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Deborah Howell (Host): You know, of course, every couple of considering fertility treatment wants the best possible chance to succeed, but it all starts with testing. Today, we'll talk about how doctors test and evaluate fertility in men and women. We'll learn what tests reveal, how long test results are valid for, the causes behind poor results, where supplements can help, how to overcome issues with treatment. Joining us today is Dr. Christopher Sipe, Medical Director and President at Fertility Centers of Illinois. This is The Time to Talk Fertility podcast. I'm your host, Deborah Howell and welcome Dr. Sipe.

Christopher Sipe, MD (Guest): Thank you so much. I really appreciate the opportunity to help educate patients.

Host: Fabulous to have you. So, fertility testing is the first step of understanding fertility potential. And it's a big one. Do most patients come in too early or do they wait to long?

Dr. Sipe: You know, it all depends upon what their underlying issues could be. Some patients who already know they don't have periods, they should come in a little bit sooner. Women who are older, should probably come in a little bit earlier, but young, healthy women who are just starting out to try and start a family probably can wait until the recommended one year.

Host: Okay. And when people say that they've waited, why the delay?

Dr. Sipe: Everyone's a little bit different, obviously we're coming out of a pandemic right now. So, the pandemic really created a lot of delays in medical care. Plus the uncertainty of, if someone's job or their health created some delays. By far the most common reason is found someone's career and usually it's, I want to work on getting this job. I want to work on establishing my career. I want to finish some of my training. Some people are working overseas, so that seems to be the predominant reason for delaying.

Host: Let's go through the testing process now for men and women, we can start with the women, if you like.

Dr. Sipe: Yeah. So, overall there are five reasons why couples can't conceive. So, when you look at those reasons, it's either going to be a sperm issue, an egg issue, ovulation, some type of anatomy issue or some type of hormonal support woman's health issue. And so as we start doing the testing, we sort of break them down into those categories. In general, for women, one of the things if there's a big delay, we, we want to start looking at what their ovarian reserve is.

Host: And the men.

Dr. Sipe: And for men, it's the semen analysis. So, men typically have one test to do and women usually have to go under a series of different tests.

Host: And what do you look for during a physical exam and vaginal ultrasound?

Dr. Sipe: So, the initial vaginal ultrasound we like to do early on in the menstrual cycle to identify what's called an antral follicle count. As most women have started to learn that they're born with the most number of eggs they're ever going to have. And every day they're living, from the minute they're created, until they go through menopause, those eggs are getting used up. We do an ultrasound in the early cycle to judge how many resting little follicles or eggs they have at the beginning of the month. And that can be predictive of what their reserve is.

Host: Okay. And I was hoping you could give us a quick overview of the standard introductory tests.

Dr. Sipe: In addition to the resting follicle count that we do, we also draw an follicle-stimulating hormone or FSH, which is a hormone made by the pituitary that tells the ovaries to grow eggs. As a woman gets older, that hormone tends to get higher and that's because they're running out of eggs.

And so we also look at an estrodial, which is in essence, an estrogen level, to try and judge how that interacts with the FSH hormone. And then more recently in the last five years or so, the anti-Mullerian hormone or AMH has become a lot more popular to draw and internists and OB-GYNs are checking that pretty easily. An AMH is a hormone made by every single egg in a woman's body. The ones we see on the ultrasound, plus the ones that are in the background. They're made by something called a granulosa cell, which is one of the cells that makes up that egg complex. And so the more eggs you have, the more granulosa cells you have then the higher the AMH level is going to be. When you draw an AMH, when you get a high level that's predictive that that woman has lots of eggs. And if you get a low level, that's suggestive that the woman does not have as many eggs.

Host: And then what about the FSH test and what does it measure?

Dr. Sipe: Yes. So, the FSH hormone is a hormone made by the pituitary that tells the ovaries to grow eggs. So, as the brain is early on in the menstrual cycle, there's no follicles made. So, the brain makes more of this FSH follicle-stimulating hormone, and it grows a follicle. As the follicle grows, it starts making estrogen in response. And then the estrogen pushes the FSH hormone down. There's a lot of variability in FSH hormones. So, you can have one month where it's low, one month where it's high. It bounces around a bit more than some of the other tests we do.

Host: Well, that tells me exactly why we take folic acid when we're trying to get pregnant. Right?

Dr. Sipe: Not exactly. Folic acid is for fetal brain development. Though it starts off with the same sort of letters, follicle-stimulating hormone, is for stimulating follicles where folic acid is for helping the fetal neural tube develop.

