Varicocelectomy
by Serentity

Why would you be having a Varicocele Repair (Varicocelectomy)?

A varicocele is a tangle of enlarged blood vessels (a varicose vein) in the testicles. It is fairly common, affecting 15 % of men overall and about 40% of men with diagnosed infertility. A varicocele is caused by faulty valves in the blood vessels, allowing blood to pool in the vein, increasing the temperature in the testicles and therefore depressing sperm production.

A varicocele repair – also known as a varicocelectomy or varicocele ligation – is a surgical procedure in which a urologist will tie off the enlarged and weakened veins. It is generally done on an outpatient basis, under general anesthesia, though some urologists prefer to use a local anesthesia.

What you can expect

The night before the procedure, you will be instructed not to eat after midnight. Someone must take you to and from the procedure – like with all procedures under general anesthesia, you will not be allowed to drive yourself home.

The procedure itself will take 1-2 hours, depending on the urologist. Once in the recovery area, you will be required to eat and drink something and walk before you can be discharged.

Most surgeons do the procedure as a laparoscopy, so you will have about a 2-3 inch incision on your groin. Expect some pain in the first few days from the incision; you will also have a lot of bruising in the area. That is normal. It will take about 2-4 weeks for the incision to heal completely, however, generally you can resume light work duties 1-2 days after the surgery and full strenuous activity within 1 week.

Generally you will be given a prescription for pain medication for the first few days, but in many cases Tylenol is sufficient to control the pain.

Your urologist will schedule a post operation follow-up with you within a couple weeks of the surgery. If the surgery is infertility related, you will have to undergo both a 3 and 6-month post operation semen analysis.

Problems that may arise

You may have some problems recovering from the surgery; some issues include infection in the incision site and/or potential fluid build-up in the scrotum.

Some people also report slight pain during sex for a couple of weeks after the procedure – mostly related to the bruising in the pubic area. This is normal. If you feel severe pain or recurring pain once the bruising is gone, call your doctor.

Personal tips

A bag of frozen peas (or corn or just ice) is VERY nice during the recovery period. My husband’s urologist used both a local in the incision area and general anesthesia, so he didn’t feel much pain at all until the next day. We found that if he iced the area every couple of hours, he didn’t need as much pain medication.

It takes longer than you’d expect for the incision to fully heal. Both my husband and I were concerned when his incision wasn’t fully closed three weeks after the procedure. However, his urologist told him at the 3 week post-op appointment that he was healing just fine.

IUI
by Melissa

Why would you be doing an IUI?

IUI or inuterine insemination is used for numerous reasons. If the woman doesn’t have a partner or her partner is also female, an IUI can be used to impregnant her. It can be used if there is borderline male factor infertility and the RE is worried about motility (this technique places the sperm close to the egg so that they don’t have to swim very far). It can be used if a person doesn’t have enough cervical mucous to transport the sperm up towards the fallopian tubes (you would know if there was a problem with cervical mucous after a post-coital exam). Often times, it is used before proceding to IVF with unexplained infertility. IUIs can either be natural or medicated. Medicated cycles range in invasiveness from Clomid to injectible medications.

What to expect

Protocols differ from clinic to clinic so ask your doctor what to specifically expect when you begin your IUI cycle. We jumped immediately to medicated IUIs with injectibles. Our experience was that drugs were used in the first half of the cycle to assist ovulation and create better eggs (Clomid and Follistim). Two nights before the IUI, we took a trigger shot of hcG at 10 p.m. (the timing is important because you will ovulate 36 hours later). We then showed up at the clinic at 8 a.m. two days later (for instance, trigger on Wednesday night and the IUI was on Friday morning) and deposited a sperm sample. Sperm can be collected at home, but there are guidelines with transporting it to the clinic to keep it viable.

We had a two hour wait while the sperm was washed. When they prepare the sperm, they concentrate the best quality sperm with the greatest motility. At 10 a.m. a catheter was inserted through a speculum and into my uterus. The sperm was then injected through the catheter and we rested on the table for 20 minutes to help the sperm stay close to the fallopian tube.

Problems that may arise and ways to troubleshoot

There aren’t many problems that crop up with an IUI that you can do anything about–it’s all in the hands of your doctor. One word of caution is that medicated cycles should be closely monitored. Blood draws and sonograms should help the RE determine the proper time to conduct the IUI. No one should take follicle stimulating drugs without monitoring (including Clomid).

