To seek a second opinion from a urologist?

[goldflakepaint]

Hi all, just seeking thoughts from others particularly from those who have been dealing with MFI.

My partner and I had our first fertility appointment where they repeated his SA test from a year ago (we have been ttc for 2.5 years, we conceived naturally at the two year mark but it ended in MMC in May). His results came back largely the same- 1.6% morphology, slightly lower than average count, higher than average motility. I had read a lot about dna fragmentation and was expecting that further tests along these lines might be suggested. But we were told that this test wouldn't tell us anything useful as he may well have high dna frag but there would not really be a treatment for that as consultant feels that partner's lifestyle/supplements are adaquate. We have been advised to try naturally for a little while longer (we've decided until the end of the year) but then progress to ivf with icsi if still not pregnant- consultant suggested that icsi would get around any dna frag issues.

There are no known issues with me- I am ovulating regularly and ultrasound came back normal with indication of good ovarian reserve (AMH is being tested). I have symptoms that could indicate possible mild endometriosis but consultant does not feel that further investigation would be useful as ultrasound normal and because we did conceive.

Since the consultation, I have been reading more about DNA frag tests being useful in our circumstances as there are things that can be done with high DNA frag and also the likelihood of it affecting chances of natural conception at least. So I'm wondering whether it would be worth seeking a second opinion from a urologist? (we would need to go private for this). Partner is currently not keen as he does not think it will add anything and may just be additional expense. But I would want us to have all info available to us so we can make the most of the time left trying naturally and make any changes to help increase our chances. I also feel that it makes financial sense for us in the longer term if we have to progress to ivf anyway (which we will also be going private for as would have to wait another 20 months to qualify again for NHS round) to increase our chances there as well.

Any thoughts/experiences of seeking advice from a urologist? I have heard some great things about Dr. Jonathan Ramsey and have heard him on a podcast/read his blog but we wouldn't be going to him-especially not in the current climate- as we don't live in London (in the Bristol/Bath area).

Sorry to hear about your loss.
Well I would say for male issues to go to Dr Ramsay, I'd rather travel a couple of hours for the best consultant. But if not then see who is local to you. There can be all kinds of issues affecting male fertility that the NHS (and some private clinics) aren't much interested in.
You could arrange the Sperm Comet test somewhere near you - their website is Examen.
Dr Ramsay did recommended Impryl supplements for my DH.

Others with more experience might suggest a second opinion re your endometriosis, I don't know much about it but have heard it can affect things and have also heard of some people finding that a laparoscopy was useful, even some natural conceptions after it.

ut we were told that this test wouldn't tell us anything useful as he may well have high dna frag but there would not really be a treatment for that as consultant feels that partner's lifestyle/supplements are adaquate.

We were also told this but did a private DNA frag test after our first failed ICSI (no embryos) it came back very high at 52% we went to a urologist who said straight away DH had a varicoele which he then had embolized and his frag went down to 25% and his count went up. It’s very much worth doing. I would also go to Jonathan Ramsey it’s not too far to travel and he is the best.

@JeNeBaguetteRien Thanks for taking the time to reply. It sounds like a positive experience that you had with Dr. Ramsey. I would love to go to see him and agree that the added travel/expense would be worth it but convincing my partner of this is another matter entirely. He is a statistician and so his whole thing is costs outweighing benefits- I am currently trying to find articles/research to send to him to demonstrate the evidence for more fully investigating MFI (you're completely right that there doesn't seem to be much emphasis on this in clinics). Can I ask if you saw a positive change in your partner's results after the supplements and seeing Dr. Ramsey? Can I also ask how much it cost in total to see Dr. Ramsey and do tests?

And its a good point about the endo, I have wondered this myself since. My consultant does not rule out that I may have it but because I recently conceived, he does not feel that it is having an impact on fertility. I don't know, its not like we conceived particularly quickly. I may call the Endometrosis UK number and try to see if I can get some advice from them.

@Racinglikeapronow Thank you for sharing that, its interesting that you were told the same thing. I am sorry to hear about the failed ICSI and I worry about that happening to us if we just decide nothing more needs to be done. Are you now continuing with further rounds? Did you also go to Dr. Ramsey? Did your DH have a sense that something was off physically before the varicocele was discovered (my partner seems to have this idea that he would know if he had something like that)?

Thanks both and sorry for all the questions, its just so helpful to speak to others with experience of these things.

@goldflakepaint my DH had no clue. It was a total shock to us that we had male issues. He had no pain etc about varicoele and actually examined himself when I suggested it and felt there was nothing there however we were only 5 mins into our urology appointment when he identified a large varicoele. His results have really improved significantly since. We have done two more rounds - one was a disaster due to egg quality issues but on our most recent we made two good quality blastocysts. Unfortunately one didn’t take but it is a big improvement on zero from round one and we are actually struggling more with my issues now than sperm (typical!) I’m not in the UK so didn’t see Dr Ramsey but I was considering flying over to him if I wasn’t happy with the urologist we saw but he was very good in the end.

