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Frequently Asked Questions with Dr. E

Welcome to Dr. E’s Frequently Asked Question page. We have taken our communities most often asked questions on: male fertility; how to enjoy intercourse while trying to make a baby; and how to optimize your Pre~Seed use, and posted answers for you here. This list will grow as we go forward, so check back often!  If you have a question you would like answered, please email us at info@ingfertility.com. Thanks for being a part of our Pre~Seed family and happy baby making!

Pre~Seed provides moisture without harming sperm. For use even while trying to conceive – a time of increased vaginal dryness when other products should be avoided due to their detrimental effects on sperm.

 

Cervical Mucus Quality, Clomid and Sperm Transport?
Q:
I have read information about the maximum amount of time that sperm can survive in fertile cervical mucus (CM). Can you tell me the maximum amount of time sperm can survive in non-fertile CM, like sticky or creamy? Is it only a problem in the vagina and once the sperm makes it into the uterus it can survive for several days? Or, is it that sperm can only make it from the vagina into the cervix if there is fertile CM?

A: After ejaculation, sperm have to be able to swim through the cervix to reach the Fallopian Tube where fertilization of the egg occurs. The sperm that can fertilize the egg begin leaving the ejaculate within 1 min after deposition, and no sperm that get to the Fallopian Tube have ever been proven to do so after 30 min of ejaculation. The "cervical reservoir" of sperm is not an actual pool of fertilizing sperm.

Sperm have to get thru CM to get to the Fallopian tube where they are then stored for hours to days until the egg comes. However, the interactions of sperm and cervical mucus that allow this migration are often disrupted in fertility patients. It is thought that at least a third (if not more) of subfertile couples have some disruption of sperm-cervical mucus interactions that limit sperm transport to the tubes.

The importance of normal CM in natural reproduction is widely recognized. For most of a woman’s cycle the CM is a thick gel and hostile to sperm, with a low pH and a structure that stops sperm transport by the presence of closely spaced microfibers. During ovulation, however, the CM becomes more alkaline (higher pH), and the fibers align in parallel with an expanded distance between them. This allows the sperm to swim through the mucus. Normally, the volume of daily CM also increases 5 fold at ovulation. CM is a hydrogel of 90% water, and its primary function appears to be bathing sperm in a fluid medium to protect them during transport . The presence of sugar-proteins in the gel that hold the water is controlled by hormone changes at ovulation (especially the presence of estrogen). These sugars increase the mucus gel’s capacity to hold water, expand fiber spacing, & allow sperm migration. Taken together, these changes permit sperm to rapidly swim through the cervix and proceed to the Fallopian tube for fertilization.

In women with poor sperm-CM interaction there is a reduction in CM fiber spacing making sperm migration difficult, a primary cause of which in many women may be inadequate water in the gel. This may be caused by advancing age (with low grade hormonal disruptions); and following the use fertility medication such as clomiphene citrate (CC or clomid). CC is a widely prescribed fertility drug. In fact, it has become increasingly used as a first line therapy for couples with fertility issues. With easy internet access, many women are also taking CC without doctor oversight. Estimates are that 40% of couples with fertility problems utilize CC at some point for the woman. Although it’s wide spread use has helped many couples conceive, it does cause significant problems with vaginal dryness and CM production and function. Specifically, numerous studies have shown that CC causes decreases in: volumes of CM; quality of CM (“egg-white like appearance”); and sperm penetration into CM. In fact, women on CC are seven times more likely to have “hostile” CM that is difficult for sperm to penetrate than are women not on the medication.

Women on CC also have an increased prevalence of vaginal dryness, which can cause pain at intercourse and decrease enjoyment for the man (which can decrease sperm counts). Many women on CC (which is already making them prone to poor sperm-cervical mucus penetration) are therefore also using lubricants that can harm sperm such as KY, Astroglide and Replens. These women may be creating a vaginal environment that limits sperm transport. Pre~Seed “sperm-friendly” Intimate Moisturizer can replenish vaginal moisture without harming sperm. A clinical trial is also planned to evaluate the effect of Pre~Seed on sperm and cervical mucus interactions, especially for women on Clomid.
Dr. E

How Long to Abstain for a Sperm Test/Analysis
Recent studies suggest that abstaining for a sperm test or a procedure such as IUI/IVF should be limited to no more than 1- 2 days. The first study looked at men with abnormal sperm (oligospermic) and found the best sperm quality occurred at 1 day of waiting or abstaining prior to production. For men with normal sperm waiting more than 10 days between productions resulted in abnormal sperm quality.