Host: Got it. Okay. Well, see, this is why we have you on and I'm sorry I said folic. I meant folic. For an estrodial. Is, did I get that right? An estrodiol hormone test?

Dr. Sipe: Yes you did.

Host: What are you assessing there?

Dr. Sipe: So that's part of that estrogen. So, as the FSH hormone goes up, it acts on the follicle in the ovary, which makes estrogen. So, we really don't worry too much about what the estrogen level is. We use that to help interpret what the FSH level is. So, if you have a really low FSH, but a high estrogen, that doesn't mean that that's actually a good sign. So, if someone just draws simply an FSH, you can't really interpret that well until unless you draw an estrogen at the same.

Host: Got it. Okay. You definitely know all the answers. So, I've got another one for you. What is luteinizing hormone and how how is it tested?

Dr. Sipe: A luteinizing hormone or LH hormone is also a blood test like the other two. The purpose of luteinizing hormone, is to cause ovulation to happen. There are certain conditions, however, where it's going to be high and certain conditions where it's going to be low. When we test it, which is typically between the second and fourth day of a woman's period, we want it to be low, but in certain conditions like polycystic ovary syndrome, it may be high. And in certain conditions like diminished ovarian reserve it also may be high. And so when, if we measure it early on that cycle, it can tell us whether there's a disease process that may be going on, something we have to address further.

Host: Okay. And while we're throwing the alphabet around what does an SHG and what does it do?

Dr. Sipe: An HSG is a called a hysterosalpingogram. So, that is a test, where we're trying to judge the anatomy of the woman's reproductive organ. So, the HSG looks at the fallopian tubes as well as the uterine cavity. By looking at the uterine cavity, it can tell us whether there's any abnormalities inside, for instance, an abnormally shaped uterus with a septum or a duplicated uterus system. And it also can let us know that the path to get the eggs and the sperm together are completely open and easy to access.

Host: Got it. Now, doctor outside of these tests, are there any other common tests you might do?

Dr. Sipe: A lot of that depends upon the woman's history. So, if she's got some underlying medical disorders, we want to make sure that everything is under as best control as possible. There's a series of other hormones that we're going to look at, one of which is a thyroid. The main purpose for checking a thyroid is because number one, it can be associated with infertility but even if it's in a officially normal level, it can actually have a negative impact on a pregnancy. So, you can help the woman, achieve a pregnancy or even she gets pregnant on her own, if her thyroid is not in perfect condition, that can increase the rate of having a miscarriage, having a preterm birth or having a child with a lower IQ.

So, the thyroid hormone's a pretty important one. And then we also check something called prolactin. Prolactin is also a hormone that can be associated with difficulty getting pregnant and it can lower some of the other hormones that a woman has. By far, the single most important hormone in every pregnancy is a hormone called progesterone.

Progesterone is a hormone that's made after ovulation. So, by checking hormone levels of progesterone, we can confirm a woman ovulates and has released an egg. There are certain progesterone levels that are associated with a good chance of getting pregnant. And there's other levels that are associated with a higher rate of miscarriage.

So, we want to check those progesterone levels, both prepregnancy in the luteal phase, as well as when a woman gets pregnant.

Host: Boy, anyone who said getting pregnant is easy and simple as not talked to you. So many

Dr. Sipe: Well, the great news on that is that 85% of couples do not need to worry about any of this. And this is simple, good old fashioned intercourse like caveman were doing before any doctors or any science or anything figured things out. We're, we're here for those 15% of folks who have a difficult time.

Host: Exactly. And now once all those tests we just talked about are complete, how long are they valid for?

Dr. Sipe: You know, that's agreat question. Some of that depends upon the woman's age. If she's young, then in general, we think those are probably pretty good for about a year. For a woman that gets into her forties, then it's probably sometime between six and 12 months that we're going to want to repeat them.

Host: Okay. And in what circumstances should a woman do testing before trying to conceive?

Dr. Sipe: So if she's has any certain type of medical disorder, then we should probably check it. If she's got an autoimmune disorder. Autoimmune disorders tend to not simply attack, like if you have ulcerative colitis and simply attack the colon, it can attack other structures like the ovaries. So, with someone with an autoimmune disease, we recommend start checking the ovarian reserve a little bit sooner.

The older a woman is obviously the harder it can be to get pregnant. Every study sort of bore that out. And so I'll usually that's related to the ovarian reserve. So, if a woman's 40 and hasn't started trying to conceive yet, but it's thinking about it, we highly recommend getting testing ahead of time, so that can really help a woman make decisions about whether she wants to seek treatment earlier or whether she can be patient or see what happens for the first three to six months of trying to conceive naturally.

