I had a case recently which demonstrated to me the utility of Gene Security Network’s (GSN) Microarray Chromosome Analysis with Parental Support.  A 40 year old patient had previously had a miscarriage and underwent a D&C procedure, complicated by her hemorrhage and appropriate vigorous curettage.  Following that procedure, her endometrial cavity appeared compromised with both filmy and dense adhesions found at a subsequent hysteroscopy.  Some of the adhesions were lysed but the question of the competency of her uterus remained.

She conceived again with fertility treatment but had a fetus that underwent demise between the 6 and the 7 week ultrasounds.  I really wanted to know if the pregnancy loss was due to her uterine compromise or due to fetal aneuploidy. 

We performed a suction D&C and the chorionic villi as well as a sample of maternal blood was sent to GSN for Microarray Chromosome Analysis evaluation.  The results of this testing indicated a fetal karyotype of 47,XX,+10 (Trisomy 10).  Unique to this testing, GSN was able to determine that the abnormality was of maternal origin.  Also, if the result had been 46,XX,GSN would have been able to definitively rule out maternal cell contamination (MCC). GSN provided me with a report in less than a week.

With this information, we knew we could proceed on without further treatment to her uterus.  We considered egg donation because it was likely this loss was due to the egg and subsequent embryo’s chromosomal non-disjunction and it was less likely to be a uterine issue.  GSN’s POC testing helped me guide this patient’s future treatment decisions.

-Carolyn Givens, M.D.

Our story began about 4 years ago, in all likelihood similar to those couples who ultimately end up seeking help from a fertility specialist.  I had just turned 36 years old and was very happily married.  My husband and I decided to put our triathlon ambitions to the side and start a family. We naively assumed after I stopped birth control pills, we would start trying and would conceive shortly after. After all, we were just in our mid 30s’ and had no underlying health issues.  Unfortunately, a few months later, I was still not having normal menstrual cycles.  But of even greater concern, we received the devastating news that both my husband and I were carriers of a rare form of muscular dystrophy, and our odds of having an affected child would be 25%. 

And so began our emotional and medical “journey”.  Through many conversations, my husband and I recognized that conceiving our own child was a dream that we were not yet ready to concede.  We also wanted to explore any possibility that would allow us to conceive an un-affected child after having seen how my niece’s life was affected by severe muscular dystrophy.  We realized that we would need to seek out the best fertility specialist possible, and thus we found our way to Dr. Givens at Pacific Fertility Center. 

As a physician myself, I had done extensive research on fertility specialists and centers and was hoping that Dr. Givens would be able to help us.  Her credentials were outstanding and were exactly what we sought – a fertility expert specializing in advanced maternal age/decreased ovarian reserve and in PGD (prenatal genetic diagnosis).  After our first meeting with her, I knew that we had made the right choice.  Dr. Givens was extremely knowledgeable, professional and most importantly caring.  She understood that this was a very challenging fertility case, but embraced the chance to help us rather than tell us we should look into adoption.

With Dr. Givens help we were able to set up PGD through a planned IVF cycle.  This treatment plan required a great deal of coordination between Dr. Givens, PFC’s dedicated staff and California Pacific Medical Center’s genetic counselor Laurie Black.  It required months of patience as we waited for “probes” to be built by the PGD center and for the IVF cycle timing to be optimized.  Unfortunately, our first PGD-IVF cycle ended in an early miscarriage.  Dr. Givens remained optimistic and with some changes in our stimulation IVF protocol and using acupuncture, my husband and I were able to conceive during our 2^nd PGD-IVF attempt. We were thrilled!! As the months went by and my belly grew, we became increasingly excited that we were indeed going to be able to have our own unaffected child! About 38 weeks later we gave birth to our beautiful healthy daughter – a gift that words cannot express, as I believe all parents can attest to.  The extreme gratitude that we felt for Dr. Given’s help, perseverance and care during this journey can not quite be expressed in words.  Without her expertise and belief in a successful outcome, we would never have been able to conceive a child.

