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Sperm morphology

male factor ICSI sperm Morphology

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#1 prarie_faerie

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Posted 23 October 2019 - 03:36 PM

Hey guys!

 

Has anyone else here (or your partner) had very low morphology results from semen analysis, but your doctor ignores this as infertility cause? I'm very curious to hear other's experience with morphology issues and conceiving, particularly with IVF and IUI success?

 

My husband had semen analysis done and had very low morphology come back at <1% normal (issue is with the shape of sperm's heads). We have had extensive testing done and everything else has come back normal, our doctor has diagnosed us with "unexplained infertility" and says the morphology doesn't play a role in infertility when rest of semen sample came back with normal results. I have had 2 successful pregnancies before with other partner, but me and husband have been trying for 3+years with no success, and 3 failed IUI's. 

 

Now moving on to IVF - transplant date will be first week of December 2019, and doctor says we do not need ICSI. I am very worried that normal IVF will not work when i strongly believe it is the sperm morphology that is the issue. It is a awkward subject to push with doctor as i don't want to blame my husband to doctor or make him feel bad, but from research i've done about sperm morphology this low, it is definitely a problem with conceiving and i'm wondering if ICSI shouldn't have been recommended by doctor?

 

Very curious to hear your stories and experiences with fertility and sperm morphology! Thank you in advance for sharing! :)


Me: 27  DH: 27   Diagnosis: Unexplained

 

  • Started TTC: Jan. 2017
  • First medicated IUI: July 2019= BFN
  • Second medicated IUI: August 2019 = BFN
  • IVF/ICSI: Dec 2019 = 4 conventional IVF blastocysts + 3 ICSI blastocysts,  frozen at 5 days. No fresh transfer due to OHSS
  • First FET: Jan. 2020 = BFP resulting in a pregnancy loss at 7 weeks

#2 MLK-N

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Posted 23 October 2019 - 07:48 PM

Hey!
We have similar issues regarding my husbands sperm (low count, <1% morph)

I have endometriosis but our first fertility dr had us go straight to IVF with ICSI and said ICSI was due to his low count. They never really talked much of the morphology but I really think that played a factor in the decision to do ICSI.

If ICSI is something you want to go ahead with, I would be upfront with your dr. This is your body, your time and you should have a say in the treatment plan!

(We were fortunate enough to be blessed with our miracle girl last June, perfectly healthy)

#3 prarie_faerie

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Posted 23 October 2019 - 08:13 PM

Hey MLK-N!

 

Thanks for the response, interesting that our doctors have taken very different approaches to a seemingly similar situation. And yes, my understanding is that ICSI is recommended in IVF patients where there is an issue with sperm being able to penetrate the egg (i.e. issues with morphology specifically, as other issues with semen are mitigated with regular IVF procedure). 

 

And yes, maybe i should be upfront with doctor, definitely food for thought. It's just tough as my husband gets quite upset if i try to talk about the issue being on his end, when doctor says it is not, but i would feel a lot better if we were proceeding with ICSI, as to me i don't understand how we can be "undiagnosed" when his semen analysis was so off. 

 

Congratulations on your healthy baby girl, i am so happy for you! Emoticons01015.gif

 

For anyone else who has had ICSI recommended, what was the reason or test results behind doing so?

Anyone else have success with regular IVF when morphology issues are present?


Me: 27  DH: 27   Diagnosis: Unexplained

 

  • Started TTC: Jan. 2017
  • First medicated IUI: July 2019= BFN
  • Second medicated IUI: August 2019 = BFN
  • IVF/ICSI: Dec 2019 = 4 conventional IVF blastocysts + 3 ICSI blastocysts,  frozen at 5 days. No fresh transfer due to OHSS
  • First FET: Jan. 2020 = BFP resulting in a pregnancy loss at 7 weeks

#4 DorothyandToto

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Posted 23 October 2019 - 08:24 PM

Hi Prarie!

Ive done two egg retrievals and we did ICSI both times. Two reasons we did it...my doctor says that egg walls tend to be hard for sperm to penetrate the older you get (Im 42) and my husbands motility and morphology were just a little suboptimal...she said ICSI would negate any sperm related issues...we had good fertilization results...first round 5/5 fertilized normally and second round 4/6 fertilized normally (the two that didnt were due to my egg issues). We have a chromosomally normal embryo from each cycle and hope to transfer one in November.