In the second study that looked at functional quality (i.e. “did the sperm result in an artificial insemination IUI pregnancy”, they found:

”Abstinence correlated positively with inseminate sperm count but negatively with motility.”
meaning that abstinence increased sperm count but lowered motility... who cares the number of sperm if they can't swim!

”Variations in inseminate parameters did not correlate with pregnancy rates”.
How the sperm looked on testing did not relate to pregnancy outcomes - discussed in the FAQ on doing sperm analysis.

However, abstinence intervals significantly affected pregnancy rates.
”The time of abstinence impacted outcome. Couples that had 10 or more days of waiting had only a 3% pregnancy rate!

Based on these studies 1-2 days wait before production is probably best.

References:
Fertil Steril. 2005 Jun;83(6):1680-6.
Relationship between the duration of sexual abstinence and semen quality: analysis of 9,489 semen samples.

Fertil Steril. 2005 Sep;84(3):678-81.
Related Articles, Links:
Effect of ejaculatory abstinence period on the pregnancy rate after intrauterine insemination.

Purchasing Pre~Seed
Q.
I went to my pharmacy and they did not carry Pre~Seed. Where can I find it and why is it so hard to locate?

A. Pre~Seed is carried in around 150 pharmacies, sexuality centers and medical clinics in the US and Canada. You can find locations near you by going to http://www.ingfertility.com/providers.html. Pre~Seed is made with unique ingredients, in a very detailed and controlled manufacturing process. It is also the only vaginal dryness relief product that has each lot tested with human sperm to ensure there is no sperm damage. I also personally try a sample of each lot prior to its sale, to ensure that the product is mild and non-irritating (I am very sensitive to other lubricant products). Taken together, we have found that independent pharmacies and medical clinics tend to understand the unique properties of Pre~Seed better than the large chains, and have provided better service for product distribution for us. Someday I am sure we will be more easily found!

But for now, check for stores at your location at our website. Or you can easily order on line or by phone! Our packages come to you and are charged to your credit card with no description of contents (under the name ING).

Thanks!
Dr. E

Sperm Transport to the Fallopian Tubes
Q:
If a man has normal sperm count and normal sperm motility, approximately how many sperm will be able to get to the fallopian tubes for each ejaculate during a woman's ovulation period? I've read different information on this. Some said about 1000 sperm to 5000 sperm but some said only about 50 sperm to 200 sperm.

A: This is actually a very good question, one only a handful of scientist around the world (including myself) have spent our careers studying.

Here is the issue-- Prior to the 1990's several good studies were done looking at sperm in the tubes after insemination, by flushing the tubes with salt water and counting the sperm. But back then we hadn't done the studies I did on my PhD, (along with others) to show that sperm actually bind or stick to Fallopian tube cells, and that they stay stuck even if you rinse the tube. These stuck sperm are released in waves over time, so there will always be sperm available to meet the egg. Once sperm are released from the tubal cells they either meet an egg or they die within a few hours as they are "capacitated". This gives a supply of ready sperm as they wait for the egg for days to a week plus.

These early studies showed really low sperm numbers in the tubes- 1 out of every 14 million inseminated sperm got inside the tube, and only 1 of every 2000 sperm inseminated made it into the cervical mucus (Settlage et al 1973).

Likely, there were other sperm in the tubes in these studies that were attached to the tubal cells and therefore, not counted. Since the 1990's though the kind of studies you can do in people have drastically changed. It is almost impossible to get permission to have a couple have unprotected intercourse at ovulation, and then surgically remove a portion of the tube to study for counting sperm attached to the tubal cells. You could be setting up a tubal pregnancy.