Within 6 months of having delivered, my husband and I approached Dr. Givens and told her how happy we were as parents and how much we would love to attempt having a second child to complete our family.  We assumed that we would be able to conceive just as we had the first time, as I was only a little bit older.  Again, I was proven naïve.  I had not realized that even 1-2 years could affect my ovarian reserve as much as we soon discovered.  The stimulation protocol we had used with our first daughter’s conception, this time produced only ½ the amount of follicles and eggs.  The quality of the embryos was also clearly less. We attempted 3 additional cycles: a frozen cycle (we had one embryo left from our initial attempt) and 2 fresh cycles. Quite tragically, we felt, we lost the second conception at around 6 weeks and then lost a twin pregnancy at around 8 weeks. The loss of miscarriage is indescribable. We realized that from a financial standpoint, we would not be able to continue attempts at IVF indefinitely.

Again, Dr. Givens advice was instrumental in helping us through this difficult time.  She expressed concern that our miscarriages were from poor quality embryos (genetic trisomy/monosomy/etc) and not from my own inability to carry a pregnancy.  She recommended that we give consideration to doing full aneuploidy screening of our embryos in addition to PGD – something that had only recently been medically possible.  Thanks to her expertise and connections with other experts in the field, we were enrolled in a clinical trial with GSN.  They were able to build probes again for our specific muscular dystrophy mutation and offer aneuploidy testing on all of our embryos.  We subsequently did our last fresh IVF cycle, this time with both PGD and full aneuploidy screening. We had a total of 10 embryos and only 1 was identified as being unaffected and with a full set of chromosomes.  We prayed that this sole embryo would implant – quite skeptical admittedly given that only one was transferred and with our daughter’s conception we had put in more.  Our prayers were answered!  We are now 30 weeks pregnant and additional testing done via amniocentesis has confirmed all of the PGD/aneuploidy test results.  My husband, daughter and I are all eagerly awaiting the birth of our second daughter in early February.

I hope that our story helps those out there who may have felt any of the things we experienced in our journey to create a family.  I learned not only to “never give up” on a dream, but that being cared for by someone like Dr. Givens is the only way for such a dream to become a reality.

-Anonymous

Update: On January 27th, 2011, our patient, the fist at PFC to undergo embryo biopsy for both genetic disease risk and chromosome analysis, gave birth to a healthy baby girl.  She weighed in at 6 lbs., 6 oz. and was 19 3/4″ long.  Congratulations to everyone involved in this success story!

These tests can be done by your primary care physician or gynecologist prior to consulting your Reproductive Endocrinologist:

• Day 3 FSH (follicle stimulating hormone) and Estradiol (Day 2-3 is acceptable)
• TSH (thyroid stimulating hormone)
• Prolactin
• Progesterone: 7 days prior to menses, this test is occasionally helpful
• Semen analysis

These tests may be useful based on each patient’s particular needs:

• Hysterosalpingogram (HSG) or documentation of tubal status
• Hysteroscopy
• Laparoscopy: The surgeon should be able to treat during this procedure, not just diagnosis.

The following treatments may be done, if indicated, for a limited number of cycles:

• IUI (intrauterine insemination)
• Clomiphene citrate (Clomid, Serophene)

At Pacific Fertility Center, we bring a complete team of specialists together to focus on your fertility situation. With extensive backgrounds as REI specialists, embryologists, nurses, marriage and family therapists and financial counselors, we develop a single, integrated solution to your medical, psychological and financial needs.

Please use our Ask the Experts resource if you have further questions.