I would personally push for ICSI if its something you want as the last thing you want them to do is do rescue ICSI if they arent fertilizing as Ive heard results for that are not great...

Another possibility and something Ive seen done at some clinics is to do half and half...half of whatever eggs you have fertilized through traditional IVF and half through ICSI...just an idea.

Good luck!

#5 Cotton

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Posted 24 October 2019 - 11:44 AM

I've had disagreements with my husband on what strategy to take too. Fortunately for me I, didn't have the doctor leaning on the scale. There's really not a whole lot that you can do. This is the kind of stuff about infertility that does a number to a marriage. I guess try to get behind his reasoning for not wanting to do ICSI? Ask him if it's worth risking a dud cycle to save the $2000? I've noticed with my husband I can ask the same question half a dozen times and not really finally get a sensible answer that explains his behaviour then the 7th time the real answer comes out.

 

I'm very surprised the doctor is saying the sperm is not an issue. Does your husband have at least 5 million motile normal sperm in sperm analysis? Can you ask the doctor why he isn't recommending ICSI? Does he think the abnormal sperm won't be able to compete in fertilization with the normal sperm? There is definitely a correlation between morphology and genetic quality of the sperm. Try to talk to the doctor without your husband there.

 

https://www.ncbi.nlm.../pubmed/7538475



#6 prarie_faerie

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Posted 24 October 2019 - 01:59 PM

Hi Prarie!

Ive done two egg retrievals and we did ICSI both times. Two reasons we did it...my doctor says that egg walls tend to be hard for sperm to penetrate the older you get (Im 42) and my husbands motility and morphology were just a little suboptimal...she said ICSI would negate any sperm related issues...we had good fertilization results...first round 5/5 fertilized normally and second round 4/6 fertilized normally (the two that didnt were due to my egg issues). We have a chromosomally normal embryo from each cycle and hope to transfer one in November.

I would personally push for ICSI if its something you want as the last thing you want them to do is do rescue ICSI if they arent fertilizing as Ive heard results for that are not great...

Another possibility and something Ive seen done at some clinics is to do half and half...half of whatever eggs you have fertilized through traditional IVF and half through ICSI...just an idea.

 

 

Congrats on the successful fertilization results and wishing you all the luck and love in the world for the transfer to go well in November!

 

Yes, i think you are right and at the very least i need to have another one on one with my doctor about these concerns - i would have before but while being on the waitlist for IVF it has given me a great deal of time to be a bit obsessive and do quite a bit of my own research and i'm coming to question my doctor a bit. She did say that if IVF doesn't work they plan to do rescue ISCI, but she didn't mention that the results from this aren't great. Thanks for sharing your experiences and what info on this you know. I think i definitely need to speak to my doctor and figure out what her rationale is in not recommending ISCI initially.

 

Interesting that some clinics could do half of each (IVF and ICSI) as i would love to know if traditional IVF can work, as we would like to have more than one child and therefore will likely have to go through this again... if it works (Fingers crossed!)


Me: 27  DH: 27   Diagnosis: Unexplained

 

  • Started TTC: Jan. 2017
  • First medicated IUI: July 2019= BFN
  • Second medicated IUI: August 2019 = BFN
  • IVF/ICSI: Dec 2019 = 4 conventional IVF blastocysts + 3 ICSI blastocysts,  frozen at 5 days. No fresh transfer due to OHSS
  • First FET: Jan. 2020 = BFP resulting in a pregnancy loss at 7 weeks

#7 prarie_faerie

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Posted 24 October 2019 - 02:08 PM

I've had disagreements with my husband on what strategy to take too. Fortunately for me I, didn't have the doctor leaning on the scale. There's really not a whole lot that you can do. This is the kind of stuff about infertility that does a number to a marriage. I guess try to get behind his reasoning for not wanting to do ICSI? Ask him if it's worth risking a dud cycle to save the $2000? I've noticed with my husband I can ask the same question half a dozen times and not really finally get a sensible answer that explains his behaviour then the 7th time the real answer comes out.

 

I'm very surprised the doctor is saying the sperm is not an issue. Does your husband have at least 5 million motile normal sperm in sperm analysis? Can you ask the doctor why he isn't recommending ICSI? Does he think the abnormal sperm won't be able to compete in fertilization with the normal sperm? There is definitely a correlation between morphology and genetic quality of the sperm. Try to talk to the doctor without your husband there.