My DH has just reminded me that while the urologist was sure there was a varicoele he did have to have and ultrasound to confirm it so your DH definitely wouldn’t feel it. Aside from varicoele it could also be an infection or high white blood cells so many reasons.

Hi @goldflakepaint I can't remember the exact cost, I think the consultation might have been £200 or £250.
You could ring and ask how much a consultation costs, the PA is not at all snooty about you asking.
DH said he was very good at putting you at ease.
He'd already had the DNA fragmentation test which was why he went there.

This is from Dr Ramsay's website:
My practice in men's fertility aims to answer three important questions:

Firstly, is there a 'male factor' problem?
Secondly, can we diagnose a cause?
Thirdly, can we offer straightforward (evidence-based) treatment?

If he doesn't think there is male factor at least you'd know, I would say to your DH the cost of a few appointments is much less than the cost of IVF, and IVF is a big investment so you want to be as prepared as possible.

DH DNA fragmentation improved a bit, not miraculously and we still need ICSI but at least we were confident that there wasn't some hidden issue we were unaware of.

I have low AMH myself, am not a great responder to IVF drugs, have had cycles cancelled because of poor response so we have those hurdles to overcome before the sperm even get a look in!

@Racinglikeapronow Thank you for sharing that, I have made the point to my partner that he may have no clue whether he has a variocele or not! I'm sorry to hear you are still struggling and wish you the best of luck for your next round. My partner and I are still struggling to agree on the best course of action for ourselves- not being on the same page just makes a difficult situation even harder. But he has at least agreed to make some more lifestyle changes even if we don't go to see a urologist now as I think he at least accepts that high dna frag is possibly affecting our chances. We just need to get to a compromise we can both work with. Thanks for letting me know about 'Impryl', this may be one of the things that we try out.

@JeNeBaguetteRien Thanks for your response and sorry to hear about the cancelled cycles. I totally see what you're saying though about it being helpful to know that there is not some unknown issue on your partner's end. I feel that the second opinion and dna frag test would really help my peace of mind. I also agree that the expense is nothing compared to the cost of the appointment/tests but partner is also factoring in time and stress (he does find giving sperm samples challenging) and whether we could just go ahead with making lifestyle changes rather than going through that. We're both reading things but weighing them up in different ways which is difficult! Thank you for your thoughts and good luck with things!

@goldflakepaint I would respectfully point out to your DH that IVF will take a large toll on you and your body and the very least he can do is get on board with seeing a urologist And committing to lifestyle changes to maximise your chances of ivf working.

I feel very lucky with my DH when I read about others trying to cajole their DH to do the bare minimum. Re lifestyle improvements my DH has given up all caffeine, all alcohol, all fizzy drinks, crisps, sweets and chocolate etc, all dairy and gluten. He eats cashew and brazil nuts every day and if he wants a treat in the evening he has some healthy nut bar thing. He takes 200 ubiquinol, proceive max, omega 3s, vitamin d and vitamin c everyday and eats healthily. He was already a healthy weight and didn’t over drink or smoke etc but these changes did make a difference prior to varicoele discovery in terms of improving his count so I recommend trying them. He also stopped having baths. If you have no issues yourself with improved sperm you stand a very good chance of success.

I’m 3 rounds in now and mentally and physically exhausted. I would throw the kitchen sink at round one and hopefully there won’t be a round two! Good luck.

Just dropping into answer the question on costs. We saw Mr Ramsay last December and at that point consultation appts were £200 and the Comet test was about £475 I think. We paid for a couple extra tests on top of that though, including a standard sperm test as my partner's last one had been a while back, but it sounds like you wouldn't need that.

@Racinglikeapronow Your dh sounds great and very committed. To be fair to mine, he does have quite a healthy lifestyle- we eat quite healthily, have both upped our leafy green content and servings of fish, only organic meat and dairy, he has very little sweet things (I'm the one with the sweet tooth tbh). He is on Wellman and Ubiquinol 200mg. All the obvious lifestyle issues are not a problem which is why the consultant said he didn't need to change anything. My main issues with him are his alcohol and caffeine use- its nothing extreme but I think he should reduce further.

We have got to a place where he is willing to only drink both alcohol and caffeine occasionally until we either conceive or he gets another sperm test which would likely be if we need to go for IVF early next year- so only one drink/coffee/tea when we got out about once a week or fortnight. He's willing to eat more nuts and antioxidants or really anything that is recommended food wise. He's also willing to change up his supplements and start wearing looser boxers. He does say he would be doing those things to appease me through rather than being convinced (from the research he has looked at) that it will make a huge difference as his lifestyle is already quite good.