For this reason, when I had my tubal ligation I took estrogen (to mimic ovulation), had intercourse and then 24 hrs later had a tubal and my tubes removed to look by scanning micrograph for the sperm attached to the tubal cells. I found about 20 sperm in the portions of the tube I looked at. Just call me Madame Currie!

So... no one knows the answer to your question for sure. In animals, where we have done many studies -- only hundreds of sperm are in the tube (even though their ejaculates can have up to 350 million sperm in them).

One other thing I have found is that with stallions, the number of sperm that attach to tubal cells in culture (laboratory) is very, very highly correlated to their ability to impregnate mares (r=0.80). The stallion is a great model b/c they may breed 20-60 mares a season so you can get good pregnancy data on more than one female, and compare that to sperm function.

In men, I have seen a wide range of ability of sperm to attach to tubal cells in culture as well. Some men have almost no sperm attaching and they die quickly within hours, while some men have a very high attachment rate and survival rate with sperm living attached to the tubal cells for up to 9 days in the laboratory. This correlates with what has been in seen in women with live sperm found in one woman’s tubes 21 days after intercourse!

Extrapolating from the well done stallion study, we can assume that the men with the most sperm attaching to the tubal cells and therefore living the longest, will have the highest fertility.

Thanks for asking a fun question!

Dr. E

Sperm Leaking Out After Intercourse- Lessons in Sperm Transport Through the Cervix
Q: Why does sperm leak out sometimes and not others? Does it mean the cervix is closed? Or there is more sperm sometimes than other times? If a lot leaks out, does that mean there was a lot of sperm? Is there any way to prevent it from leaking?

A: In a 5 yr study of 11 women (Baker & Bellis, 93), sperm loss after intercourse ("flow back") was observed- Flow back occurred 94% of the time, with an average loss of 35% of the sperm. It is totally normal and is not a sign that there is anything wrong. It is more pronounced the larger the ejaculate volume, and remember ejaculate quantity is impacted by "how turned on" your husband is. So if you have a great session, or it has been awhile seeing doing the deed, there will be more.

The sperm that penetrate into the cervical mucus begin to do so within 1.5 min, and they are pretty much done by 30 minutes, with no gain in sperm numbers in the cervical mucus or Fallopian tubes after 45 min from intercourse. Only thousands of the millions of sperm ejaculated in the vagina make it to the cervix and only hundreds of these make it to the Fallopian tube!

The very best of the best get there, the rest get washed out- it is OK!
Dr. E

Understanding a Sperm Analysis
Sperm analysis or tests are a critical part of finding out what why a couple may not be conceiving. Male low fertility is usually involved about 60% of the time, with 40% of the time the man being the main cause and 20% of couples having shared male and female issues.

First of all the results of a sperm analysis are your medical records and you have the right to them, and the right to a good conversation of what was found. I am surprised how often people don't get reports back or how poorly the material is reported back. YOU need to be aggressive about talking to your doctor and understanding what they found. YOU also have the responsibility of making sure your clinic is using state of the art methods to look at DH's (darling husband’s) sperm. If not, find another clinic! One recent study showed that showed only 30% OF ALL CLINICS doing sperm tests in this study had accurate readings of motility and morphology.

That said it is important to understand that there is NO sperm test that can tell you if a couple will conceive or not - except if there are no sperm in a man's semen- then of course the chance is zero.

There have been thousands of studies with every one wanting a magic bullet that says "this ejaculate can make a baby, this one can not". NO SUCH Test exists.

What we do have is studies relating various quality sperm to various levels of fecundity (this means the chance of conceiving). Men with normal sperm parameters in regards to count, motility, and morphology (shape) tend to have normal chances of impregnating their wives (20-30% chance each month). Although other things can be wrong with sperm that appear normal at sperm analysis. The chromatin (DNA) can be damaged, there can be antibodies etc... Meaning that just b/c DH has a normal basic sperm analysis does NOT guarantee he is "fertile". Many couples with unexplained infertility have stopped evaluating the man because he has normal parameters on a semen analysis. This is not good medicine.

Infertility with normal sperm counts: If your DH has a normal sperm analysis, but you have been trying over 12 months, or 9 months and the woman is 35 or older & there are no obvious female factors...you need to see a Clinical Andrologist- a male sperm specialist- NOT an RE to look deeper into more subtle sperm defects.