– Philip Chenette, MD

These tests are best done through your Reproductive Endocrinologist (fertility specialist):

• Strict sperm morphology
  Strict morphology is a very specific method of evaluating the shape of sperm. Most laboratories do not use strict criteria thus potentially missing a sperm problem. Our laboratory is staffed with embryologists trained to analyze sperm with these strict criteria.
• Evaluation of ovarian reserve
  Evaluation of ovarian reserve includes family history, ultrasound to detect the antral follicle count (AFC), a cycle day 2-3 FSH and estradiol level (both must be done at the same time), Anti-mullerian Hormone AMH, and clinical and family history.  An REI can bring all of these assessments together into one consistent picture of a woman’s ovarian reserve.
• Ultrasound
  A pelvic ultrasound is a very useful test when it is done at the appropriate time in the menstrual cycle. A few days prior to ovulation an ultrasound can evaluate ovulation, follicle growth, endometrial thickness and pattern, polyps, and fibroids. During menses is the best time to evaluate the ovary for cysts and endometriosis.
• Genetic testing
  Genetic testing is important in women with premature menopause and multiple miscarriages and men with very low sperm counts.  Patients with a family history of a genetic disease can use genetic testing to determine if they are carriers of the disease.  Universal genetic testing (Counsyl, www.counsyl.com) can be used to assess risk for certain genetic illnesses that run in families. If detected, Preimplantation Genetic Diagnosis (PGD) can help prevent genetic illness in your child.
• Insulin
  Women who have irregular periods and have been told they have Polycystic Ovary Syndrome (PCOS) should be evaluated by an REI.  Testing can lead to more effective treatment.

Treatments by a fertility specialist

The advanced training of an REI is helpful to provide the most successful treatments for infertility.

Some of these treatments include:

• In vitro fertilization with embryo transfer (IVF, or IVF/ET),
• Fertility preservation
• Egg freezing
• Intracytoplasmic sperm injection (ICSI)
• Preimplantation genetic diagnosis (PGD)
• Ovulation induction
• Intrauterine insemination

A specialist is able to evaluate simpler treatments and finely tune them to make them more effective. For example, a specialist can monitor ovulation induction with clomiphene (Clomid) with ultrasound and blood tests. The vaginal ultrasound can be used to assess follicle development and endometrial pattern and thickness. Intrauterine inseminations can be done to bypass hostile mucus caused by clomiphene. The specialist can also help decide when to stop a particular treatment and/or proceed with more.

Alternative medications like letrozole (Femara) are just as effective as clomiphene but have fewer side effects.  Since letrozole is not approved by the FDA for marketing for fertility use, its use is generally restricted to specialty clinics, that is, REIs.

Gonadotropins, the injectable drugs, for example Follistim, Gonal-F, Bravelle, and Menopur, are potent stimulants to the ovary.  They are designed to produce multiple follicles, in order to improve pregnancy rates.  Due to the risk of multiple pregnancy and overstimulation of the ovaries, the medications should be used only by experts in the field.  Most of these treatments are performed by REIs in the United States.

At Pacific Fertility Center, we bring a complete team of specialists together to focus on your fertility situation. With extensive backgrounds as REI specialists, embryologists, nurses, marriage and family therapists and financial counselors, we develop a single, integrated solution to your medical, psychological and financial needs.

Please use our Ask the Experts resource if you have further questions.

– Philip Chenette, MD

Ovarian reserve is an expression of the number and quality of eggs available for conception. As a parameter for predicting pregnancy, ovarian reserve testing is often part of a fertility evaluation. Such testing requires specific measurement, and clinical judgment to interpret the results.

Egg numbers are at a maximum before birth, at around 20 weeks gestation. After birth, there is a progressive decline in the number of eggs from roughly one million at birth to 300,000 at puberty. Through the reproductive years the remaining eggs are lost, with the rate accelerating around the mid-30s, resulting in few eggs left at menopause, around age 50-52. The number of eggs available for reproduction at a certain age is the ovarian reserve, which is the target of the diagnostic tests described here.

Age is the most accurate predictor of egg health, but within age groups, there is considerable variation in the number of eggs remaining for reproduction. Age alone as a predictor of ovarian reserve is not sufficient, since, for individuals, fertility may be better or worse than the average for that age. Extreme examples of this variability include the teenager in menopause and the 59 year-old that delivered a natural pregnancy in 1997. This variability in pregnancy rates within an age group is present in all reproductive age groups.

To predict an individual woman’s fertility rate, in addition to her age, both clinical and laboratory methods are available to evaluate ovarian reserve. The best tests are direct measures of the ovary, such as the Antral Follicle Count (AFC) and Anti-mullerian Hormone (AMH) level; indirect measures, such as clinical history and levels of pituitary hormones, are common tools for prediction of ovarian reserve.