Host: Sure. Now there are men listening. So, I got one for them. I know there's a physical exam and semen analysis. So, what are you looking for during this physical exam?

Dr. Sipe: Typically what we really focus on is the semen analysis. Everyone always thinks that, you know, sperm ie sperm, and you can get pregnant with anything. Cause that's sort of what we're taught in our grade school sex ed. But the reality is it's not all the same. You need on average 20 million sperm that swim to conceive efficiently with sex. Great numbers are going to be between 100 and 300 million sperm. Obviously you only need one single sperm that conceive. But when we look at efficiency models, you're gonna need at least 20 million swimming sperm. So, when we do a semen analysis, we look at a variety of different factors.

One of them is simply how much semen there is. Obviously semem isn't where the sperm lives. And so usually you want between one and a half and six milliliters of semen. Then we also look at how much sperm is actually in that semen. And so that would be denoted as the concentration. And as I said before, it takes one sperm to get pregnant, but what we're looking for are things that fall outside of a normative range.

So, what we really want to see is where they have 15 to 20 million sperm per milliliter. And then we want to see how much of that sperm swims. So, we literally do a test where we look at the sperm and then we count in a specific area how much of that sperm is actually swimming and moving around. And so you'd like to see minimally 40% of the sperm swim.

And then another test that we do is looking at the shape or morphology of the sperm. And so sperm shape becomes important, not because we're worried about the sperm being genetically abnormal, if the sperm's funky shaped, but more because you need a normal shaped sperm for that sperm to be able to bind to the egg and be able to navigate to the egg.

So, some women who we'll read some older textbooks and older blogs come across the term, cervical mucus. And a long time ago, people did a lot of research into cervical mucus. So, as a woman makes estrogen in her menstrual cycle, she starts producing this clear sort of sticky cervical mucus. And that acts as the highway or the ramp for the sperm to sort of travel from the vagina up through the cervix, into the uterus and that cervical mucus has a crystalline structure, sort of like a filter and the filter can keep away all the big funky shaped sperm or any of the other shaped sperm that are not normal so that you can have better sperm make it through.

But if all the sperm are abnormal or a low amount of sperm are normal, then they can clog up the sort of ramp and the normal sperm can't get there.

Host: Okay. And is there anything else you're looking for when evaluating a sample?

Dr. Sipe: The rest of the details, we actually look at about 12 different things. And so depending upon whether the sperm count's normal, that can sort of denote whether we care about the other things. I think a lot of people know that there some sugar in sperm and that's to help the sperm move and navigate from the vagina up through the cervix and into the fallopian tube and to feed it along its way.

And so, you know, if you have different levels of sugars, that can be a problem, you know, pHs of sperm, but really that's, that helps us to know when there's a problem what's going on. One of the other things we look at is white blood cells inside the semen. So, there are times when a man might have something called prostatitis or epididymitis, which are inflammations or potential infections in their reproductive tract.

And those are things we'd want to treat ahead of time. It's not like a sexually transmitted infection that a woman could catch. It is just something that will drive down sperm counts and drive down motility's and drive down the sperm shapes.

Host: Got it now after that semen analysis is complete, how long are those test result good for?

Dr. Sipe: Once again, we think that's probably about a year unless the man's health changes. So, there are certain diseases and things that can negatively impact sperm counts. We don't usually have to worry about them dramatically changing, you know, in asix month period. Heat negatively impacts sperm. The whole reason why the testicles are in a scrotum, is to keep them cooler than the rest of the body.

So you want to keep it on average one and a half to two degrees cooler than the rest of the body. So, if you're always taking hot tubs or in a super hot environment or riding a bicycle with tight-fitting shorts, that can overheat the testicles and actually damage the sperm making cells inside the testicles.

In those instances you want try and get them off of whatever is increasing the heat. That doesn't mean you take the testicles and put them on ice all the time, cause that can have a negative impact as well.

Host: You just remove the environment as much as you can. My sister was married to a pilot who sat in the cockpit, which was broiling hot with the sun shining on it. And so they had problems for a while until they figured that out. Now, in what circumstances should a man have a semen analysis before trying for a baby?

Dr. Sipe: You know, if he has any major underlying medical disorder. Diabetes is a condition that is associated with a lower sperm count. If they've had any type of chemotherapy, radiation or cancer, what type of treatment, and that can negatively impact a semen analyses and sperm numbers. So really it comes down to the man's history.

