If your pelvic exam does not turn up anything significant, then the infertility workup proceeds to some relatively inexpensive, noninvasive lab tests.

Semen Analysis

This test is easy to do, and it can rule out (or diagnose) certain causes of male infertility. You and your partner should not have intercourse for two or three days before the sample is collected. Your partner provides a sample of sperm by masturbating into a sterile cup or, if he has religious strictures against masturbation, a special condom can be used and the sample collected during intercourse.

Sometimes it is difficult to get the man to donate a sample. Even when I suggest that his partner take the specimen to the lab to spare him embarrassment, some men simply refuse. Presumably they fear being responsible for the infertility problem. In away, this test also shows the man’s commitment to having a child; if he is not willing to give a semen sample, the couple has problems other than those strictly related to infertility. If male-factor infertility does turn up, then the woman may be able to avoid or at least put off tests that are far more invasive than donating a sperm sample.

What does a semen analysis measure?

For the simplest tests the lab looks at five things: volume, viscosity, sperm count, motility, and morphology. First the lab looks at how much semen there is. Most labs define as normal anything between 2 and 5 ml, though others look for as little as 1.5 and as much as 8 (a teaspoon is 5 ml). It is unusual to find less than 1 or more than 8 ml of fluid in the ejaculate. Less does not necessarily mean that the man cannot father a child, but it does indicate a possible problem. More is not always better, since concentration is important.

Viscosity, the thickness of the fluid, is important because sperm must be able to swim easily in this medium. If the semen is too thick, it impairs motility, the sperm’s ability to move around.

One of the most telling tests is the sperm count. A normal sperm count is 60 million per milliliter of fluid; most fertility specialists consider something like 20 million per milliliter an acceptable minimum, and certainly a man with a count in that range can father a child.

The lab will also look at motility. How fast are the sperm swimming around? Are they moving forward? Are they still active an hour later? (We hope to see at least 60 percent continue to move around energetically, though probably the motility during the first hour is most important.) It is a bad sign if the sperm count is normal but only 10 percent of the sperm are mobile.

The test also looks at morphology, the shape of the sperm. How many are normal in appearance and how many abnormal? Do the abnormal ones have one head or, as occasionally happens, two heads? Are the tails normally formed?

What factors can affect sperm production?

Illness, injury, infection, perhaps a drug reaction or exposure to pollutants can interfere with sperm production. Another potential problem, though this is controversial, is a varicocele, a cluster of varicose veins in the scrotum near the testes.

Since sperm take about two months to make, a low sperm count or other poor evaluation may reflect an illness two months previously. So it is worthwhile to do a repeat test a few weeks later. If the count improves with the second test, so much the better. If not, then the man should seek help.

Does a varicocele interfere with sperm production?

It is possible that a varicocele interferes with sperm formation because its distended veins either cause a backward flow of hormones or allow more warm fluid to bathe the testes. The reason the testes are outside the body, of course, is that in order to thrive, sperm must live in an environment cooler than body temperature.

However, these theories are controversial. A varicocele can be corrected with surgery, and many researchers believe the procedure really helps; others are not so sure.

What kind of doctor deals with male infertility?

A urologist specializes in urinary problems and male reproductive difficulties. There are a few gynecologists in this country who also specialize in male infertility, but for the most part the two specialties are segregated by the sex of the patient. Urologists are trained to help with physiological problems (for example, poor sperm production) as well as anatomical ones (for example, blocked tubes) that require surgery.

Tests to Pinpoint Ovulation

Another easy and inexpensive test is a month-long basal body temperature check for ovulation. I am not a great believer in basal body temperature charting as a way to determine ovulation; there are more sophisticated and accurate ways to find out the same thing. Furthermore, you can have a classic temperature pattern, with dips and rises in all the right places, and still not be ovulating. Conversely, your temperature pattern on the chart can look extremely doubtful, yet you can be ovulating perfectly.

What are ovulation predictor kits?

