued infertility (even with donor eggs).

I have seen cases where women are on their 4th or 5th IVF cycle before the doctor recognizes some signs that sperm may contributing to the lack of success.  Here are some things that may be an indicator that further sperm testing should be discussed with your doctor:

  • sperm does not survive freezing and thawing well
  • semen analysis shows high levels of abnormal sperm
  • male partner is over 45 years old
  • higher than normal embryo demise between day 3 and 5 in the IVF laboratory (the sperm has a lot of responsibility for growth during those days)
  • recurring miscarriages

I think often it isn’t until eggs and other female factors have been eliminated that the potential sperm issues finally get attention.  But why wait until the second or third very expensive unsuccessful cycle to explore something that is so easy, non-invasive and inexpensive to check early?

While the SCSA and other sperm testing is not some magic solution, it is most certainly worth discussing with your doctor to see if it may be a valuable tool in assessing your own fertility issues and treatment plans.


RESOLVE has started a petition directed to the Department of Health and Human Services Secretary Sebelius who is tasked with determining the Essential Benefits to be included in each state’s health insurance exchange effective January, 2014. RESOLVE’s goal is to gather 7,300 signatures, one for every one thousand Americans impacted by infertility. I think that we can do MUCH better than that.

Please join me and add your name to this initiative aimed at requiring health insurance coverage for the 7.3 million Americans diagnosed with infertility each year. Click here to make your voice heard.

A recent New York Times article posed the question “Do You Suffer From Decision Fatigue“?  It went on to describe how making decision after decision can wear people down, sometimes resulting in poor choices or a different choice than may have been made with a fresh mind.

It reminded me of the overwhelming number of decisions that have to be made during an infertility journey, particularly the choices made during an IVF cycle.  By the end of the cycle, or end of the journey, are we making the same decisions we would have made when our minds were fresh (or maybe we were more naive)?

I think there is something to be said for the fact that some decisions should be made after a good night’s sleep.  Whether it is own egg or donor egg IVF, fresh cycle or frozen donor eggs or donor embryos, domestic clinic or international clinic, proven or unproven donor, how many embryos to transfer, whether to do PGD testing, what foods to eat or avoid, accupuncture or not, which type of progesterone, POAS or not?  The list feels like an endless number of decisions that have to be made.

By the end of a cycle  we’re on the rollercoaster of emotions hopped up on estrogen and progesterone (and maybe steroids or blood thinners) and that is when we are making these all important decisions – and then second guessing them over and over again.  It is no wonder that we are driving ourselves simply crazy with worry and “what ifs”.  And usually, that is when we gather our trusted friends and confidantes around us to talk us off of the cliff and help us hold on to hope or at least cautious optimism or neutrality.

Although not much can be done to lessen the number of hard choices to be made, I think we can be cognizant of identifying which choices will need to be made, and when – and what decision points or input will be necessary prior to making those decisions.  I think it is the last minute – “quick, decide now” types of decisions that are most often replayed over and over in our minds.  The ones where perhaps we felt unprepared, or caught off guard – those are the ones that often keep people awake at night wondering…..what if.

So, my advice is to know yourself (when you are at your best decision-making) and try to make the majority of the important decisions with a clear, fresh head and full stomach. Then, make sure you review with your clinic and doctor what decisions you will be asked to make, and when. That way you can be prepared, and maybe even have a chance to discuss it with your partner (if you have one) or trusted IVF friends in advance for additional input.  And lastly, trust your instincts.  Usually your gut will not steer you wrong.   And if all else fails and there is no one “right” answer, what always worked for me was asking myself “if things go wrong, which choice will I regret less”.

Happy decision-making.

Although it sounds counter-intuitive, in the past few years, several studies have shown a marked increase in IVF implantation/success when patients have undergone an endometrial biopsy (also known as LEI – luteal phase endometerial injury) prior to IVF treatment.

In the initial Israeli study by Dr. Dekel in 2003, they seemed to sort of “discover” this happy outcome by happenstance.  They noticed a correlation between women (doing own egg IVF) who had an endometrial biopsy and also had increased implantation success rates – regardless of the findings from the biopsy when the tissue was tested.  The initial study was quite small –  134 women – 45 who had the biopsy, and 89 who did not.   In that study 27.7% of women who had the biopsy got pregnant vs. 14.2% of the control group who did not have the biopsy.

