Developing a Comprehensive Fertility Plan
Introduction to Developing a Comprehensive Fertility Plan
The goal the Sperm Boot Camp is to optimize the environment for sperm production as much as possible over a ten-week spermatogenic cycle. When these ten weeks are complete and all of the sperm in the body have been produced in this improved environment, then repeat fertility tests should be performed in order to assess the impact of the interventions. For most couples, this will involve repeat semen analysis testing. However, some couples will be repeating other testing, such as sperm DNA fragmentation testing, that had previously been abnormal.
(For more information on sperm DNA fragmentation, please see the "Advanced Sperm Testing" section of this website).
In some circumstances, to save time, some couples may choose to proceed with an intervention from the female side (such as intrauterine insemination or in vitro fertilization) at the end of the ten weeks without repeating formal semen analysis testing beforehand. As long as baseline semen parameters were adeqaute, this approach is fine. At the time of IUI or IVF cycles the lab generally checks a few basic semen parameters (such as volume, density, and motility), which can provide some degree of feedback to the couple on their male-factor status.
The timeline for repeat testing is sometimes delayed due to certain circumstances. For example, if the dosages of hormonal medications (such as clomiphene) needed to be adjusted multiple times in order to normalize blood hormone levels, then repeat fertility testing can be performed eight to ten weeks after the man made his last medication dosage change.
The Sperm Boot Camp and Medical Optimization Programs are designed to efficiently optimize a man’s fertility potential to the highest degree possible, and the majority of men with male factor infertility have problems that are amenable to effective treatment. That is not to say that all men can be restored back to what are considered "normal" semen parameters. However, by optimizing the quality of their sperm, couples can potentially increase the choice of fertility treatments they are candidates (such as IUI), increase the chances of establishing and maintaining a pregnancy, and potentially improve the chances of delivering a healthy child.
To sustain any gains in fertility that a man has made while completing the Sperm Boot Camp and Medical Optimization Programs, the changes (in lifestyle, hormones, and so on) must be sustained, or else his fertility parameters will typically revert back to the way they were before the plan was started. I generally recommend that most interventions from the male side be continued until the woman is pregnant and through her first trimester (at which time the chances of miscarriage is relatively low as long as the pregnancy is progressing well).
What if Repeat Fertility Testing Shows No Improvement?
We know that most men with male factor fertility problems have reversible issues, and that addressing these issues can improve fertility potential. However, not all male-factor issues are reversible, and about 25 to 30 percent of men do not show any improvement in their fertility testing results, even after treating all reversible fertility factors that are uncovered during the course of the plan. There are two things to keep in mind in these situations.
First, some men need two spermatogenic cycles to see improvements in their fertility following interventions. It’s a good idea to consider repeating fertility testing in another eight to ten weeks to see if more time will result in improvements. Of course, the couple’s overall situation needs to be taken into consideration when making this type of decision. If the woman is forty years old and her partner has a total motile count of only 1 million sperm, which hasn’t changed after ten weeks of interventions, then maybe they should proceed with IVF/ICSI if possible, since her age may make waiting an additional two and a half months potentially undesirable. In such circumstances, good communication between the couple and their fertility physicians is especially important.
Second, some men have improved fertility potential even though there is no detectable change in their basic semen parameters. We know that the semen parameters of density, motility, and morphology are not the whole story of male fertility potential. Sperm DNA fragmentation testing is just one of many other male fertility tests that will eventually be developed and refined to provide further fertility potential information beyond knowing just how many sperm are present, how well they swim, and how many have normal shapes. The interventions described in this website may improve a man’s fertility even if his semen parameters do not change appreciably, so I urge men in this situation to continue to follow the Boot Camp and Medical Optimization guidelines.
Developing a Comprehensive Plan
As discussed earlier, successful fertility efforts always need to take into account both the male and female factors that are present. The Sperm Boot Camp and Medical Optimization Program focuses on improving male fertility parameters to the fullest extent possible. Once this has been accomplished, the next step is to assess where things stand for both members of the couple and to develop a plan that is going to achieve their fertility goals as effectively as possible.