Also, though it’s very rare, report any pain after an IUI because infections can occur any time a catheter is placed inside the body.

Unsurprisingly, IUIs have a lower success rate than IVF. The rate varies from clinic to clinic and also varies due to other factors such as age or the number of follicles. The decision to try IUI should be made in conjunction with your doctor. On one hand, the lower success rate may mean that it’s not worth the time and money to try it before IVF. On the other hand, IUI is much less expensive and much less invasive. Some religions that do not permit IVF do accept IUI.

Personal tips

I found the IUI uncomfortable only because they had trouble inserting the catheter due to the way my uterus tipped. Ask for pictures of your follicles to keep in case the IUI is a success.

Clomid
by Kelly

Otherwise known as Clomiphene Citrate

Why would you be taking clomid?

Clomid is generally the first fertility drug that women use and has been in use. It is (relatively) inexpensive as fertility drugs go, it is easily taken (orally rather than by injection) and it is the first line drug used for ovulation induction in patients with PCOS and other ovulatory disorders. It has been used for patients with luteal phase defect.

When used to induce ovulation, Clomid is taken for approximately five days early in the menstrual cycle. This may be either days 3-7 or days 5-9. Some women who do ovulate also use clomid to induce a ‘stronger’ ovulation.

Most women begin with 50 mg and this is increased if ovulation does not occur. Once ovulating, most pregnancies occur in the first 6 cycles of treatment. Clomid is said to be able to induce ovulation in as much as 85% of the women who use it, though only half of those will actually become pregnant. Most authorities agree that continuing for more than 6 ovulatory cycles in not likely to increase the chances of success.

What to expect

The most common side effects of clomid are hot flashes, multiple births (most commonly twins. There is a 7% chance vs. 2% in the general population), minor GI symptoms, visual symptoms, headache, ovarian hyperstimulation (OHSS), cysts, breast discomfort, weight gain, moodiness, stronger PMS symptoms–bloated, cramps, sore breasts, etc, allergies, rash, cervical mucus changes, and tubal pregnancy.

Problems that might arise and ways to troubleshoot

Many people advise on taking clomid at night–this way they say that the hot flashes are less severe and generally do not interrupt their sleep. I get dizzy and feel ‘stoned’ while on clomid and find that I actually like to take it in the morning. For me, those side effects don’t get too bad until the afternoon. Also, the hot flashes at night are an annoyance but don’t bother me as much as the other side effects. I think the ‘stoned’ effect of clomid lasts for me for the time while I am taking it until a day or two after finishing the pills. I usually get very weepy after taking the last pill. I always get very bad PMS while taking clomid too.

Progesterone Supplements (Oral and Vaginal)
by Kris

* Please note that while I reference intramuscular progesterone injections, I don’t go into detail as I have no experience with them.

Why would you be taking progesterone supplements?

There are a few reasons you might be taking progesterone supplements, which can be delivered orally, through vaginal suppositories, or via intramuscular injection (commonly referred to as PIO). Some examples: (1) You have low progesterone levels. This is usually diagnosed by having a blood test done 7 days post-ovulation. (2) You have a short luteal phase regardless of the results of the 7 dpo progesterone results. I believe that any luteal phase less than 12 days is considered short. (3) Even if your progesterone level and luteal phase are fine, if you are doing IVF (and depending on the RE, IUI) you will probably be prescribed progesterone supplements. Taking the supplement just covers your bases.

Why would you take them orally or vaginally?

The oral supplement is definitely the least invasive way to do the job if it works for you. However, when you take progesterone (or apparently any hormone) orally, it must be metabolized by the liver, which makes the delivery system inefficient and less effective. As for vaginal supplements versus injections, all I can offer is what I’ve been told. For most women, there seems to be no difference in the results. My clinic uses the suppositories because they feel after all the pre-procedure injections they just don’t want to prescribe more injections. My RE also informed me that when they switched to suppositories their pregnancy rates increased. However, there does seem to be evidence that some women have a better response with the injections. I know there are women out in bloglandia who agree with this.

