You are currently browsing the Dr Licciardi blog archives for May, 2006.

Who is Reading Your HSG?

Let’s say your HSG is performed in the proper way. What about the interpretation? The results of your HSG may have a big impact on your course of therapy. If it’s normal, but someone says the tubes are abnormal, you may be pushed into surgery or directly to IVF. If your tube or tubes are really blocked and the report says they are open, you will waste months or years trying intercourse or insemination with no hope for a pregnancy. And as we said in the last blog, the jury is out on what people are saying about the uterus. Is it really possible that the readings could be so off? You bet it is. It happens every day, many times per day. I see it over and over again.
Your infertility doctor needs to look at the films directly. When my patients bring in their films for me to review, the first thing they say is, “the report is in there too”. I say thank you and look at the report, but the report is mostly useless. It’s the films that I want to see.
Now to be fair, there are a few radiology groups who do an excellent job with both the films and the reports. Most, however, do not have the experience to write an accurate report. They may have experience in doing the x ray, but because they are not surgeons, it’s hard for them to relate the x-ray to what’s really going on inside.
So, make sure your fertility doctor looks at your films, not just the report. If you are concerned about the interpretation of your HSG, get a second opinion.
I will get to the accuracy of a hysteroscopy. Thanks for reading and see post 5/17/06.

References:

  • Steinkeler JA, Woodfield CA, Lazarus E, Hillstrom MM. Female infertility: a systematic approach to radiologic imaging and diagnosis. Radiographics. 2009 Sep-Oct; 29(5):1353-70.
  • Ayida G, Chamberlain P, Barlow D, Kennedy S. Uterine cavity assessment prior to in vitro fertilization: comparison of transvaginal scanning, saline contrast hysterosonography and hysteroscopy. Ultrasound Obstet Gynecol. 1997 Jul; 10(1):59-62.
  • Swart P, Mol BW, van der Veen F, van Beurden M, Redekop WK, Bossuyt PM. The accuracy of hysterosalpingography in the diagnosis of tubal pathology: a meta-analysis. Fertil Steril. 1995 Sep; 64(3):486-91.

Hysterograms: Let’s Not Forget the Uterus

Hysterosalpingogram: it means an x-ray of the Hyster(uterus) and Salpinges(tubes). Both are very important. Again and again I see films that are reported as normal, yet the uterus is not in proper view. If it’s not in proper view, it can’t be seen well and we can’t say its normal. We may be missing hidden abnormalities.
One common problem is the placement of a balloon inside the uterus during the test. The balloon is helpful because it acts as a plug, preventing the dye from spilling back out through the cervix, so that the dye can go up and out the tubes. The problem is that the balloon fills up the uterus so one can’t get a good view of what is inside the uterus.
Another problem is the angle of the uterus. The uterus is in a slightly different position in all women. In some women it’s tilted way forward, some way back and for most people its somewhere in between. If the uterus is pointing towards the camera, the picture will be through the top edge of the uterus, and the inside cannot be seen well. Imagine trying to tell the date on a coin if you only could look at the coin from its edge. The uterus needs to be straightened out during the procedure so that we can see it from a side view, not a top view.
A patient this week had both issues. Her HSG was read as normal. Yes her tubes were open, but the uterus could not bee seen well because it was on edge and a balloon was used. I strongly recommended repeating the test the proper way. She was reluctant, but after the repeat we found the uterus was not normal: there was a septum (subject for another day). Thanks for reading and please see post 5/17/06.

References:

  • Steinkeler JA, Woodfield CA, Lazarus E, Hillstrom MM. Female infertility: a systematic approach to radiologic imaging and diagnosis. Radiographics. 2009 Sep-Oct; 29(5):1353-70.
  • Ayida G, Chamberlain P, Barlow D, Kennedy S. Uterine cavity assessment prior to in vitro fertilization: comparison of transvaginal scanning, saline contrast hysterosonography and hysteroscopy. Ultrasound Obstet Gynecol. 1997 Jul; 10(1):59-62.
  • Swart P, Mol BW, van der Veen F, van Beurden M, Redekop WK, Bossuyt PM. The accuracy of hysterosalpingography in the diagnosis of tubal pathology: a meta-analysis. Fertil Steril. 1995 Sep; 64(3):486-91.