More accurate than the basal body temperature method (but not 100 percent foolproof) are kits that confirm ovulation by measuring the so-called luteinizing hormone surge. Luteinizing hormone (luteinizing hormone), which triggers ovulation, rises dramatically in the blood just before the egg is released; it is excreted in the urine, where it can be conveniently measured. These tests indicate the extent of the surge by color changes or other means. The kits are available over the counter at a pharmacy. Some common brands are First Response, Clear Plan, and Conceive. They cost less than thirty dollars, which you will probably have to pay out of pocket, since your insurance is unlikely to cover them.

Ovulation predictor kits will tell you whether you are ovulating and will give you a little advance notice to help you time intercourse for your most fertile days. But remember, even if you time the act perfectly, you still have only a 15-20 percent chance of getting pregnant in a given month.

Is it possible to have an LH surge and still not ovulate?

Although possible, it is very rare. The condition is called luteal unruptured follicle (LUF) syndrome. It means that your hormones surge in the usual way and the follicle matures, but it does not burst out of the ovary. It remains inside and is gradually reabsorbed.

Are there other ways to test for ovulation?

A blood test that looks for a high progesterone level can confirm ovulation. It should be taken toward the end of the menstrual cycle, day 23 or 24 of a twenty-eight-day cycle. A level below 3 nanograms per milliliter (a nanogram is one billionth of a gram) indicates that you are probably not ovulating at all. A level lower than 10 might indicate that you are ovulating but not ovulating well, which means that the egg leaves the ovary and can be fertilized, but does not implant solidly in the uterine wall and is not hormonally well supported during the early stages of pregnancy. The condition is known as inadequate luteal phase and is so controversial that some researchers do not even believe it exists. A progesterone level higher than 10 suggests that you are ovulating well.

What can you do if ovulation tests show that you are not ovulating?

Fertility drugs can enhance ovulation, but if tests show that you are not ovulating or not ovulating well, then it is advisable to try to ascertain the cause before proceeding. Some of the reasons women fail to ovulate include problems with weight (being overweight or underweight), and certain diseases or conditions (including polycystic ovarian syndrome) that interfere with the normal cycle of hormone control.

What is polycystic ovarian syndrome (PCOS)?

Polycystic ovarian syndrome is a noncancerous condition in which the ovaries contain many partially developed eggs (cysts) just beneath their outer walls, which become thickened and fibrous. Women with PCOS have abnormally high levels of androgens (male hormones, including testosterone) circulating in their blood, much higher than the small amounts all women normally produce.

The symptoms of the condition include loss of ovulation and of menstrual periods, unwanted hair growth in a masculine pattern, and sometimes obesity. Women with PCOS who do not ovulate can be treated with Clomid or Perganol.

How is body weight related to ovulation?

Although researchers do not understand the exact mechanism, it is clear that body weight (or the ratio of fat to lean tissue) and ovulation are related. Girls do not begin to menstruate or ovulate until they have reached a certain critical body weight. Women who are extremely thin — whether because of anorexia, excessive dieting, or an extremely high level of exercise — often fail to ovulate and stop having menstrual periods. In terms of infertility treatment, women with anorexia and athletes are very different, though both have infertility problems because of low body weight.

Some women who are obese do not ovulate. Their fat tissue makes a kind of estrogen that circulates in the blood at a more or less constant level, unlike the usual monthly hormonal ebb and flow whose ups and downs rouse the pituitary gland to action. The constant level tricks the pituitary into “thinking” that ovulation has already occurred, and it does not start the hormonal process that results in ovulation. Sometimes obese women begin to ovulate once they have succeeded in losing weight.

Is there a way of knowing whether you are eating too little or exercising too much when normal ovulation doesn’t occur?

If low body weight seems to be inhibiting ovulation, it is worthwhile to determine the underlying causes of the problem before you start dealing with pregnancy. Is this woman underweight because she is anorectic or because she runs ten miles a day?