 

https://www.ncbi.nlm.../pubmed/7538475

 

 It's not that my husband is against ICSI necessarily, it's more that he gets upset with me, saying that i'm not a doctor and therefore we should just be following what the doctor says. Although he is supportive of me, ultimately it is the woman (me) that has to go through this process and so i think i deserve to have a say and to be knowledgable on what's happening with my body (i.e. be doing my own research).

 

Yes, when our family doctor initially got a semen analysis done (as well as extensive bloodwork ups and pap on me) to send to fertility specialist, he said that the issue appeared to be that there were no normally shaped sperm. So personally i was relieved that we finally had an answer after years of trying with no success, but my husband understandably felt very guilty that it was "his fault" which of course isn't the case. In the first meeting with our fertility specialist she told us that morphology does not necessarily play a role in infertility patients and after doing more extensive testing on me she diagnosed us with unexplained infertility and recommended 3 rounds of IUI, which did not work. My husband likes the idea of it being an unknown and it not being on his end, which is why he is resistant to these conversations i think. But now here we are being recommended IVF and not ISCI and i still feel that it is the morphology that is the issue, but of course our doctor would know best, i just feel frustrated with things i guess and i would like more specific answers from our doctor.

 

Anyway, yea i think you're right. i need to have another sit down with the doctor and air some of this out. Specifically why ICSI isn't being recommended with sperm morphology <1% normal and also request a secondary semen analysis maybe. Thank you for the advice! It's a relief to see i'm not crazy to be feeling/thinking this way.


Me: 27  DH: 27   Diagnosis: Unexplained

 

  • Started TTC: Jan. 2017
  • First medicated IUI: July 2019= BFN
  • Second medicated IUI: August 2019 = BFN
  • IVF/ICSI: Dec 2019 = 4 conventional IVF blastocysts + 3 ICSI blastocysts,  frozen at 5 days. No fresh transfer due to OHSS
  • First FET: Jan. 2020 = BFP resulting in a pregnancy loss at 7 weeks

#8 Cotton

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Posted 24 October 2019 - 02:49 PM

He's only had one sperm analysis?!? He needs at least 2. I'm shocked the fertility clinic didn't order one. I can't believe they did IUIs on you with only 1 sperm analysis. BTW did they make sure your tubes are open with hysterosalpingogram or a sonohistogram?

 

From what I've read, a man can still be fertile even if a high % of his sperm are immotile or have abnormal morphology if the overall count is high enough to give a critical mass of normal sperm.

 

It sounds like your husband is emotionally wounded that "he's the cause". Except he's not. He didn't do anything to cause the low morphology. Try to tell him that. I'm in the same exact situation but it could have just as easily been "my fault". I view it as crying over spilt milk. Actually when we did the workup before our IVF cycle I came back with low AMH so maybe it was partially my fault. You never know.

 

My husband has been very resistant to these conversations as well. He doesn't want to contingency plan, wants to do everything by the seat of the pants, "I don't want to talk about hypothetical when we can wait" etc. I think this is part of the man package. ohmy.png

 

Maybe try telling him you want the ICSI because it will make you feel better that you're doing everything you can to avoid another cycle. Maybe he can handle an emotional reason coming from you better than a scientific reason coming from "his fault".



#9 prarie_faerie

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Posted 24 October 2019 - 03:11 PM

We've only had 1 full semen analysis done and that was when we lived in Calgary, the clinic in Saskatoon has not done one at all. He did undergo an HBA semen test at our current clinic, which looks at maturity of sperm and their binding capacity, but all research articles i've found on HBA testing says that Morphology is a far better indicator for success in IVF over HBA test results.

 

And yes the rest of his semen analysis results (total amount of sperm, motility, etc.) all came back normal. Theonly issue was having no normally shaped sperm. But i  would think if none of them have normally shaped heads then they would have issue penetrating an egg, right? I really need to talk with my doctor before beginning IVF (Big Sigh).

 

And yes i have had HSG. All of my results came back optimal with no issues.

When i was younger and with another partner, i became pregnant - while on birth control no less (terminated by my choice - please no judgement on this). So i just don't see what else it could be besides the morphology issue.