I would still much rather we go to a urologist to check out things like varicocele and/or infections but dp has shown me info which indicates the likelihood of him having these- as we did conceive- appears low although obviously still possible. I obviously can't do his point of view justice fully here but there are also some psychological aspects we need to consider- he finds giving sperm samples very difficult and last time, it meant that we had no chance of conceiving that cycle as he was basically unable to finish for like a week afterwards. If he's very stressed, the likelihood of sex going well goes down (not deliberately on his part but it happens) and then we're definitely not conceiving!

So at this point, I doubt I will get my urologist appointment BUT I will be getting the lifestyle changes. I think we'll probably have to settle on that compromise and hope that it makes a difference. I'm wondering now whether to hold off on exploring IVF for a bit longer to see if the changes make any difference to us conceiving naturally. I do completely hear you about the toll IVF takes and it is solid advice to do everything possible to improve chances of a first round being successful. Thank you so much for sharing.

@LennyFitz Thank you for that, that's not an unreasonable amount. Do you feel that it was worthwhile for your partner to go to see Dr. Ramsey? I doubt that we'll be heading there right now but its good to know for the future.

Sorry to hear about your DH issues around sample. It’s pressure on them. I know women do most of the lifting but for them they need to actually enjoy it to produce the sample which is difficult. Our clinic uses the same sample for SA and DNA frag so maybe if clinic did want another sample in future you could ask they also do dna frag then. The clinics just enrage me as our consultant also didn’t believe in DNA frag but my husbands sperm has improved so much since we did the test and addressed it. If we listened to them we’d be no better off now. We actually moved to a clinic that took it seriously.

Definitely persevere with lifestyle changes as my DH lifestyle was also very good but the Marginal changes have helped. My DH has always had his best results after going zero on alcohol and caffeine for a few months so now believes himself it makes a difference! He should do it for the 3 months prior to IVF anyway.

I'd say definitely see a urologist before next cycle. We saw Mr Ramsey and it made a huge difference to our next cycle. We have severe oligozoospermia and finally pregnant after my 4th transfer. Check out PaiCSI and MACX too these are methods of retrieving the healthiest sperms for ICSI. Good luck!

Just to add DH felt that finally someone was listening to him and reassured that this is a common problem, he felt mentally much better after seeing Mr Ramsey. It was not easy to do the lifestyle changes but it worked eventually. Mr Ramsey suggested he sees a nutritionist Mel Brown she consults over Skype. That helped a lot with quality of little sperms he had.

@Racinglikeapronow Thanks, I completly agree about the frustration over clinic's not taking MFI seriously. I do think if the consultant had just said that the dna frag test would be useful, dp and I would not have had the lengthy debate that we did! It is really quite mad that the treatment for MFI is putting the woman through the invasive and physically demanding process of IVF rather than actually diagnosing and treating the problem . Can I ask which clinic you are now with? I would very much like to be with a clinic that takes our issue seriously if we get to that point. I do worry that it'll only be after a failed round that we will properly get to grips with dp's sperm issue but there is nothing more that I can do at this point and I need to try to think positive for now

@Viletta Congrats on your pregnancy! What do you think made the difference in this cycle and can I ask whether you had Picsi or Macx? It's a great point about seeing Dr. Ramsey potentially being quite normalising and I do think that if we end up with a failed first round, I will not be accepting anything less than further investigations (hopefully with Dr. Ramsey).

@goldflakepaint I think ultimately the quality of sperm made the difference in our second cycle. We had too few numbers to do picsi or macs. As to why third transfer of this cycle worked while others failed I think it's just luck. Hope all works well for you!

@All, we went through a lot in the last 7 years....meeting a lot of doctors, tests, cycles, etc...etc... After few years under Dr Ramsay he suggested to my DH that he had not chance to become natural dad, instead after few years we did it. We have an healthy 3 years old boy with us.

Hi all, sorry to jump in the conversation, we hame male infertility factor and even after ICSI, none of our embryos made it to blastocyst. Your posts have been so useful. I am convincing now my partner to see dr Ramsey. I am a bit disappointed that Lister did the cycle without recommending is first treatment for my partner. We know he has the bilateral varicocele and I need a specialised opinion whether to embolise it. He took Proxeed before with no improvement but he had improvement taking Clomiphene! However we still needed ICSI. This is our 2nd cycle without success :( it might be my eggs too as I am 40 but we had top quality embryos on day 3 and they stopped developing on day 6. Please share your success after hubbys treatment and what it was exactly? Thank you 😊