A man who is drinking a lot of alcohol, smoking a lot of cigarettes or marijuana, those can have negative impacts as well. So, that's areas where we can try and improve on their health or try to improve on some of their social habits to sort of see if we can increase the sperm numbers.

Host: Okay. Here's the a hundred thousand dollar question, Dr. Sipe. Are these tests covered by insurance?

Dr. Sipe: Well, the good news is most testing is covered by insurance. Most of the insurance, it doesn't differentiate between the testing and infertility. Now, once the tests come back, if you're going to start treating someone for infertility, in certain states, in the United States, infertility is covered. In the majority of them, however, it's not. Illinois happens to be one of the states where infertility is covered mandated by the state government.

Host: Okay, now, some people like to take matters into their own hands and do tests from the drug store, like ovulation test kits or a sperm count checks and mail order tests for what you described earlier. should patients know?

Dr. Sipe: Well, first of all, ovulation are urinary kits. So, if you have a lot of water or drink a lot of water, there is a chance you can get a false negative on that test. Conversely, if you're really dehydrated, you could get a false positive on those tests. So, tests are only as good as the mechanism by which you measure them.

The ovulation prediction kits are very predictive of when someone ovulates, but it doesn't work for everybody. So, the last thing we want to do is have someone peeing on a stick for three weeks. It never turns positive and it really makes them anxious and, makes them sad. And so in that instance, you know, it's not the best test for those folks. If the average person is having intercourse a couple of times a week, then usually the urine ovulation kits are not necessary because sperm tend to live three to four days. So, if you have intercourse every two to three days, you don't have to spend the extra money on the kits.

Conversely the mail kits that test semen, the jury's out on that one. And the kits that I've seen, they just report, yes, we have sperm or it's a normal range of sperm. Essentially by the time that sperm sample has been shipped, everything has dried out and it's hard to get a really good count and a really good motility from that. Cause as I mentioned, sperm only live a certain number of days and they have to be kept at a certain temperature to be as optimal health as possible for testing. So, I highly recommend against doing the mail order semen analyses and going to your doctor's office to have them order one at a local hospital or infertility clinic.

Host: That's good advice. Final question. Are there any supplements men and women can take to boost their fertility after test results?

Dr. Sipe: Well, it all depends upon what the problem that's been identified is. So let's take it for men because the sperm counts tend to be easier to manage and monitor. So, coenzyme Q10, lycopene, selenium, zinc, fish oil, vitamin C. Those are all vitamins that have been shown to improve sperm morphology, and sometimes sperm motility. But if they've got an underlying disorder that's damaging the sperm, then those supplements aren't going to do anything. For a woman's ovaries, obviously that's a little bit harder to check, and people have looked at things, but very few things have shown a significant improvement in ovarian reserve.

So, a lot of times we'll put women on antioxidants because it's felt that maybe these free radicals are damaging to eggs. And by having more antioxidants, they can bind the free radicals that can cause potentially less damage to any cell, including the egg. So, that's generally what we recommend for women.

Host: Great. Thanks doctor. And before we wrap up, can you share some words of hope with our listeners?

Dr. Sipe: Yeah. As I mentioned earlier, that the most important thing is that 85% of people get pregnant without ever having a problem. And so it's not uncommon for me a couple of times a year to get someone as a patient who's never tried before. They've been married for a few years and they just want to get things started and they want to get testing ahead of time.

And if the testing all comes back normal, we're going to give them the same advice. Try at home. Everything at home is a lot more fun than what I'm going to offer you in the office. And it's a lot more romantic, and it brings you guys closer together as a couple. There's a lot of good data that shows that fertility treatments and things are very stressful and anxiety provoking. So, whatever we can do to avoid having patients having to go through that is ideal. The majority of patients never need our help. And that's what I always want people to focus on first.

Host: Dr. Sipe, we can't thank you enough for being with us today and for giving us a complete guide to fertility.

Dr. Sipe: Deborah, thank you so much. You have a wonderful day. Thanks for doing all these podcasts. It really helps our patients.

Host: Trying to get the word out there. Right. That was Dr. Christopher Sipe, Medical Director and President at Fertility Centers of Illinois. Find out more about the services FCI provides for patients by calling 877-324-4483 or head over to FCIonline.com for more information. And if you enjoyed this podcast, you can find more like it in our podcast library, and be sure to give us a like, and a follow, if you do. This has been The Time to Talk Fertility podcast. I'm your host, Deborah Howell. Have yourself a terrific day.