On the other side, an abnormal sperm count does not mean your husband is sterile- sterile means NO functional sperm in the ejaculate. It truly does only take one normal sperm and we have all heard of couples that could not conceive for years and years due to male factor, who suddenly do become pregnant. Lower quality sperm, meaning outside of average, means your fecundity or chance of conceiving each cycle drops. There is one recent study with Dr. Kruger as an author (i.e. Kruger's strict morphology criteria) that studied all the other studies and basically said that you can break ejaculate quality into "fertile" or "subfertile" based on "thresholds of <5% normal sperm morphology, a concentration <15 x 10(6)/ml, and a motility <30% should be used to identify the subfertile male”.

You will note that this study used the strict criteria for morphology - Other forms of looking at sperm shape are not as accurate or predictive of subfertility.

Subfertile doesn't mean sterile- it means your chances are less and as you move to worse and worse quality the chances continue to decline somewhat.

Infertility with abnormal sperm analysis: If you have this situation you need to repeat the sperm analysis to confirm accuracy. I NEVER use a first sperm sample even in my totally normal young volunteers in my studies- b/c the first time a guy performs in a cup- the sperm are usually bad!!!! A recent study showed that sperm motility, and counts differed AMAZINGLY for monthly sampling over a year from the same guy. Four times, even 17 times! the number of sperm in an individual ejaculate. The only parameter that did not vary was the percent of morphologically normal sperm - the shapes. The one caveat here is that these guys all collected into a cup - probably dry handed (without lubricant). Numerous other studies have shown that you can improve the normal morphology % using collection into a condom during intercourse based on the man being more stimulated.

It is also important to note that sperm counts and quality decrease as your DH ages over 45 yrs...see below. Another study has shown that sperm DNA quality also goes down after age 45. SO... if your DH is older for sure really stimulate him for any semen collection. Try to make it as exciting as possible and think about using that collection condom.

Also, many, many studies have suggested the benefit of antioxidants in men that are trying to conceive. I have posted one here that looked at it the other way - instead of an effect of vitamins on sperm quality- they looked at fertile versus infertile guys and found that the fertile guys had more antioxidants in their semen. So any man with a poor semen analysis should be put on fertility vitamins with antioxidants such as FertilAid.

Good luck-
Dr. E

Using a Sperm Collection Condom?
Q:
A friend told me about using a condom to collect sperm for our IUI. What does this require and why would you use choose this message?

A: Here is a copy of a newsletter that I wrote on this subject.
Semen Collection by Masturbation vs. Intercourse with a Condom
Millions of sperm samples are processed each year for both diagnostic procedures (to determine sperm quality in a man) and therapeutic interventions, such as intrauterine insemination (IUI) and in vitro fertilization (IVF). The majority of these samples are collected manually by masturbation. However, this method can cause a great deal of stress in men, and it can lead to production of inferior sperm samples, with lower sperm counts and motility resulting. Whether men morally object to masturbation to collect semen, or if the whole process of performance "on demand" is too much to allow for good sample collection, numerous studies have shown that collecting sperm in a condom during intercourse is an excellent alternative to masturbation.

Data Supporting Sperm Collection Using Condoms at Intercourse
Studies over the last three decades, have shown that sperm quality can be strongly impacted by collection method, especially in oligospermic men (men with low sperm counts). A review of the published literature shows that total sperm counts, sperm motility, and the percentage of sperm with normal morphology are often 2-3 times higher in samples collected in condoms at intercourse than by masturbation in the same men (Sofikitis & Miyagawa, Journal Andrology, 1993). Sperm function tests like hamster zona penetration or membrane swelling are also significantly improved for sperm from condom collection versus masturbation. In fact, in one study (Zavos, Fertility & Sterility, 1985), 38% of the patients that were classified as having low sperm counts based on masturbated sperm samples, were reclassified as normal after semen collection at intercourse in a condom. Furthermore, in this study, the total functional sperm fraction (numbers of normally shaped motile sperm in the sample) increased by 190% in oligospermic patients, and 69% in normospermic men.