The simplest method of predicting fertility rates is clinical history, of both the individual and her closely related family. The number of months spent attempting to conceive predicts fertility. A couple that has been trying for some time will naturally have a lower fertility rate than a woman that has not had unprotected intercourse. Response to ovarian stimulation can also be used as a marker, as it is fairly consistent between cycles. Family history, i.e., the fertility of the woman’s mother or sisters reflected in age at menopause and age at conception are useful predictors. Such factors from clinical history can help define the risk of a problem with ovarian reserve.

Ultrasound is a useful tool for predicting ovarian reserve, as in measuring the Antral Follicle Count (AFC). Antral follicles are the smaller follicles, visible on ultrasound, between 2 and 10 mm, that are lost as a woman ages. In younger women, the AFC is 10-20, declining by 5% per year through age 37, and then accelerating to a loss of 10% per year thereafter. Women show a fairly consistent AFC loss rate of one follicle every two years.

AFC predicts the response to ovarian stimulation at least as well as blood tests, but its ability to predict pregnancy outcomes is limited, particularly when low. A woman with a higher AFC will show a better response to fertility drug treatments. A high AFC seems to predict pregnancy rates, but data remains limited, as there are no prospective studies published. A low AFC seems to be a less accurate predictor of ovarian reserve, particularly in older age groups. AFC may help predict outcomes, but should not be used to exclude patients from treatment.

Anti-mullerian hormone (AMH) is a blood test that directly measures ovarian reserve. Produced directly by early stage ovarian follicles, high levels (over 1.0) are favorable, while low levels (less than 1.0) indicate decreased ovarian reserve. AMH may be the best measure of the menopausal transition and ovarian age. It may also be useful in predicting ovarian hyperstimulation syndrome, the effects of chemotherapy, and in determining the treatment of PCOS.

AMH seems a superior predictor of ovarian response compared to other markers, including age, and day 3 FSH and estradiol. It offers similar predictive value compared to AFC. AMH can be drawn at any time in the menstrual cycle, and is not affected by hormonal therapy, including oral contraceptives.

AMH still requires further study. The range of normal variation is still being determined, and the true predictive value of the test requires a great deal more analysis. The specific range of reliability and predictive value by age is yet to be established.

Cycle day three FSH and estradiol, and, to a lesser extent, the clomiphene challenge test, remain viable tests for estimating ovarian reserve. These tests are established as predictors of response to ovarian stimulation. Prediction of pregnancy rates is more difficult. Recent studies concentrating on the predictive value of these tests have shown that they cannot be used to determine which patients cannot conceive, but are useful for screening and counseling.

All in all, these tests are only rough predictors of ovarian reserve. They are moderately good predictors of ovarian response to stimulation, and relatively poor predictors of pregnancy outcome. In a particular patient, the tests can be used to counsel about potential response to ovulation induction, but it remains difficult to predict pregnancy outcome based on the test results.

The ultimate test of ovarian reserve is response to treatment and whether a pregnancy results from that treatment. Stay tuned as we evaluate further research to establish the validity of ovarian reserve testing methods.

Many populations of the world have specific genetic conditions that are prevalent within their ethnic group. Consequently, numerous medical organizations have recommended that genetic screening for these conditions should be offered when women are either planning for, or are currently pregnant. We are all carriers of genetic conditions: generally this is of little concern, as it is highly unlikely that we would have children with a partner who is a carrier for the same condition.

The genetic conditions listed in the table below are recessive. A recessive gene mutation is “carried” by someone who is unaffected by the disease, and thus unaware of their carrier status. Men and women have equal potential to be carriers for recessive conditions. Even if someone is a carrier, we would not expect to see a family history of the disease. If there is a family history, the likelihood of being a carrier of that condition is generally greater than in the general population. Being a carrier for a genetic condition typically has no impact on the carrier’s health and development. However, if a carrier has a child with another carrier of the same genetic disease, the chance that the child will be affected with the disease is 1 in 4 (25%).