There is no one strategy that is applicable to all couples; each plan must be based upon their individual situations. Some couples are just starting the fertility treatment process, while others have already undergone multiple interventions (like IUI and IVF) without success. Others are dealing with abnormal sperm DNA fragmentation levels or recurrent unexplained pregnancy loss. Depending on the results of repeat fertility testing after the initial ten weeks, individual couples, with guidance from their fertility specialist providers, will have to decide how to proceed. Perhaps they will try another cycle of IVF now that the DNA fragmentation levels have normalized, or they will go ahead with another cycle of IUI since the total motile count has improved by 50 percent.
For couples that are just starting down the fertility treatment path, deciding on the next step can be an intimidating process. All female partners should undergo a basic female fertility evaluation by an ob-gyn or a specialist in female fertility, and this can often be accomplished while the man is going through the Sperm Boot Camp and Medical Optimization Program. Taking into account both the female and male fertility issues that are present can help to determine the best next course of action. Open, honest communication between the couple and their respective medical care providers is very important to establishing an effective and efficient comprehensive fertility plan.
Typically, once the male parameters have been optimized, the focus will shift to interventions from the female side that can enhance the chances of successful interventions. Some couples in whom significant improvements in sperm counts have been seen with the Boot Camp and Medical Optimization may simply decide to try natural timed intercourse for several more months, and this is a reasonable plan, especially if semen parameters are decent and the woman is young. However, most couples who are using the plan have been trying to conceive for at least 6 to 12 months, so pursuing interventions from the female side may increase their chances of reproductive success.
These interventions include:
1) Medications for the woman, such as clomiphene (Clomid) or letrozole (Femara)
2) Intrauterine insemination (IUI)
3) In vitro fertilization (IVF)
4) Intracytoplasmic sperm injection (ICSI)
More information on these can be found in the "Female Fertility Treatments" section of this website.
Choosing the Right Female Treatments for a Couple
From the woman’s side, many different factors can play a role in determining which types of treatments she is a candidate for. Examples include whether the woman is ovulating normally, if her fallopian tubes are blocked, how good her ovulatory reserve is, and whether she has any uterine or cervical abnormalities.
From the male side of things, the total motile count (TMC) is usually the most predictive factor as to what types of treatments the couple is a candidate for (see the “Interpreting Semen Analysis Testing” section for more information on TMC).
One of the goals of the 10 week Boot Camp is to increase TMC as much as possible, so as to improve the range of treatment options available to a couple. The following are general guidelines for the number of sperm that make a couple eligible for the different treatment options available from the female side:
These are only general recommendations, and the exact clinical circumstances for each couple should always be used to make the final decisions on what course of action to pursue. In general, for couples with no precluding female fertility issues and decent semen parameters that make them candidates for any of the above listed female fertility treatments, a step-wise progression is often recommended. If natural intercourse has not been successful after twelve months, then a trial of timed intercourse combined with medications (such as clomiphene or letrozole) is tried. If this has not been successful after three or four cycles, then the couple moves on to intrauterine insemination. If IUI does not produce results after three or four cycles, then the couple generally moves on to IVF.
Many factors can modify the course of treatment, however. If the woman is older, then moving more quickly to a more aggressive form of treatment (such as IUI or IVF) may be indicated. Also, some couples who have been trying for a long time may not wish to wait any longer, and prefer to move straight to a more aggressive intervention. For couples in which the man’s sperm count is borderline to be considered to be a candidate for an intervention, the couple may also choose to modify their approach. For example, a man with a pre-wash TMC of 5 million sperm may choose to try only one or two cycles of IUI (instead of the standard three or four cycles) before moving on to IVF if no pregnancy has been established.
The formulation of a fertility management plan that is specific for each particular couple and takes into consideration both the male and female factors that are present is extremely important to optimizing the chances of establishing a healthy pregnancy. The couple's preferences on acceptable timelines for establishing a pregnancy, ethical viewpoints on certain treatment options, and personal financial considerations all need to be taken into account as well. Excellent communication and coordination of care between the man’s and woman’s fertility specialists is vital to successfully forming a treatment plan for the couple that maximizes their chances of achieving their fertility goals.