In these studies sexual satisfaction at collection is also greatly increased, lessening the stress of the collection process. In fact in one study, patients preferred condom use so much over masturbation that the scientists had to stop randomizing collection method and only have men collect at intercourse AFTER the masturbation collections were done, or the men would stop participating in the study!

In general, all studies comparing masturbation to condom collection of sperm have found that those sperm parameters historically associated with and related to fertility show improved outcomes when collected into condoms at intercourse. Sperm samples collected by masturbation, therefore, do not represent the optimum quality sample a man can produce and may lead to diagnostic mistakes and/or lowered success rates in assisted reproduction.

This is especially important for sperm samples to be used in assisted reproduction techniques such as IUI, where total motile sperm count critically impacts successful outcomes. For men with borderline sperm sample quality, using a condom at intercourse instead of masturbation could provide significant clinical benefit by increasing the potential fecundity rate (the chance of conceiving per cycle) as the number of motile sperm inseminated is increased.

These previous studies have lead one clinician to write "It appears that for cervical cap insemination, intrauterine insemination, and IVF coitus condomatus (collection into a condom) is preferable to regular masturbation" (Gerris, Human Reproduction Update,1999). He further concludes, that for "artificial reproductive technology, masturbation as a method for semen collection should not be recommended".

Specially Designed Condoms for Sperm Collection
Almost all commercially available condoms are made of latex. Latex condoms have been shown to be toxic to sperm and never should be used for sperm sample collection. In contrast, two types of condoms are approved for sperm collection. These include silastic (silicone rubber) condoms manufactured by HDC Corporation (Mountain View, CA) and polyurethane condoms manufactured by Apex Medical Technologies (San Diego, CA), called the "Male Factor Pak". Both of these types of condom are sold by several fertility supply companies, including INGfertility (the makers of Pre~Seed).

Previous Problems with Sperm Collection Condoms
In spite of all of the studies discussed above, many people are unaware of the possibility of using a special condom during intercourse with their partner for sample collection. Part of the reason for this, is that many doctors became discouraged with these condoms due to patient frustration with them. In the past, patients had a difficult time using the condoms due to vaginal dryness and lack of lubrication, leading to pain and performance issues. Previously available vaginal lubricants harm sperm and could not be used with the condoms. This made both intercourse and removal of the condom difficult and at times painful. I am aware of numerous couples who tried the semen collection condoms, only to have to stop during intercourse because of pain from the lack of lubrication.

A Solution to Non-lubricated Semen Collection Condoms
Pre~Seed Intimate Moisturizer has been specially formulated to not harm sperm while replenishing personal moisture. It can provide moisture both in the vagina and on the penis, inside the condom to facilitate intercourse and sample collection. The Pre~Seed formula has been tested and is compatible with the Apex condoms (we have not yet evaluated the silastic condom). INGfertility is now offering a Sperm Collection Kit including the approved condom and a Pre~Seed applicator to optimize the collection process.

Couples who plan to use condoms to enhance sperm quality for assisted reproduction procedures such as IUI should practice at least once with the condom and Pre~Seed to learn how to best use the system, without the stress of the procedure hanging over them. Additionally, a new (but very small) study has suggested that it is best if couples can get their semen sample to the laboratory 30 minutes after collection. For couples who live a distance from their clinic, renting a hotel room may offer a more romantic and enjoyable experience for condom collection, than having to rush out the door at home. Finally, individuals need to make sure their laboratory has experience with sperm samples in condoms. They will need to rinse the condom in order to optimize sperm recovery. It is perfectly acceptable for any one to ask to have this done!

Assisted reproduction procedures, such as IUI, all have tremendously variable outcomes based on the clinic and technique used. In general, cumulative pregnancy rates for 3 cycles of IUI should equal rates of an IVF cycle at around 25%. Three cycles of IUI is actually more cost effective for couples with unexplained infertility and moderate male factor infertility, than IVF. The most important thing a couple can do to optimize their chances for conception is to increase the number of motile sperm in the ejaculate. The best option for doing that is likely through condom collection of sperm at intercourse - where the couple can function as a team the way it was meant to be!

Dr. E

 
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