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Hi Dr. Ramirez -

I've read all of you responses to posts through 2012 and 2011 and have been so impressed with your willingness to take and answer questions from all over the world.  I have two questions which are unrelated but both potentially affect my fertility.

I am 34 and have done all the necessary screening.  CD3 bloodwork; HSG; AMH; etc. and everything turns out fine.  I have also done a number of ultrasound and blood work monitored natural cycles (no stimulation drugs) with HCG trigger and either timed intercourse or IUI and again everything checks out fine.  I typically get triggered and coincidently also tend to get my first positive OPK (testing done before trigger)around the same time. my follicle has been between 17-18mm; lining is between 10-12.5mm; and E2 is between 207-296 at last ultrasound before told to trigger.  I typically O around CD 11 and my luteal phase is between 13-14 days.

My husband's sperm count is good - typically about 110 Million pre-wash and motility pre-wash about 55%.  His post wash count has been between 25 million - 65 million with motility between 90% and 98% depending on how soon before the IUI we have last had sex.  They don't test his morphology at the time of IUI but his baseline Semen Analysis noted a morphology of 4% with strict Kruger.  His predominant abnormal was 22% with tapered/elongated heads.  Since then he started vitamins (Wellman's Conception from England) but we have never gotten morphology retested.  Could the morphology be negatively affecting us? Would it still be affecting us even though we are now doing IUIs?

One interesting thing about me is that I tend to have allergies (terrible sneezing) that coincides with right before O or midway during the luteal phase.  My allergies before O are far worse however then what I get during my LP. I have undergone allergy testing and did not react to anything and over the year or two of BBT charting have realized that I must be reacting to either estrogen increasing or progesterone increasing.  Could this negatively be affecting my ability to conceive?  I have never had a positive on a pregnancy test.  Recently since doing the IUI - for the first time I have been experiencing some cramping for a couple of days around the time of implantation (9-111 dpo) so I think something is going on finally.

I haven't done clomid or femara yet as my RE says I don't need it and is not a proponent of giving it to me given my results so far which he says is exactly what we try to get drugs to replicate.  He has prescribed me progesterone now that I am doing IUIs but I was hesitant to take them as my LP was 13-14 days with no spotting except for the day before my period showed and my temps stay high.  I am however finally willing to try them now (just did my 4th natural cycle IUI) and so have started taking them this cycle for the first time.

Any advice you an provide would be greatly appreciated.

Answer
Hello Sunny from the U.S. (D.C.),

I think you have definitely been trying to maximize your natural chances of pregnancy but disagree with your doctor about using a fertility drug.  He is correct in that the purpose of these drugs is to induce ovulation, which you already do naturally, but that is not the purpose in your case.  The way that IUI increases pregnancy rates is not necessarily by getting the sperm closer to the egg for fertilization to occur, or by increasing proper timing for the sperm to be in place; both of these are true also, but it is increased mainly through "superovulation" which is increasing the number of eggs ovulated at the time.  There is a misunderstanding that when ovulation occurs, eggs go directly into the tube.  In fact, the end of the tube "fimbria" extend about 2cms (1 inch) from the ovary and lie within a space behind the uterus called the "culdesac."  When ovulation occurs, which can occur from any surface of the ovary, the egg, unlike a laser guided missile, goes wherever it falls because it doesn't know where the end of the tube is.  The fluid it is bathed in (the black part of the follicle that makes it very visible on ultrasound) rushes out, like a water balloon with a leak and the fluid collects in the culdesac taking the egg with it. And, voila, the egg and fimbria are in the same location so then with fluid motion (or your body's motion), the egg gets in contact with one or the other fimbria.  Sometimes they never meet and you don't get pregnant in that month.  So, by increasing the number of eggs available in the culdesac, you increase the chances that one of the eggs will find the fimbria and be available for fertilization.  I tell my patients it's like having a fleet of boats looking for an island rather than just one.

The second issue is the sperm problem.  The semen analysis was developed to evaluate sperm because that is the only way that we can.  The real importance of sperm is whether it can fertilize your egg but there is no test for that without in vitro fertilization.  So we do a semen analysis and measure the things that we can, again a limitation of our technology, and make an interpretation.  Some of those parameters are certainly valid because we know that there has to be certain quantities for natural pregnancy to occur, but it is not the whole story.  In your case the number of anatomically normal sperm is decreased.  By the 2010 WHO criteria, this is within normal limits (>3%), but that seems like an awfully low number and doesn't coincide with the ESHRE criteria, so I would worry about it.  What is more important, however, and what I will usually insert into my decision making is whether this implies that there is  "functional" problem, meaning, does the sperm have a definiciency in fertilization.  We know this can be the case because with IVF, if a sperm or male factor problem was present, we saw significantly poor fertilization rates.  That is why ICSI was developed.  So this could be part of the problem.

Finally, and I apologize for the long response, did you have a laparoscopy done?  Many patients have a complete evaluation, sans the laparoscopy, and report that "everything was normal" or they have "unexplained infertility", but ultimately are found to have endometriosis.  Endometriosis is an insidious abnormality that can cause infertility.  I especially since it when I have a patient that has no obvious cause for their fertility failure and we finally do the laparoscopy.  So, if you are still trying for a natural treatment option, that may be something you want to consider having done.  If your plan is to proceed to IVF, then the laparoscopy is not required since you will bypass the pelvis with IVF.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

Monterey, California, U.S.A.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf.  Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate

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Edward Joseph Ramirez, MD, FACOG

Expertise

I am a specialist in infertility and advanced gynecological care. I can answer questions about infertility, gynecology related ills, menopause...virtually anything that affects women's health. PLEASE tell me where you are writing from as I am always interested.

Experience

I have been practicing as an Ob/Gyn and Infertility Specialist for over 23 years. Gynecology, advanced laparoscopic surgery, basic infertility, IUI's, IVF, reproductive surgery, and ovulation induction are all areas of my expertise. I am Board Certified. I have been doing In Vitro Fertilization in my clinic for 19 years.

Organizations
American College of OB/GYN, American Board of Obstetrics and Gynecology, American Society of Reproductive Medicine, Society of Assisted Reproductive Technology, American Association of Gynecologic Laparoscopists, Fellow of The American College of Obstetricians & Gynecologists,Resolve-National Chapter, Open Path - Northern California, Board of Directors Monterey Medical Society

Publications
American Journal of Obstetrics and Gynecology, Wall Street Journal, Monterey Herald, SERMO, Women's Health and Fertility Blog

Education/Credentials
Medical Degree from Stanford University, Residency at Tripler Army Medical Center, Reproductive Training at Pacific Fertility Center, San Francisco

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