If only one partner is a carrier, and the other tests negative, then the risk of an affected child is low, but not zero (a result of the limited ability to test for all defects that would make one a carrier; see table). These genetic screening tests are typically performed on a blood sample.

Below is a table listing the minimum number of tests for various ethnic groups recommended by the physicians at Pacific Fertility Center prior to starting assisted reproduction treatment. Additional genetic tests may be considered after a discussion with your physician.

If you know that both you and your partner are carriers of the same genetic defect, you may be able to have embryos created in an IVF cycle and tested for their status. Preimplantation genetic diagnosis (PGD) is a technology that allows embryos to be tested for specific disease causing mutations. PGD can identify unaffected embryos for transfer back to the uterus or freezing.

—Guest Contributor – Certified Genetic Counselor Lauri Black, M.S., C.G.C

*See lab specific accuracies on test result

Question: I’m 38 years old and have been trying to get pregnant for about a year. All of my lab tests and my husband’s semen analysis have been normal. What do you think is the problem?

Answer: For women in their late 30s, it is naturally going to take longer to get pregnant. They are experiencing what I like to call “age-related sub-fertility.” Some may be lucky and become pregnant right away. However, for the majority of women, as we age fewer of the eggs we ovulate are chromosomally normal; and therefore fewer ovulations result in the release of a normal egg. It just may take more ovulations before that normal egg is released, fertilized, implants, and succeeds in becoming a baby. It is estimated that about 1 in 5 eggs are normal at age 35, about 1 in 10 at age 40, and only 1 in 25 at age 45. So, at age 38, if about 1 in 8 eggs are normal, you may have only 1 or 2 chances a year for successful conception. If your intercourse was not well-timed that cycle or there was some other subtle inefficiency, the chance for conception may be lost. The catch-22 with age-related sub-fertility is that it takes longer to get pregnant and meanwhile, you are getting older and your egg quality is also declining. For this reason, many women seek treatment with fertility medications or IVF as they get older. These treatments can increase the number of eggs produced and exposed to sperm in a single month, thus improving the odds that normal eggs will be found. The good news is that for most women still in their 30s, fertility treatments for age-related sub-fertility are often successful.

– Carolyn Givens, M.D.

An Example X-Ray of a normal HSG	An example X-Ray of an abnormal HSG

Infertility due to blocked fallopian tubes was a common cause of infertility in the 1970’s and 1980’s. Some textbooks from that era quote an incidence as high as 25% of all infertility causes. At Pacific Fertility Center in 2005, only 10% of our in vitro fertilization patients were noted to have a tubal factor contributing to their infertility. Fallopian tube damage is most commonly due to prior infection with a sexually transmitted disease such as gonorrhea or Chlamydia. Most chlamydial pelvic infections are relatively asymptomatic and may go unrecognized; therefore many patients with tubal obstruction are unaware they have a tubal problem. Better safe-sex practices and improved screening of young women are possible factors for the lower incidence of tubal disease we are seeing, at least in our Bay Area infertility population.

Even though there is less tubal factor infertility these days, if there is a tubal obstruction, the course of fertility treatment becomes quite definitive: in vitro fertilization. No other treatments, including surgery, are likely to result in a healthy intra-uterine pregnancy. Therefore, we are still advocating some type of screening test for tubal factor in the evaluation of infertile couples.

There are two common ways to determine whether there is tubal obstruction. One is surgery, where dye is passed through the cervix, uterus and tubes, and there is direct visualization of the flow of the dye out the ends of the tubes into the pelvis. The other is the HSG, or hysterosalpingogram. The HSG is an X-ray procedure that involves placing into the cervix a small flexible catheter with a balloon around the tip to hold the catheter in place and close off the cervical opening. Radiographic contrast dye is then instilled into the uterine cavity, using a syringe attached to the tube. Under X-ray visualization, the dye is tracked into the uterine cavity and into the tubes. Pictures are taken during this process to document the shape of the uterine cavity and whether or not the dye enters and flows through both tubes into the pelvis.