What to expect

You can expect to take the supplements until you take your beta. If it is negative, you will stop and your period will arrive. If it is positive, you will continue taking the supplements for at least a few more weeks and possibly through the entire first trimester. If you are having blood tests done after insemination or transfer and are using vaginal supplements, your blood tests may not reflect high progesterone levels. Do not freak out if your level seems low compared to your friend doing injections. The vaginal suppositories are not systemic- all the progesterone stays right around your uterus and does not show up in blood tests. That doesn’t mean it isn’t there. The common oral supplement is prometrium. If you are taking this, expect to feel tired… fast. Twenty minutes after taking this I was dead to the world. But I slept great.

There are two vaginal forms: suppository (yellow pill–see picture) and suspended in gel (white bullet-like pill–see picture). The suppositories can be either prometrium (yes, the exact same pill you can take orally) or they can be pharmacy compounded. Not all pharmacies have the capabilities to compound these suppositories- at least not all American pharmacies. I have been told by my RE it doesn’t matter if you use prometrium or pharmacy compounded, but his preference is to use the pharmacy compounded. Whether you use prometrium or the compound suppositories, your dose will typically be 2 to 3 times per day. Expect to feel like you have constantly wet your pants. The prometrium is like a vitamin E–a softish gel capsule. In my experience, prometrium is much less oozy–one or two pantyliners a day should cover you just fine. You may notice some of the yellowish coating on your pantyliner. Gross, but normal. Prometrium can be kept at room temperature. The pharmacy compounded suppositories are very oozy. I frequently change panty liners when using these suppositories. These need to be kept cold or they will melt. When you take it out of the wrapper, it feels kind of waxy. But if you let it rest in your hand, the surface feels slick and oily. This is only the outer coating–if you look at the non-pointy end, you can see there is white goo inside the waxy shell. You may notice some of the disintegrated shell on your panty liner amongst the ooze. Also gross, but also normal.

The suspended in gel supplement (Crinone and similar products) comes in a pre-filled applicator (the pharmacy also gave me an applicator for taking the prometrium vaginally but I’ve never used it. I use my finger because it’s easier to wash.).

It’s been awhile, but as I recall, these applicators do not need to be kept cold. I don’t really remember any oozing, either. But I definitely remember this…when I read the insert, it said that I might see some of the suspension gel ooze out. I imagined that would be some sort of liquefied substance and I never saw any. Then one day I went to the bathroom and saw on my panties this disgusting glob of grainy cottage-cheesiness and I was horrified. That was a few days of the suspension gel–which doesn’t liquefy like I thought–finally succumbing to gravity. It was very gross and completely not what I expected, but also…normal. With all of these supplements, you may feel some bloating. They also cause me to have to pee a lot–especially in the middle of the night.

Problems you may encounter

Other than feeling like you are going to develop some sort of mold on your constantly moist naughty bits, there really aren’t too many problems. I have noticed that some time into the second week of the vaginal suppositories, my vagina feels irritated. If you’ve ever removed a tampon that was too dry, that’s what it feels like. Oh, and this (which I’m sorry, is painfully graphic)… I wiped front to back and when I first used the compounded suppositories and I noticed some irritation around my anus from the progesterone ooze that would linger behind when I was done. Now I just make sure I wipe the excess away from there–usually with damp tissue–and all sees to be well.

Personal Tips

As if the tush-wiping wasn’t personal. I try to make sure I space my dosages as evenly throughout the day as I can. And I try to lay down for as much of that as possible to allow the progesterone to absorb before oozing out. No one told me to do that…that’s just my neurosis. I have a three-a-day dose. I do one at 8 p.m. and then crawl into bed and read. I set my alarm for 4 a.m.- I usually have to pee around then anyway- and put in the next dose. At night, I fill a small glass with ice and just set the wrapped compounded suppository on top. This way I can keep the glass on my nightstand and avoid fumbling around my kitchen at 4 a.m. Then I go back to sleep for a few more hours. I take the third dose at noon and just deal with the instant ooze, since I’m at work. But if it’s a weekend, I think an afternoon nap is in order.

by Serenity

Why would you be doing a Semen Analysis (SA)?

