Request for advice on how to proceed regarding trying to conceive

    • New

    Dear Team,

    My husband is 36 years old and I am 35 years old, and we have been trying to conceive since July 2023. After a (natural) ectopic pregnancy in 2024, which was terminated with methotrexate, I have not become pregnant again so far. My anti-Müllerian hormone level was 23.20 pmol/l in January 2026.

    I ovulate regularly. I now have to take progesterone during the second half of my cycle because my progesterone level is slightly low, and I’ve always had acne, PMS, and spotting before my period. All other necessary blood and hormone levels are within normal range,

    Both of my fallopian tubes are patent, though the right fallopian tube has limited transport capacity. During the hysteroscopy/endometrial biopsy, my uterus appeared normal, but there was a strong suspicion of chronic endometritis.

    The biopsy from May revealed 9 stromal CD138/MUM1-positive plasma cells per 10 HPF and 100 stromal CD56-positive NK cells. I underwent a 14-day course of Doxylin therapy. In the follow-up biopsy in August, 8 stromal CD138/MUM1-positive plasma cells per 10 HPF and 60 stromal CD56-positive NK cells were detected. My second 14-day course of antibiotic therapy with Anaerobex and Ciproxin ended today. I am taking probiotics and will also start using Döderlein vaginal suppositories starting tomorrow.


    My husband’s hormone levels were found to be normal. A few years ago, he had testicular inflammation, which was treated with antibiotics. A minor varicocele and a spermatocele were found on the left epididymis, but this has no impact. Five semen analyses are available:

    • Jan. 2025: 43.7 million sperm/mL, 153 million total, 29% rapidly progressive motility, and 6% normally shaped. Assessment: asthenozoospermia.
    • Nov. 2025: 47.7 million/mL, 143.2 million total, 46% rapid forward motility, and 11% normally shaped. Assessment: Normozoospermia.
    • January 2026: 58 million/mL, 174 million total, 15% with progressive motility, and 3% with normal morphology. Diagnosis: asthenoteratozoospermia.
    • May 2026: 33.35 million/mL, 175.36 million total, 28% with progressive motility, and 4% normally shaped. Assessment: Asthenozoospermia. The DNA fragmentation index was 16%, and the MAR test results for IgA and IgG were both 0%.
    • August 2026: 29.90 million/mL, 63.39 million total, 27% with progressive motility, and 2% normally shaped. Diagnosis: asthenoteratozoospermia.

    In the meantime, we consulted a urologist specializing in fertility. He nevertheless considers the semen analyses sufficient for a natural pregnancy. My husband has been prescribed clomiphene to further improve his sperm parameters. Another hormone panel is scheduled; a follow-up semen analysis is planned in four months. The urologist mentioned that artificial insemination might be an option, especially if we are experiencing significant emotional distress.

    - Given the fluctuating semen analysis results, how do you assess our next steps? Would you recommend waiting to see if treatment with clomiphene brings about an improvement, hormonal stimulation with timed intercourse, or would you advise proceeding with insemination right away? What would be the benefit of stimulation given my regular ovulation? When should we move on to IVF?

    - Do you recommend a follow-up biopsy and another smear test to identify the predominant bacteria? If so, how long after the end of antibiotic therapy and at what point in the cycle should these be performed? Should the results be available before a potential insemination?

    - What other tests are still necessary? Should I have a laparoscopy, even though I have no other symptoms?

    Thank you very much for your assessment.

    Edited 2 times, last by Berlinerin_1991 (September 25, 2026 at 9:26 PM).

    • New

    Dear Berlinerin_1991

    You’re doing everything right.

    Several important factors are crucial for a successful pregnancy, such as high-quality eggs, sperm, embryos, and a healthy uterine lining.

    I know and understand that the approach in Germany is quite different, but in Spain we like to take all these aspects into account, including success rates as well as the patients’ needs and goals.

    While intrauterine insemination (IUI) or timed intercourse can work, the success rates are very low because you have absolutely no control over fertilization—so you don’t know if there’s a problem and whether it’s due to the quality of the eggs, the sperm, or the embryo. Therefore, it’s a major advantage to create several good-quality embryos now if you’re planning to have multiple children, because this way you’re essentially preserving your fertility and avoiding the risk of adding another fertility issue, such as advanced maternal age. And right now, you’re at a good age to consider IVF and achieve good results. In a year or two, it might become more difficult.

    If you decide to take a more natural approach, it would be advisable to have another biopsy during the luteal phase to check for chronic endometritis.

    If you’d like to seek a medical opinion and find out what your treatment plan would look like here in Spain, please don’t hesitate to contact us.

    Have a wonderful day,

    Sincerely,

    Dr. K. Spies.

    Ihr Vida Fertility Team <3

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