GIVF Fertility eNews
July 2009

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Male Infertility: the Other Half of the EquationDr. Sunita Kulshrestha
Sunita Kulshrestha MD, FACOG
Reproductive Endocrinologist

When a couple has trouble getting pregnant, there is about a 50% chance that there is a male factor causing or contributing to their infertility. In order to achieve pregnancy, a man must deliver into the vagina healthy sperm that are able to reach, penetrate and fertilize the egg.
The first test to assess male fertility potential typically is a semen analysis. Semen is the fluid that contains both the sperm and the secretions from glands that nourish and protect the sperm. A normal ejaculate contains more than 40 million sperm! A semen analysis measures several factors, including: the amount of semen produced (volume); the total number of sperm in each milliliter of semen (concentration); the percentage of sperm moving (motility), and the percentage of sperm that are normally shaped (morphology). Abnormalities seen in the analysis may include too few sperm (oligospermia), sperm that are not motile and do not move the way they should (asthenospermia), abnormally shaped sperm (teratozospermia) or a combination of all of the above. The number of sperm and the percentage of those sperm that are motile influence how many sperm are able to reach the vicinity of the egg. Sperm motility and morphology determine the ability of the sperm to penetrate the egg.
Historical risk factors for infertility and abnormal semen analysis include a history of sexual/erectile dysfunction, history of sexually transmitted diseases, exposure to environmental toxins including tobacco, drug use, and alcohol, prolonged exposure of the testes to high heat, history of undescended testes, history of mumps, chronic medical conditions such as diabetes, a family history of cystic fibrosis, urological procedures including inguinal hernia repair, history of cancer treatment, use of anabolic steroids, and the use of certain types of medications.
If a semen analysis is abnormal, another test should be performed at least three weeks later to confirm the findings. For any given man, semen quality can be quite variable and simple environmental effects (such as a fever, excess alcohol use, medications) can temporarily decrease the quality of the semen. If an abnormality persists, a urological evaluation can be informative. A physical exam can evaluate the size and location of the testes and the presence of a varicocele. A varicocele is a dilated testicular vein that can compromise fertility. The physical exam can also determine the presence of a patent vas deferens, the duct through which sperm flow from the testes to the penis.
Additional testing for the male may include a blood hormonal profile. Total testosterone and FSH (follicle stimulating hormone) are both indicators of testicular function. A prolactin excess or thyroid abnormality can also be evaluated with blood tests and can affect fertility. If the sperm concentration is less than 5 million/ml, genetic blood testing such as a chromosomal analysis (karyotype) and testing for missing segments of the Y chromosome (Y deletion) is recommended. A karyotypic abnormality can not only cause infertility, it can increase the risk of miscarriage and an abnormal pregnancy.
The treatment for male infertility is based on the suggested cause. Some causes of infertility can be accurately defined and effectively treated. Lifestyle changes such as avoiding smoking, excess alcohol, and heat to the scrotum can improve semen quality. Medication can help men with erectile or sexual dysfunction. Varicoceles can be treated through outpatient procedures. Hormone treatment can be instituted if there is a hormonal insufficiency of the thyroid gland or the signals from the brain that control sperm production (FSH, LH). Antibiotics can be given for prostatitis or other infection.
Most causes of male infertility, however, do not have an identifiable cause. For mild to moderate abnormalities in sperm numbers, sperm motility or morphology, an intrauterine insemination (IUI) can improve fertility. An IUI delivers a higher concentration of sperm closer to the egg and improves the efficiency of the process.
For moderate to severe abnormalities, in vitro fertilization with ICSI (intracytoplasmic sperm injection) can be performed with great success. IVF involves the female partner taking hormones to stimulate the ovaries, collecting eggs through an office procedure called an egg retrieval, and then injecting a single sperm directly into each egg (ICSI) to create embryos. These embryos then grow in the lab and are transferred back into the female's uterus. IVF with ICSI has revolutionized the treatment of male infertility because the vast majority of problems that lead to male infertility can be completely bypassed, as long as just a small amount of normal sperm is present (rather than the normal millions).
Sperm can be obtained for IVF/ICSI from an ejaculate or directly from the testes/epididymides using the techniques of testicular biopsy, epididymal sperm aspiration and non-surgical sperm aspiration (NSA). An NSA can be performed in a simple medicated procedure in the office at the time of the egg retrieval. This procedure can also be used to obtain sperm from men who have had vasectomies.
For men who are azoospermic (no sperm produced at all), the use of donor sperm offers an option for achieving pregnancy. Donor sperm can be obtained from either a known donor or an anonymous donor (or both) and can be used with both IUI and IVF.
Many advances have been made in the treatment of male fertility. Schedule an appointment with a physician to learn more.

What's New at GIVF

SPLIT CYCLE: THE MOST AFFORDABLE WAY TO USE DONOR EGG IVF. GIVF has expanded its split cycle donor egg IVF program to now include a two cycle multicycle option. A split cycle is when two patients share the eggs from a single egg donor. Patients can choose to do a split cycle for single or multicycle base fees that ordinarily apply to donor egg IVF, but at only half the price for the donor fee. Split cycle is not only a more affordable option, but due to the large donor egg pool GIVF provides, we believe our program offers the fastest match for a split cycle or donor egg IVF cycle available anyplace in the United States. For details, click here
Through July 31, GIVF is offering free in-office consults to patients who qualify and schedule before that date, even if the office appointment happens to take place after that date. For a free consult with one of our expert physicians, call 800-552-4363.
NEW AFFORDABLE IUI OPTIONS. GIVF is proud to announce that we have simplified and reduced our cost structure for intrauterine inseminations.  For more details about pricing, visit our website at or click here
GIVF TO OFFER PCOS DISCUSSION GROUP.  Dr. Ervin Jones will host an informal discussion on the infertility aspects of PCOS at GIVF's clinic in Fairfax on Monday, July 27, 2009, at 6:30 to 7:30 PM. Dr. Jones will give participants an overview of the topic, answer questions and then will take attendees on a tour of the clinic. If you are interested in attending, click here to register.  