HSG procedures are usually performed by radiologists; however, if there is difficulty placing the catheter securely into the cervix, the radiologist may ask the patient’s gynecologist to assist. This test is valuable in determining tubal blockages, but it has some disadvantages. It is very important to get the balloon properly inflated in the cervix to keep enough pressure on the fluid (no back flow into the vagina) so it will enter the fallopian tubes. Unfortunately, this pressure on the walls of the uterus can cause the uterus to contract, causing the patient to experience significant cramping. For this reason, it is recommended the patient take 2 or 3 ibuprofen prior to the procedure.

In some cases, the pressure is enough to cause the smooth muscle walls of the fallopian tubes themselves to spasm, blocking any dye from entering the tube. Sometimes the dye flows so easily through one tube that there is not enough pressure generated to get the dye to fill the other tube. These are some of the drawbacks of the procedure. This is why, even when we get a report of one-sided tubal obstruction, we are often skeptical that this is really due to some abnormality of the tube.

Although there are some false positives associated with this test, if the dye fills both tubes and does not flow out the ends of the tubes, this is highly suggestive of true tubal obstruction. In this instance, IVF is indicated.

1. A healthy woman in her late 30’s or even in her 40’s, will have the fertility of a younger woman.
   Although it is always better to be healthy, especially when it comes to carrying a pregnancy, the likelihood of conception is tied to the age of a woman’s eggs and is not closely related to her general health.
2. You should have sex every other day during the fertile window.
   For most men, sperm recovery is very rapid. Sometimes when an IVF cycle is done and there are many eggs to fertilize, we ask for a second semen sample. We are often amazed when the second sample, collected just 2 hours after the first sample, has even better numbers. So, rather than attempting to “save up good sperm” by having less frequent intercourse during the most fertile time period, we recommend more frequent intercourse. A home ovulation predictor kit is useful to time sex to ovulation. When using the ovulation predictor kit, we recommend sex on the first day of the LH surge and the next day too.
3. Fertility medications are associated with a higher risk of cancer.
   In the early 1990’s, some concerns were raised that taking fertility medications might be associated with a higher lifetime risk of ovarian cancer. Since then, several studies have been published that did not find this to be true. Because of this thorough and extensive research we feel comfortable using these medications not only on patients, but our egg donors as well.
4. Fertility medications (especially injectable fertility medications) cause women to be emotional wrecks.
   Although Clomid (clomiphene citrate) has well-known side effects related to its anti-estrogen effects, the injectable fertility medications do not tend to cause the same negative mood alterations. These drugs increase estrogen levels, a hormone which tends to have positive affects on mood.
5. Using fertility drugs and getting multiple eggs might use up my future eggs and cause me to go into menopause earlier than expected.
   Humans usually only ovulate one mature egg each month. This egg is contained in the dominant follicle and grows in one ovary or the other. For each dominant follicle that develops in any particular cycle, there are several other follicles/potential eggs available that are also trying to become that dominant follicle. The number of these other “antral” follicles varies from woman to woman and to lesser degree, from cycle to cycle. In general, the number of antral follicles declines with female age. Once the dominant follicle has been selected and the egg ovulated, the menstrual period or a pregnancy begin, and the other antral follicles, undergo programmed cell death, called atresia. The use of fertility medications rescues this group of antral follicles from atresia. For this reason creating multiple mature follicles and obtaining multiple eggs in any one cycle does not use up future eggs. We are simply rescuing eggs that would have otherwise died that month.
6. Having a miscarriage is a good sign that a woman is fertile.
   Approximately 70% of miscarriages are due to abnormal chromosomes (DNA) in the embryo. As a woman ages, more and more of her eggs become abnormal In fact, at age 40, only 1 in 10 eggs on average has normal chromosomes; so a woman at that age may only ovulate one normal egg per year. While a miscarriage may indicate that fertilization and implantation can occur, it doesn’t necessarily mean that overall egg quality is good. Egg quality is the best indicator of the ability to produce a viable pregnancy.
7. Stress is a major cause of infertility.
   There is enough circumstantial evidence to indict stress as a collaborator when it comes to fertility; however, there is very little evidence to convict stress as a major perpetrator. Usually there is some other underlying cause to the problem, even if it is just age-related sub-fertility (decline in fertility due to female age and therefore higher numbers of abnormal eggs). Stress, however, can compound the problem and possibly negatively impact egg quality and uterine lining quality. Look for a new addition to our website, the Domar Fertility Stress Questionnaire, to assess your stress levels.
8. In Vitro Fertilization can help women in their late 40’s and even 50’s to conceive with their own eggs.
   Despite the number of celebrities having babies in their mid-forties and beyond, these babies may not necessarily have been the result of an in vitro fertilization process using their own eggs. While we respect a woman’s right to privacy and their decision not to divulge this little detail, the perception left with the public is that fertility treatments can extend one’s reproductive life. Unfortunately, this simply is not true. There is a very, very low probability of improving one’s success of conceiving after age 43 by using assisted reproduction, unless the woman considers using donor eggs.
9. In Vitro Fertilization success rates are low.
   Across the United States, including patients of all ages, the delivered success rates for in vitro fertilization have risen from about 20% in the mid-1990s to about 35% in the mid-2000s. During this same period, fewer embryos were being transferred to the uterus per cycle and the triplet and higher-multiple pregnancy rates dropped dramatically. Though it may take more than one attempt to conceive, the majority of patients are successful.
10. Very few people ever experience infertility.
    Many fertility patients feel they are the only ones in their circle of friends and acquaintances suffering from infertility. At times, it seems as though everyone else is having a baby. Actually, one in six couples is having trouble with conception, they just may not talk about it. Since they are not pushing a stroller, there is no outward visible sign of their fertility status. When couples decide to share the story of their fertility quest, they often find there are many of their peers experiencing similar difficulties. They discover friends who can not only relate but also provide valuable support.

