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oct01 - December 20th, 2005 5:55 PM

Dr. Smith,

My husband and I have been TTC baby #1 for 19 months. We are both 31.

All of my tests have come back normal (ovarian reserve is considered excellent, no blocked tubes). My RE suspects possible mild endometriosis but she cannot confirm.

After 4 failed IUIs with letrozole/follistim, my husband had a SCSA test because of consistent borderline SA results.

SCSA #1-- DFI: 47.3%, HDS: 18.9%
A bi-lateral varicolectomy was then performed with a second SCSA test done 3 months post-op
SCSA #2-- DFI: 19.8%, HDS: 20.9%

Question 1
I have read several studies regarding DFI and HDS levels and have reached the conclusion that although our DFI is now in the "good fertility" range for natural conception, our HDS level is considered above normal and requires ICSI. In other words, we would still need ART to conceive. Am I correct?

Question 2
Also, since DFI seems to be correlated with miscarriages while HDS is correlated with fertilization, shouldn't we have achieved at least one chemical pregnancy (day 3 embryo) over the course of 19 months and 4 IUIs, based on my husband's first SCSA test? Just trying to figure out if HDS is our only issue at this point or if there may be something else going on.

Thanks so much for your help.

Dr Smith - December 22nd, 2005 9:48 AM

Whether or not you require ART will depend on the other semen parameters as well. Unless I have that information, I cannot advise you. Please provide a bit more information. I'm going on vacation until 02/06, so I may not be able to get back to you until the new year.

oct01 - December 22nd, 2005 10:46 AM

The following semen analyses were done before the SCSA tests as well as the bi-lateral varicolectomy.

SA #1
Concentration: 69.80 mill
Motile: 45%
Progression: 3
Morphology: 14%
Round cells: 2 mill

SA #2 (IUI-- pre-wash)
Concentration: 49 mill
Motile: 20%
Progression: 2

SA #3
Concentration: 81 mill
Motile: 65%
Progression: 1-2
Morphology: 8%
Round cells: <1.0

SA #4 (IUI-- pre-wash)
Concentration: 68 mill
Motile: 62%
Progression: 2
Round cells: 3 mill

SA #5 (IUI-- pre-wash)
Concentration: 36 mill
Motile: 35%
Progression: 2

SA #6 (IUI-- pre-wash)
Concentration: 12 mill
Motile: 35%
Progression: 2

Would the round cells that were noted in some of the SA's be related to the above normal HDS levels of the SCSA (immature chromatin)?

Thanks again for your help. Hope you have a great vacation!

Dr Smith - December 22nd, 2005 12:11 PM

O.K., now I have a better picture. From the information you provided, I would recommend IVF/ICSI as the most efficient way for you to conceive. The abnormal semen parameters (especially the low motility and low progressive motility) are the likely reason the IUI's failed, but if there is an "egg problem", you wouldn't know it unless you do IVF. IVF would provide the first opportunity to evaluate the quality of your eggs.

The "round" cells noted in the SAs were probably white blood cells. If the concentration of white blood cells in the semen is more than 1 million per milliliter, it suggests that your husband may have a subclinical UTI. The usual treatment is antibiotics. Since it appears to have resolved on its own, treatment may be unecessary. In any case, it would not be related to the elevated HDS index.

oct01 - January 19th, 2006 2:00 PM

Dr. Smith,

Thanks so much for your previous responses. My husband is having a new SA performed in a few weeks (it will be his first since the bi-lateral varicolectomy) and we are also having a sperm anti-body test conducted before we move to another round of IUI or start IVF/ICSI.

In addition, I just found out today that I tested positive for ureaplasma. My husband and I will both be treated with antibiotics for 10 days to clear it up.

Could ureaplasma explain the high round cell count in his previous SA's?

To what extent does ureaplasma impact fertility? I've found mixed opinions about this.

Lastly, could ureaplasma negatively impact the success of an IUI? Just curious about whether or not it possibly played a role in our previous failed IUI attempts.

Thanks again for your help. I'm very interested in this new finding in our fertility evaluation.

Dr Smith - January 19th, 2006 2:52 PM

Your question is more of a medical question, so I think you should get Dr Jacob's opinion as well. From what I understand, there is no conclusive evidence to suggest that ureaplasma impacts fertility one way or another. It one of those things that they test for and treat if they find it. And no, its unlikely that ureaplasma caused the elevated WBC in the semen. You husband may not even of had ureaplasma.

oct01 - January 31st, 2006 2:41 PM

Dr. Smith,

Our 4 failed IUI's last year included 2 rounds with Letrozole and 2 rounds with Letrozole and Follistim combined.

As indicated in my previous posts, we have rectified the only known male factor (bi-lateral varicoceles) and my husband's DFI has gone from 47% to 19%, HDS stayed the same at 20%. We are waiting on his new SA results.

Given the improvement in DFI, our RE suggests another round of IUI before moving to IVF/ICSI. However, she is recommending that the cycle include a combination of Letrozole and Follistim to increase the chance of pregnancy.

I responded well to 2.5 mg of Letrozole last year (producing 1 egg and a good cycle). I also responded well to 5 mg of Letrozole with Follistim (producing 3 eggs and a good cycle).

My question is:
Given that our circumstances have improved, is it necessary to increase the number of eggs for IUI when it may result in multiple pregnancies? Is it possible that our odds are just as good with producing just one egg?

I want to do whatever makes the most sense but I'm also concerned about the risk of a multiple pregnancy unless it is necessary (in other words, unless it is a necessary risk in order to get pregnant).

Thanks again for your thoughts.

Dr Smith - February 1st, 2006 5:49 PM

I think the most expedient way for you to become pregnant is through IVF/ICSI. You have already spent a significant amount of time and expense with 4 unsuccessful IUIs. I think its time to move on. Also, IVF will provide information about egg quality (which at this point we know nothing about) and allow the number of embryos transferred to be strictly controlled and thereby reduce the risk of high order multiple gestation. Based on your history, I would estimate your chances of conceiving on a natural cycle IUI to be pretty low, not zero, but pretty low (e.g. <10%). I would estimate your chances of success on a stimulated IUI cycle are around 15%. Based on your age alone, IVF/ICSI should put you in the 40-50% take home baby bracket.

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