Women with anorexia do not handle pregnancy well because they have problems with body image, problems that are made worse by the weight gain and increasing girth of pregnancy. Because an anorectic woman is likely to starve both herself and her unborn child during pregnancy, it is vital that she resolve the issues underlying her anorexia before she becomes pregnant. We think of the body as wise, as capable of making subtle adjustments in its own interests. If a pregnant woman continues to starve herself, the fetus will also be malnourished. It seems that the body, sensing its own malnutrition, shuts down ovulation and eliminates the possibility of an unhealthy pregnancy.

Women who exercise a great deal, for example elite runners, have a different problem. Most of these women are not troubled psychologically; they just like to run. Sometimes changing their exercise habits a little, training a little less, and putting on a little weight will solve the problem. Or these women may need help starting a pregnancy, but they usually do very well once they conceive.

What can be done about failure to ovulate?

It is quite easy to bring about ovulation in women who are underweight or have certain types of hormonal problems by using so-called fertility drugs, medications that imitate the natural hormones that prod the ovaries into action. One of these drugs is Clomid (generic name clomiphene citrate); the other is Perganol, a preparation of the actual hormones follicle-stimulating hormone and luteinizing hormone.

Clomid is less powerful and simpler to use because it comes as a pill, taken five days in a row, around days 4-8 of the cycle. Clomid seems to work by blocking estrogen receptors at the pituitary level. That is, it prevents the pituitary gland from recognizing that estrogen is circulating in the blood; the pituitary “believes” that there is no estrogen in the body, so it kicks into overdrive to stimulate the ovary to ripen follicles and head toward ovulation.

Perganol, given as an injection, stimulates the follicles to grow and mature, but does not actually cause the follicle to burst out of the ovary. It is sometimes used along with human chorionic gonadotropin to accomplish that purpose. It is more powerful than Clomid and needs more monitoring. Both these drugs are used in assisted reproduction technologies, such as in vitro fertilization.

Do these fertility-enhancing drugs have side effects?

Clomid has relatively few serious side effects, and most of the drug has been released from the woman’s system by the time she ovulates. A few women get headaches and have hot flashes. A few notice visual changes, for example spots and dots in front of their eyes. If any of these things happen to you, call your doctor.

Other women report that they have premenstrual symptoms. They may become irritable and have hormonal mood swings; some notice cramps, which may be focused on one side of the abdomen. These symptoms are indications that the woman is ovulating well, so they are good signs. Rarely, Clomid can cause ovarian cysts and ovarian enlargement. Pergonal can cause the same and other side effects, including ovarian cysts.

What is the likelihood of multiple births with these fertility-enhancing drugs?

With Clomid, the rate of multiple births is fairly low, about 6-8 percent, and most of those births are twins. With Pergonal the risk is in the range of 20-30 percent, and the pregnancy is likelier to produce triplets or larger numbers of infants. Of the total births to women who took Pergonal, 5 percent involve three or more babies.

Since multiple births can be dangerous to both mother and infants (even without considering the difficulties of raising several children at once), you and your partner should understand and accept the risk before you agree to this therapy. The number of fertilized eggs can be reduced from several to two, but obviously this is a type of abortion and poses its own set of questions.

Do Clomid and Perganol increase the risk of ovarian cancer?

No one knows. Early research was based on case reports of very few women, and to date there have been no rigorous studies on women who took either Clomid or Pergonal for certain numbers of months.

Miscellaneous Blood Tests

Easy and inexpensive blood tests for two other hormones, thyroid hormone and prolactin, can help rule out other causes for infertility. Women with abnormal thyroid function, either too much or too little, often have difficulty getting pregnant because proper ovulation depends on a normal level of thyroid hormone. The thyroid function test measures for a hormone called TSH (thyroid stimulating hormone) and for thyroid hormone itself. Abnormal thyroid function is easily corrected with medication.

Prolactin, a hormone made by the pituitary gland, stimulates the breast to produce milk after the birth of a child. When its levels in the blood are elevated, it can inhibit ovulation and interfere with the normal menstrual cycle without causing noticeable symptoms. Elevated prolactin levels are easy to remedy with medication.

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