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GIVF ACHIEVES 20,000 PREGNANCIES WORLDWIDE! Since its first year, 1984, GIVF has now helped patients achieve over 20,000 pregnancies.
Ask a Question  
"What is diminished ovarian reserve?"

Ervin E. Jones, MD, PhD, FACOG
Reproductive Endocrinologist

Diminished ovarian reserve is a term used to describe a woman's potential for successful pregnancy--the desired end-point of all fertility investigation and treatment. In order for a pregnancy to occur, a normal egg must be available. The presumed ability of a woman to produce normal eggs underlies all so-called tests of ovarian reserve. There is no single test or group of tests capable of answering this question directly. All tests of ovarian reserve are indirect nonnumeric estimates of a woman's ability to produce normal eggs and of how many normal eggs remain in her ovaries. Such endocrine tests include, but are not limited to, cycle day 3 follicle-stimulating hormone and estradiol levels, the clomiphene citrate challenge test and measurements of other endocrine substances such as Inhibin-B and anti Müllerian hormone. These tests are often combined with what is referred to as the antral follicle count, i.e., the number of small follicles that can be seen on ultrasound during the early follicular phase.


Tests of ovarian reserve should be viewed as global estimates of ovarian competence. No test of ovarian reserve is completely predictive of a woman's ability to have a child. Instead, tests of ovarian reserve are used for counseling, decision making with respect to choice of treatment, and for inclusion and exclusion criteria. A normal test of ovarian reserve does not insure a woman's ability to produce normal eggs and embryos and an abnormal test of ovarian reserve does not always predict for failure. If they do not achieve pregnancy with their own eggs, women with significant diminished ovarian reserve often find that donor egg is a great option for achieving pregnancy.  

When Staying Pregnant is the Problem: Recurrent Pregnancy Loss

Harvey J. Stern MD, PhD
Director, Reproductive GeneticsDr. Harvey Stern

The loss of a pregnancy is a very unsettling experience for couples, but when multiple miscarriages occur, the effect is even more devastating. The American Society of Reproductive Medicine (ASRM) defines recurrent pregnancy loss (RPL) as a condition, distinct from infertility, characterized by 2 or more failed pregnancies. Some experts consider 3 or more losses in a woman less than 35 years of age as warranting evaluation. Although about 15% of all clinically identified pregnancies end in miscarriage, less than 5% of women experience 2 consecutive losses and only 1% experience 3 or more. In women who have a history of 2 miscarriages, the subsequent risk of pregnancy loss rises to 25%, while 3 losses raises the risk of a fourth to 33%.


Often, the patient's obstetrician will initiate an evaluation of couples with recurrent pregnancy loss, but frequently, experts in reproductive medicine and medical genetics are also asked to provide consultation to these patients. At GIVF, we offer our experience in reproductive medicine and genetics to couples with RPL and work with their obstetricians to devise an appropriate evaluation and treatment plan.


There are many causes of RPL, and in at least 50% of couples who undergo evaluation, no explanation for RPL is identified. Possible reasons for RPL include:

  1. Chromosomal abnormalities in embryos from egg or sperm, particularly in women over 40 years of age
  2. Endocrine (hormonal) abnormalities
  3. Diabetes and other metabolic disorders
  4. Anatomical abnormalities of the uterus
  5. Autoimmune disorders
  6. Thrombophilias (clotting disorders)
  7. Sperm chromatin abnormalities
  8. Possibly some infections, lifestyle factors, or exposure to toxins

The typical evaluation will include a comprehensive medical and family history, physical exam, blood tests for chromosome analysis, measurement of hormone concentrations, autoimmune and thrombophilia testing, semen analysis and bacterial culture of the male and female reproductive tracts. For women, the anatomy of the uterus is evaluated with transvaginal ultrasonography, hysterosaplingography or saline hysterosonography. Any findings in the male can be further evaluated by a urologic specialist.


Testing can take several weeks to complete and, when results are available, the couple returns for a detailed discussion with their physician. All reproductive options are discussed, including assisted reproduction by IUI, IVF or donor gamete where appropriate. A comprehensive medical summary and treatment recommendations are forwarded to the patient's obstetrician.


Most patients do not need IVF and, in many cases, couples can be successful with natural conception. For patients identified with structural rearrangements of the chromosomes, IVF with preimplantation genetic diagnosis has been shown to be very effective. Patients with thrombophilia are often treated with anticoagulation, and surgical correction of structural uterine anomalies is generally possible.


The chance of having a successful full-term pregnancy is dependent to some extent on the number of miscarriages and whether any previous conceptions ended in a live-born child. Other significant prognostic factors include the maternal and paternal ages, presence of polycystic ovaries or other hormonal defects, maternal BMI and lifestyle choices such as smoking and alcohol consumption. In women with RPL without an identifiable cause, approximately 70-75% of women are able to have a successful pregnancy. If you wish to schedule a consultation with our medical staff for evaluation of RPL, please call our scheduling office at 703-698-7355.

Copyright © 2009 Genetics & IVF Institute