 

Thanks for the support Cotton, I'm glad i'm not the only one that has a man who communicates/processes this way! I think that's great advice. definitely a sit down with DH and doctor needs to be in order before starting IVF


Me: 27  DH: 27   Diagnosis: Unexplained

 

  • Started TTC: Jan. 2017
  • First medicated IUI: July 2019= BFN
  • Second medicated IUI: August 2019 = BFN
  • IVF/ICSI: Dec 2019 = 4 conventional IVF blastocysts + 3 ICSI blastocysts,  frozen at 5 days. No fresh transfer due to OHSS
  • First FET: Jan. 2020 = BFP resulting in a pregnancy loss at 7 weeks

#10 Cotton

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Posted 24 October 2019 - 03:27 PM

I really don't know much about morphology. Our issue was obstruction and that necessitated ICSI right off the bat so we didn't have to go through this conversation. I would think you'd want to do ICSI so the best looking sperm can be hand selected by the embryologist rather than random sperm fertilizing the eggs. I suspect you would get some fertilized if you didn't do ICSI but if you do ICSI your numbers might come out a bit better. BTW we had 100% fertilization with our ICSI, even with immature testicular sperm, so our embryologist did an amazing job picking the best swimmers. It could mean the difference between a second cycle for a sibling or not.

 

If it makes you feel any better, male factor is one of the "better"  infertility issues to have. It has been prognosis than some of the others, and it looks like you've ruled out uterine and immune issues too with a prior pregnancy (hopefully).



#11 prarie_faerie

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Posted 24 October 2019 - 03:43 PM

Wow, sounds like you had some great results with fertilization using ICSI- congrats on that Cotton! Have you undergone transplanting any embryos yet? 

 

And from your last response, of course it is absolutely no one's fault, no matter what the cause is, it is a problem i want to tackle as a team. No one does anything to deserve infertility or bring it upon themselves.

 

But yes, i agree, that male factor is definitely a "better" diagnosis than many others. In my opinion, including "unexplained" as it was more comforting to me to have concrete answers so that we can navigate treatment with more information and make better choices for ourselves. 

 

Thank you all so much for your responses, its given me a lot to think about. Definitely need to have some conversations with partner and doctor about it, but i am going back and fourth between pushing for ICSI because i believe it would be best and going through with IVF regularly, as recommended by doctor, as a sort of "test run" to see how my body responds and how things work out. Because if it works regularly, that would be preferred and good to know moving forward for future attempts. But if they have to do emergency ICSI than at least i finally have my concrete answer moving forward.


Me: 27  DH: 27   Diagnosis: Unexplained

 

  • Started TTC: Jan. 2017
  • First medicated IUI: July 2019= BFN
  • Second medicated IUI: August 2019 = BFN
  • IVF/ICSI: Dec 2019 = 4 conventional IVF blastocysts + 3 ICSI blastocysts,  frozen at 5 days. No fresh transfer due to OHSS
  • First FET: Jan. 2020 = BFP resulting in a pregnancy loss at 7 weeks

#12 Cotton

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Posted 24 October 2019 - 07:20 PM

We were lucky to get a BFP with the first embryo transferred but it's still very early and we are luckier still to have spares (or siblings) on ice.

 

I thought of something else that might make your husband feel better. I don't know how old he is, but in younger couples infertility is closer to 50-50 male factor/female factor. So he's not alone at all. For some reason society doesn't really talk about male infertility.



#13 wannabeamama

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Posted 24 October 2019 - 08:49 PM

My Dh was just officially diagnosed with a morphology issue, also an issue with the sperm heads.

The analysis came back with ~93% abnormal.

We did some cycles with a previous clinic and they just told us everything was normal but recommended ICSI because it would increase the chances of fertilization. We ended up with 4 embryos in the end, 4/5 fertilized. 

 

This new clinic that made the diagnosis told us that there was very little chance that the sperm would fertilize an egg naturally with that morphology. This was news for us and maybe explains some of our issues.

 

I don't know why there are so many differences among clinics!

I agree with you, it seems like abnormally shaped sperm would have a more difficult time penetrating an egg. 

It's nice to keep yourself informed about things and do your research. Talk to your husband and your doctor. I hope things go well for you!