Since male factor accounts for about 35% of infertility, a RE’s office will administer a SA as one of the first tests they’ll do to diagnose you as a couple.
A SA measures the following:
Volume (measured in mL)
Liquefaction time
Sperm count (both the overall count and per mL)
Sperm motility (the percentage of sperm that are moving – these are your “swimmers”). Most clinics also measure how many sperm are moving forward, which is called the “forward motility” test.
Morphology (the percentage of sperm that have a normal shape).
The SA also measures the pH balance, number of white blood cells, and amount of fructose in the sample.

What you can expect

Giving a sample
Generally, clinics require that you to not ejaculate for 48 hours before the test, BUT also do not abstain for more than 72 hours. In layman’s terms: they want you to ejaculate once between 2 and 3 days before the SA, but then abstain until after the SA.
Obviously, this is not a painful process, but it can be embarrassing. I have heard stories where someone’s husband had to use a bathroom off the waiting area to produce his sample – the poor guy! In most clinics, especially the bigger ones, though, they have a room set up with magazines (and even movies) for you to do his thing. And in most cases they’ll let the wife go in with him if he so desires.
Some clinics also allow for the sample to be produced at home if you live close to your clinic. Once the sample is produced, though, you need to keep it warm and get it to the clinic within 1 hour, or some of the sperm begin to die off.

Results
Generally you’ll get the results back within a couple of days of the SA, but it depends on your clinic. We got our SA results the following day.

Normal parameters of sperm are the following (*Based on World Heath Organization criteria, 1992. Table excerpted from Berger, G.S., Goldstein, M., and Fuerst, M. (1995). The Couple’s Guide to Fertility. New York: Doubleday):

Normal Ranges for a Semen Analysis*
Liquify?: Yes – within one hour
pH: 7.5 to 8.1
% Motility: Greater than or equal to 50%
% of 3-4 + Forward Motile Sperm: Greater than or equal to 50%
Sperm Concentration: 20-200 million per mL
Total Sperm Count: Greater than or equal to 40 million
Total Motile Sperm: Greater than or equal to 20 million per mL
White Blood Cells: Less than or equal to 1 million per mL
% Normal Morphology: Greater than or equal to 30%

Problems that might arise

There aren’t many problems that will present themselves in terms of the collection process, unless you miss the cup or can’t ejaculate.
If the results come back abnormal, your RE will suggest that you see a urologist, who can provide a further diagnosis. Additionally, at times, you can bypass sperm issues by trying IUI or even IVF with ICSI to get pregnant. I have also heard from my RE that there are other nifty high-tech sperm extraction procedures that can give you a chance of getting pregnant – even if your husband has a zero sperm count. At the same time, there will be men who will need to use donor insemination if this is your diagnoses.

Personal tips

Get one done as soon as possible! We didn’t get my husband’s SA done first because I had a lot of spotting and very irregular cycles; so we focused right away on diagnosing me. It wasn’t until we started thinking about treatments (3-4 months into the process) that my RE realized that he didn’t have a SA for my husband. I suppose I was trying to save him from the ‘embarrassment’ of doing one, but it ended up putting us back quite a few months, since his SA came back low.
Remember that counts wax and wane. My husband’s first SA came back pretty low – 20 million overall sperm, but 60% motility. The second one came back abysmally low – 4 million overall count and 20% motility. His third one was higher than the second, but lower than the first – 14 million overall sperm, and 50% motility. Chances are if you have a slightly low count one time, it might be normal another time. Or vice versa.

If the SA comes back abnormal, get thee to a urologist STAT! If there is a structural or hormonal problem, it can be treated. Your RE is NOT a male infertility specialist. For us – my husband had two varicoceles (varicose veins in the testicles) which needed to be surgically corrected. It took a couple of months to schedule the surgery, and since sperm take 90 days to be generated, it usually takes 3-6 months to see a result from that surgery. The sooner you see a specialist, the better.

Remember that there are some treatments for male factor. For us, our counts were so low we weren’t sure we were even a candidate for IUI – so we moved right on to IVF with ICSI. In the meantime, my husband got treatment for his varicoceles. It’s treatable, just takes a little time.
Keep a sense of humor about the collection part- the first one sucks, but it does get easier. I can’t tell you how many times we laugh about the rooms he’s been in for the process. Keeping a sense of humor about the whole thing really helps lighten it up and take the pressure off him a bit.