New Treatments for Infertility 3

What are some of the other concerns? We all know that over 35, as a general rule, we recommend that people get some sort of counseling so that they know what their options are in terms of amniocentesis, CVS, what have you. Why is that? Not only in spontaneous pregnancies, but obviously in IVF, you can show that the incidence of aneuploidy is astronomically higher independent of anything else, just from age.

So what do we do? Well, the place to start is with the semen analysis. Pretty much anybody who comes into my office as a couple who have six to 12 months of infertility, depending on age, has a semen analysis. We do this regardless of the male’s history, regardless of whether he had a child two years ago with another partner, or whatever. We do a semen analysis because the incidence is pretty high of finding something – somewhere around thirty to thirty-five percent of all couples that just show up at your doorstep, before you know anything about them, will have a male factor. This is something that we can pretty much cure if you take money out of the equation. Close to ninety-nine percent of male factor is curable, even with so-called testicular failure.
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What is a semen analysis? The numbers you need to remember are 20 million motile sperm per cc in the ejaculate and 3 to 5 ml is the normal ejaculate and at least fifty percent normal forms – normal morphology. The reason that the numbers are low – fifty percent – is because in the normal ejaculate you find other things and that is to be expected. So you have to take that into account.

Pretty much the one male factor that everyone talks about is varicocele. It is really quite controversial. Does it even cause infertility? Does it cause oligospermia? Does it cause azoospermia? The truth is that we don’t actually know the answer to that question. We also clearly don’t know the answer as to whether or not varicocelectomy – removing it – makes a bit of difference. I can tell you that there is no randomized trial to answer that question and you can find just as many cohort studies of people who stay that removing it will make a difference as people who say that removing it doesn’t, regardless of their background – urologic or gynecologic. I can tell you that for the same money, if it boils down to that, nowadays, to me it personally doesn’t make a lot of sense if you have some sperm in the ejaculate and you can get around the problem. If there is a urologic reason and you are worried about what this really is – is it veins, is it a tumor or is it something else – that is obviously a different story. But if you are sure that it is a varicocele, which usually you can be with simple palpation, then I would believe that surgery is pretty much secondary. That is pretty much the standard nowadays.

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