Me: 37 DH: 36

 

TTC since 2014

 

IVF #1: November 2016

ER: Retrieved 5 eggs, 5 fertilized, ended up with 4 five day blasts

 

Fresh ET Nov 2016: BFN

FET w/ ICSI #1         Feb 2017: BFP,  M/C Apr (Lost at 7 weeks, found out at 14, had D&C)

FET  w/ ICSI #2       June 2017: BFP,  M/C Sept (Lost at 9 weeks, found out at almost 13 weeks, had D&C)

FET w/ ICSI #3        April 2018: BFN

 

IVF # 2: January 2020

ER: Retrieved 15 eggs, 10 fertilized, ended up with 7 five day blasts

 

Fresh ET Jan 2020: BFN

FET w/ICSI #1          Aug 2020: BFN

 

5 frosties left, likely not cycling again until next spring.

 


#14 prarie_faerie

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Posted 25 October 2019 - 11:05 AM

We were lucky to get a BFP with the first embryo transferred but it's still very early and we are luckier still to have spares (or siblings) on ice.

 

I thought of something else that might make your husband feel better. I don't know how old he is, but in younger couples infertility is closer to 50-50 male factor/female factor. So he's not alone at all. For some reason society doesn't really talk about male infertility.

 

 

Well a very early congrats to you then and i hope that your pregnancy continues to be strong and healthy! I'm so excited for you! 

 

I didn't know it was 50/50, interesting (DH is 27 as well)


Me: 27  DH: 27   Diagnosis: Unexplained

 

  • Started TTC: Jan. 2017
  • First medicated IUI: July 2019= BFN
  • Second medicated IUI: August 2019 = BFN
  • IVF/ICSI: Dec 2019 = 4 conventional IVF blastocysts + 3 ICSI blastocysts,  frozen at 5 days. No fresh transfer due to OHSS
  • First FET: Jan. 2020 = BFP resulting in a pregnancy loss at 7 weeks

#15 prarie_faerie

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Posted 25 October 2019 - 11:10 AM

My Dh was just officially diagnosed with a morphology issue, also an issue with the sperm heads.

The analysis came back with ~93% abnormal.

We did some cycles with a previous clinic and they just told us everything was normal but recommended ICSI because it would increase the chances of fertilization. We ended up with 4 embryos in the end, 4/5 fertilized. 

 

This new clinic that made the diagnosis told us that there was very little chance that the sperm would fertilize an egg naturally with that morphology. This was news for us and maybe explains some of our issues.

 

I don't know why there are so many differences among clinics!

I agree with you, it seems like abnormally shaped sperm would have a more difficult time penetrating an egg. 

It's nice to keep yourself informed about things and do your research. Talk to your husband and your doctor. I hope things go well for you!

 

That is so bizarre that with 96% abnormal sperm heads, that became a diagnosis for you and with 99%+ abnormal sperm heads in our situation it is not thought to be an issue. Logically, if the sperms heads are not formed correctly it would stand to reason they would struggle to penetrate the egg. 

 

Did your husband undergo an HBA test? and if so do you mind me asking what the results were?

 

Thanks for sharing your story/diagnosis with morphology. It is really helpful for me to put things in perspective. I think i'm going to have to be my own advocate in this situation, and request ICSI

 

Good luck to both of us wannabeamama! heart.gif


Me: 27  DH: 27   Diagnosis: Unexplained

 

  • Started TTC: Jan. 2017
  • First medicated IUI: July 2019= BFN
  • Second medicated IUI: August 2019 = BFN
  • IVF/ICSI: Dec 2019 = 4 conventional IVF blastocysts + 3 ICSI blastocysts,  frozen at 5 days. No fresh transfer due to OHSS
  • First FET: Jan. 2020 = BFP resulting in a pregnancy loss at 7 weeks

#16 twinmania

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Posted 25 October 2019 - 09:05 PM

I just wanted to chime in as my husband was also diagnosed with poor morphology with less than 1 percent normally shaped sperm. He was 45 and I was 37 and diagnosed with unexplained infertility. At the time I was devestated and frantic to improve his diet and lifestyle choices in the hopes of improving his sperm quality. We as women tend to do everything in our power in our efforts to conceive and his unwillingness to change in order to have a baby almost ripped our relationship apart. Well those misshaped, square headed sperm fertilized all 6 of my 6 eggs without icsi. They also lead to 3 live births and 2 remaining 5 day blasts. It is so difficult not to over analyze every element of the ivf process but often there is no rhyme or reason to ones results. But if my hisband's poor sperm could result in such results, so could others. Hoping the best for all of you.
  • DorothyandToto likes this

#17 prarie_faerie

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Posted 28 October 2019 - 02:13 PM

Hey Twinmania,

 

Thanks for chiming in, it's good to hear the other side of it, that regular IVF worked for you when you got the same diagnosis (or lack thereof) as us with the sperm morphology issues.  I'm so happy for you that it was so successful -congrats! It is very reassuring to me that i am not the only one in this situation who was not recommended ICSI.