Although there is no clear explanation for the increase, the general theory was that by injuring the lining of the uterus, the body was sending increased blood flow or proteins with healing properties that improved the ability of the embryos to attach to the uterus.

More recently, at the European Society of Human Reproduction adn Embryology (ESHRE) meeting in Stockholm, Dr. Fernando Prado Ferreira from the Federal University of Sao Paulo presented the findings of a similar study based at Santa Joana Maternity Hospital in Sao Paulo Brazil.  In his trial of 144 women, 46 were given biopsies and 98 were not.  He reported that in the patients who had a biopsy, there was almost double the chances of a pregnancy over patients who did not have the biopsy.

He went on to explain that “The endometrial biopsy appears to lead to scarring in the uterus that provides better adhesion of the embryo, either through the scarring itself or through substances called cytokines released when the wound is caused in the womb.”

Many reproductive experts have been skeptical of the outcomes and have called for further randomized studies on this subject.  It has been suggested that perhaps Dr. Ferreira’s use of the word “scarring” wasn’t the best word to use because the uterine lining would normally heal without scarring from this procedure.  Perhaps referring to it as “healing” may have been more appropriate, but the use of the word “scarring” may be attributed to the fact that English is not Dr. Ferreira’s native language.

There also appears to be a difference of opinion about when is most effective to perform this biopsy.   Generally, it seems to be performed shortly before starting the medications for the IVF treatment, FET (frozen embryo transfer), or donor egg IVF treatment cycle.

Still, the studies of this procedure to date have been small, and no randomized studies have been done, so there still remains much to be learned about the use of this procedure for increasing success.

The good news is that – unlike most fertility procedures – this one is relatively inexpensive to do.  Just a few minutes in your RE or OB office where they use a suction catheter through the cervix into the uterus where they take a small biopsy of the uterine wall.  There is no need to send the tissue out for testing, it is simply discarded since the value of this procedure seems to be the injury rather than any potential information gathered from the tissue.

In any event, in cases where there have been repeated IVF treatments with failure to implant and no known cause, it may be worth exploring this option.

I think perhaps the best advice is to discuss this with your RE to see if it might be beneficial in your specific case.

Sometimes when the first plan for family building isn’t working out, plan B can be perceived by some a bit like a “consolation prize” or a less optimal choice.  Recently I was thinking about how so many of us in infertility land go through the pain of losing one dream and finding a new one – and how after the new one comes to fruition we just can’t imagine it ever being different.  In family building, that alternate plan is often some sort of fertility treatments such as IUI, IVF, or using donor eggs or donor sperm; or it may include surrogacy, adoption, or any other family building option. 

And even if it wasn’t a first choice, the child who comes to you most certainly isn’t a lesser choice or a consolation prize.  It isn’t that any of the choices are better or worse- it is that they are a different choice.   And what may be a good choice for some, may not be right for others. 

Going through our own fertility struggles, we often deal with myraid losses.  And at some point I believe it really comes down to whether the heart’s desire is about experiencing pregnancy or a genetic connection or about being a parent or someone’s mommy (or mommy to an additional child).  Some people are at peace with not being pregnant or passing along their own genes, but simply cannot fathom the idea of not parenting, or not being someone’s “mommy”.  For others, they long for the experience of pregnancy and birth.  As I often say, there is no one right answer – just the one that is right for you.  And we can be thankful that so many options are available to us with today’s technology and social environment.

Someone wrote a blog post recently that resonated with me.  It  was about how making a different plan isn’t a consolation prize – not second best even though it might not have been a first choice or the first thing we tried in our family building.   I know this analogy/story has been used to talk about accepting the challenges that come with special needs children – but I think you can substitute fertility treatments, egg/sperm donors, adoption, or surrogacy, it applies just as well.  It is about when the path to get what you want isn’t what you originally planned.   It doesn’t mean the new path is bad or wrong – just different, and there is no shame in mourning the loss of what you had originally planned.  