Interested in self-diagnosis of fertility? The ability to screen for fertility in private, on one’s own schedule, with an at home diagnostic kit is an appealing option. A company from the UK, Genosis, has developed such a kit, called Fertell.

Fertell is a testing kit that offers a basic assessment of male and female fertility.

Fertell for the male is a specimen collection and testing kit that measures the concentration of motile sperm. A sperm specimen is collected into a cup and allowed to liquefy and then warmed to body temperature. Motile sperm pass through a filter and are colored red by exposure to a gold-coated antibody. Appearance of two red lines in a testing chamber indicates a sperm count over 10 million total motile.

Fertell for the female is a conventional urine test strip very similar to an ovulation prediction kit. The female places the absorbent tip in her urine stream for 5 seconds. FSH in the urine reacts with antibodies on the test strip and shows as a red line in the result window. The intensity of this line reflects the FSH concentration (the darker the line, the more FSH present in urine). High FSH levels are indicated by two dark red lines.

Traditional semen analysis measures sperm volume, count, and motility. Multiplied together, these numbers yield the total motile sperm count, that is, the number of moving sperm in the ejaculate. Total motile sperm count is a reasonable predictor of fertility for men. Fertell establishes that the sperm count is over a specific value of 10 million total motile, a reasonable threshold for male fertility.

The male test kit is not able to determine subtle gradations of male fertility. It cannot detect the effects of treatment or change in lifestyle that may cause improvement in sperm count, nor can it detect alterations in sperm morphology (shape). More sophisticated testing is available at a sperm lab.

The female test kit is used as a screening test, and cannot detect subtle gradations in FSH levels, or the relationship of FSH to other important hormones such as estradiol. Such issues have dramatic effect on the patient’s prognosis.

Neither of these tests can replace an expert’s opinion. An expert’s ability to interpret test results with a broad knowledge base and experience remains the best way to diagnose and treat infertility problems.

Of primary importance is that, while both test kits have been correlated with existing assays, neither has been evaluated for its ability to predict pregnancy. Such research takes time, and hopefully will be forthcoming. For now, Fertell is an interesting option for those seeking a private screening assessment of their fertility.