 

On the personal side, me and my husband have been going through something similar. He has been having the odd cigarette still and the anger i feel over this has been HUGE and led to some very bad fights. As you said, i am doing everything in my power to improve our chances, i'm consumed with it, and his unwillingness to be 100% on board with these efforts has cause our relationship to suffer big time. 

 

Perhaps you're right and i should just calm down, trust what our doctor says and relax about it all. It's hard though, at this point i'm not sure what to do: just trust in what doctor says and go with that or advocate for ICSI.

 

An Update on the situation: Husband and i spoke, he is alright with doing ICSI, but would rather trust in whatever doctor recommends. Basically it's up to me. So I'm having a sit down with my doctor before beginning IVF treatment next week to discuss ICSI. I plan to share my concerns: why there was no secondary semen analysis done and also her reasoning on not recommending ICSI or presenting it as an option at all for us. If she is strongly against ICSI then i will trust her, but am hoping we can proceed with ICSI to try to increase our chances of success.


Me: 27  DH: 27   Diagnosis: Unexplained

 

  • Started TTC: Jan. 2017
  • First medicated IUI: July 2019= BFN
  • Second medicated IUI: August 2019 = BFN
  • IVF/ICSI: Dec 2019 = 4 conventional IVF blastocysts + 3 ICSI blastocysts,  frozen at 5 days. No fresh transfer due to OHSS
  • First FET: Jan. 2020 = BFP resulting in a pregnancy loss at 7 weeks

#18 Cotton

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Posted 28 October 2019 - 04:52 PM

Men in general just don't care as much about health, unfortunately. I could write a wall of text about several different experiences with my husband but I won't threadjack. ohmy.png

 

When you ask the doctor, ask specifically what the morphology issue is and whether or not it impacts the integrity of the DNA and the fertilization potential of the abnormal sperm. Maybe his particular issue isn't that big of a deal. Ask if the embryologist is likely to fine ANY normal sperm if they do ICSI or are you likely to be working with all abnormal sperm. Also, I've heard of men having borderline sperm results then the sample on the day of the egg retrieval happens to be total garbage (probably due to stress) and they have to freeze all the eggs. Ask about the chances of that happening and whether or not it makes sense to have a backup sample on ice. There is alot of variability between samples.

 

Does your clinic have an andrologist?

 

Let me know how it goes!



#19 prarie_faerie

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Posted 27 November 2019 - 11:17 AM

Hey so a quick update for anyone who was interested in this..

 

Spoke with our doctor and she agreed to perform ICSI on half of the eggs harvested from IVF procedure if there is 8 + eggs. If we get 8 or less eggs then ICSI will be done to all of them. feel so much better about this as it will act as somewhat of a safety net if the morphology does turn out to be our issue. As some of you said though, maybe it won't have been needed, but having the ability to do half of them will give us some answers and gives me some peace of mind! Very happy our doctor was willing to listen to my concerns and go ahead with this. Now in the midst of stimulating injections and expect to have the harvesting surgery the first week of December 2019 - fingers crossed it all goes well and we get lots of healthy embryos.

 

Thank you so much everyone for your support and opinions/personal stories on this matter, it was so helpful to me and made me feel very supported and much less alone and gave me courage to advocate for myself. Much love and well wishes to all of you!!


  • DorothyandToto likes this

Me: 27  DH: 27   Diagnosis: Unexplained

 

  • Started TTC: Jan. 2017
  • First medicated IUI: July 2019= BFN
  • Second medicated IUI: August 2019 = BFN
  • IVF/ICSI: Dec 2019 = 4 conventional IVF blastocysts + 3 ICSI blastocysts,  frozen at 5 days. No fresh transfer due to OHSS
  • First FET: Jan. 2020 = BFP resulting in a pregnancy loss at 7 weeks





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