Welcome to Holland

When you are going to have a baby, it’s like planning a fabulous vacation trip – to Italy. You buy a bunch of guidebooks and make your wonderful plans. The Coliseum, Michelangelo’s David, a gondola ride in Venice. You may learn some handy phrases in Italian. It’s all very exciting.

After months of eager anticipation, the day finally arrives. You pack your bags and off you go. Several hours later, the plane lands. The stewardess comes in and says, “Welcome to Holland.”

“Holland?!?” you say. “What do you mean, Holland? I signed up for Italy! I’m supposed to be in Italy. All my life I’ve dreamed of going to Italy.”

But there has been a change in the flightplan. They’ve landed in Holland and there you must stay. The important thing is that they haven’t taken you to a horrible, disgusting, filthy place, full of pestilence, famine, and disease. It’s just a different place. So you must go out and buy new guidebooks. And you must learn a whole new language. And you will meet a whole new group of people you would never have met.

It is just a different place. It’s slower paced than Italy, less flashy than Italy. But after you’ve been there for a while and you catch your breath, you look around, and you begin to notice that Holland has windmills; Holland has tulips; Holland even has Rembrandts.

Everyone you know is busy coming and going from Italy, and they’re all bragging about what a wonderful time they had there. And for the rest of your life you will say, “Yes, that’s where I was supposed to go. That’s what I had planned.”

The pain of that will never ever go away, because the loss of that dream is a very significant loss. But if you spend your life mourning the fact that you didn’t get to Italy, you may never be free to enjoy the very special, the very lovely, things about Holland.

c1987 by Emily Perl Kingsley.

A favor

Today’s post is just a short request. A blogger friend, Amy Rauch Neilson, is a writer, a mom, and is currently undergoing chemo to fight a recurrence of breast cancer. She needs our help – and it won’t cost you a penny, only a minute or two of your time.

Since breast cancer has touched our family and so many people that I know, I am asking a personal favor.

Amy is trying to get her book “It’s In the Genes” published, and to do that, the publishers want to see that she has a following – 5000 subscribers is what they want to see, and she is trying to do that by March 3rd. She is well on her way there, but every subscriber counts.

Please just go to her blog and subscribe via email using the link at the top of her page. I know, I know, we all read blogs in our Google Reader – but just this time, make an exception and sign up for emails – that is the only way she can show the publishers how big of a following she has. Then, later, when you have some time, I highly recommend that you go back and read from her archives. She is a talented writer, with a great sense of humor. I couldn’t help but become part of her cheering section, and I hope you will feel that way too.

In case you want to cut and paste it rather than link, here is the url: http://itsinthegenes.wordpress.com/


I recently read this really terrific blog post about if and when to POAS (pee on a stick – or take a home pregnancy test)  after an IVF treatment.  The author, Lisa Rouff, Ph.D., is a psychologist specializing in infertility and adoption.   You can read the full post here.

Dr. Rouff  offers some great insight about deciding IF you should consider POAS, and if so, when to start trying – based on your own expectations and tolerance. In other words, she tells you how to be “smart” about POAS based on your own personality. 

One consideration that she doesn’t cover, is that sometimes home pregnancy tests can give you a sense of whether the embryo is implanting or not.  If your clinic tells you to test at day 12 – 14 post transfer, you may have a negative test – but not know that the embryo had implanted but your hCG has already fallen to the “not pregnant” level.  The one benefit of POAS rather early (say around 6 – 8 days post transfer for a donor IVF cycle, or 10 – 12 days post trigger shot for an own egg IVF cycle) is that if the embryo implanted and hCG started rising, you will likely get a positive test result early – even though it may turn into a negative if the pregnancy is not viable.   

While that seems like it would get hopes up unnecessarily (which is why some clinics prefer to test around day 14 post transfer), I have seen patients with more than one failed IVF use this information to help determine whether there is simply a failure of the embryo to implant, or whether it may be immune or embryo quality issues that are happening after implantation.  

I don’t necessarily recommend this option for everyone, but it is something to consider as an additional information tool in figuring out the infertility puzzle.

PS- In my experience, the most sensitive test on the market right now is the Target brand (called “UP” I think) two line test.   Stay away from the digital tests – they generally are not as sensitive as the two line tests, which seem to be even more sensitive than the + or – tests.