The Disclaimer

I am very happy to write my blogs. I feel that I am helping people by giving them information they don’t get elsewhere. Thank you all for the positive feedback. Please keep in mind that the information provided here is not ment to be a medical opinion about your specific case. The problems of every patient are unique and should be addressed by their physician in a face-to-face conversation. You are welcome to bring up questions about my writings with your doctor. However, no one should use this blog as a source of medical care, athough I believe that reading it frequently is a good idea.
Dr. Licciardi

Abnormal Sperm Can Fertilize Eggs and Make Babies

How do I know that? Because it happens every day at the NYU Fertility Center.
If we have a man with good counts, good motility and low morphology, we do not recommend IVF with ICSI. We will treat him as if there is not a problem (because we don’t think there is one) and allow the couple to do insemination. If they do go on to IVF, we do not perform ICSI, and the eggs fertilize just fine. Of course, we would not follow this plan if the counts or motility were very low. And we at times have exceptions.
Other clinics do things differently. Sometimes its because other places have found that they need to do ICSI to get good fertilization rates in their patients with low morphology. I can’t speak for the techniques of other offices, but you should know things are done differently in different places. As with all of my entries, don’t change any of your treatment plans without speaking to your doctor first.

References:

  • Demir B, Arikan II, Bozdag G, Esinler I, Karakoc Sokmensuer L, Gunalp S. Effect of sperm morphology on clinical outcome parameters in ICSI cycles. Clin Exp Obstet Gynecol. 2012; 39(2):144-6.
  • De Vos A, Van De Velde H, Joris H, Verheyen G, Devroey P, Van Steirteghem A. Influence of individual sperm morphology on fertilization, embryo morphology, and pregnancy outcome of intracytoplasmic sperm injection. Fertil Steril. 2003 Jan; 79(1):42-8.
  • Hodes-Wertz B, Mullin CM, Adler A, Noyes N, Grifo JA, Berkeley AS. Is intracytoplasmic sperm injection overused? J Urol. 2012 Feb; 187(2):602-6.

Sperm Morphology Mythology

This week I saw a couple who were told the reason they were not getting pregnant was “bad morphology”. The sperm, they were told, could not penetrate the egg because of the abnormal shape of the sperm. Because of this, they would need to go directly to in vitro fertilization with ICSI. This was in spite of the fact that they were young, had normal hormone levels and open tubes. I’ll tell you what I told them.
When we test sperm (the semen analysis) we look at a few different parameters. First is the volume, which should be 2cc or higher. Second is the count. This is the number of sperm per cc, so it’s technically a measure of the sperm concentration. This should be 20 million per cc or higher. The average is around 35 million. Next is the motility: the percentage of sperm moving. Should be 50%, most normal samples are not much higher. And then there is the morphology: the percentage of sperm normally shaped. This should be 14% or higher. The average is 2-6%, but why?
The original guidelines for sperm parameters, from the WHO, stated normal morphology should be 30%. Then about 20 years ago, Dr. Kruger came out and said we really need to be looking more carefully at sperm shapes. If we are really careful we will see that there are more abnormal sperm than we think, and the cutoff should be 14%. He called his classification “strict criteria”. He also said that by being more careful we could better identify the men who are infertile due to badly shaped sperm. This all sounded well so the andrologists (the people who do your sperm test) started looking harder, and harder, and harder. They now deduct for every sperm that does not look perfect. So over the past 20 years, the andrologists have been getting pickier and pickier, and now a man is lucky if his morphology is over 5%, and almost everyone is less than 14%.
Obviously this has all gone too far. We are telling almost all men that their sperm is abnormal, and that just can’t be. The fact is we do not know what a normal sperm looks like. More on this next time.

References:

  • Demir B, Arikan II, Bozdag G, Esinler I, Karakoc Sokmensuer L, Gunalp S. Effect of sperm morphology on clinical outcome parameters in ICSI cycles. Clin Exp Obstet Gynecol. 2012; 39(2):144-6.
  • De Vos A, Van De Velde H, Joris H, Verheyen G, Devroey P, Van Steirteghem A. Influence of individual sperm morphology on fertilization, embryo morphology, and pregnancy outcome of intracytoplasmic sperm injection. Fertil Steril. 2003 Jan; 79(1):42-8.
  • Hodes-Wertz B, Mullin CM, Adler A, Noyes N, Grifo JA, Berkeley AS. Is intracytoplasmic sperm injection overused? J Urol. 2012 Feb; 187(2):602-6.