Every year, several Pacific Fertility Center professionals participate in ASRM’s national meeting. They evaluate the research and share their findings with PFC and Fertility Flash.

Among those attending the conference from PFC were Dr. Philip Chenette and Dr. Isabelle Ryan and Peggy Orlin, MFT. Their reviews cover the following topics: Update #1: Ovarian Stimulation Techniques, Update #2: PGD and Aneuploidy Screening Techniques, Update #3: Egg Freezing, Update #4: Acupuncture, and Update #5: Men and ART.

Update #5 Men and ART

The Mental Health Professional Group (MHPG) course entitled Men and ART: The Missing Voice, blended medical, psychological, ethical and legal information relating to men who participate in Assisted Reproductive Technology (ART).

The legal issues confronting single men and gay men considering the use of egg donors and gestational surrogates continue to be controversial. Adoption legislation in many states prohibits gays and lesbians from adopting. In a study reported in 2005 by Gurmankin, et. al, 44% of ART programs responded that they would not turn away gay couples seeking surrogacy with one partner’s sperm and 48% responded that they would turn them away. This is in contrast to the higher rate of acceptance of lesbian couples. In lesbian couples seeking treatment using donor insemination, 82% of ART programs agreed to treat versus 17% who refused to treat them.

Though often presented exclusively to women, men can also benefit from the use of stress reduction strategies and following a healthy life style which includes regular exercise, normal body weight, no smoking or recreational drug use and avoidance of environmental toxins. In addition, the effects of aging and cancer on sperm quality should not be overlooked when men seek reproduction assistance. (See articles on: Sperm Aging: Fertility Flash Feb. 2004, Sperm Fragmentation: Fertility Flash March 2005, Cancer and Infertility: Fertility Flash Oct. 2004).

The psychological component of this course was compelling. Approximately 50% of cases of infertility involve at least some degree of male infertility. Why is it that most infertility references are traditionally directed at women? By definition, Infertility is “…the inability of a woman to conceive after some months (12-24) without contraception, or the inability to carry a pregnancy to term.” (Institute of Medicine and National Research Council, 1989). Ancient biblical references and popular literature focus on women’s infertility – e.g. Sarah and Hannah in the bible, Sylvia Plath’s Barren Woman, Jane Smiley’s 1000 Acres. The list is long. Google hits by gender for infertility and psychology show 542,000 for men and 700,000 for women.

The cause of this discrepancy is multifaceted. There are fewer psychological studies on men simply because men have a lower study response rate than women. A variety of successful techniques have been developed to overcome male related medical issues. Additionally, most men spend less time in treatment and experience fewer invasive procedures than women. In general, it is more socially acceptable for women to express their feelings regarding infertility. The opposite is true for men whose fertility often is a taboo topic. Furthermore, some cultures protect their men from the unacceptable stigma of infertility and even falsely describe men as having “poor” coping skills.

Despite these discrepancies, men do have feelings about infertility and may need support and assistance to better cope with the diagnosis. A study by Mason MC in 1993 found that men felt guilt, shame, anger, isolation, loss and a personal sense of failure. This is not all that different from what women feel, but each individual’s coping mechanism is unique. We all, however, find ways to protect ourselves from what we perceive as painful information.

These coping skills can be divided along gender lines. There are ways that many, but certainly not all, men commonly protect themselves from the pain related to his or his partner’s infertility diagnosis. Frequently men are able to distance themselves from the feelings. They appear to have the ability to take painful information and put it in a little box that they then file away in the back of their minds. The box stays tightly shut. Other men want to problem-solve for their partner or avoid the topic completely, throwing themselves into work or hobbies. Some men become extremely optimistic to avoid or counter their partner’s pessimism.

These are different styles- not right or wrong. For many of us, particularly women, the closed box technique does not work. The box is opened often, and feelings appear to refuse to stay tucked away. When partners have different coping styles, it’s important to both learn to tolerate and support these differences. Sometimes that is easier said than done…

Peggy Orlin, MFT

Introduction

Sara (a hypothetical patient) found a breast lump. 36 years of age, she was a single active professional, otherwise healthy, careful about her diet, and carefully evaluating her options after a diagnosis of breast cancer. Along with the discussion on surgery, chemotherapy, and radiation therapy came the question “Were you planning to have children?”

A diagnosis of cancer presents many decisions that must be made quickly. Confirming the diagnosis and planning therapy will be the primary concerns, but the implications of therapy on long-term quality of life must be assessed. One of the primary issues facing women with a diagnosis of cancer is future fertility.

Candidates

Cancer treatment can interfere with future fertility. Toxicity varies by treatment. Cyclophosphamide, an alkylating agent used in many chemotherapy regimens, is highly toxic to sperm and eggs; methotrexate and 5-flouro-uracil (5FU) are not. Medications used for longer time intervals create a higher risk of fertility problems than shorter time intervals; effects on women in older age groups are more severe than younger. Radiation therapy, in high doses, can have effects on eggs and sperm. Surgery and anesthesia are not known to have direct effects.

It is difficult to give specific fertility risks for chemotherapeutic regimens, since studies are not yet definitive. Among the more toxic treatments are stem cell transplantation for leukemia in which total body irradiation and cyclophosphamide are used, beam radiation to a field that includes the ovaries, and extended chemotherapy of up to 6 cycles using cyclophosphamide in combination with other agents. After conventional chemotherapy for breast cancer for women under 40, the chance of infertility is roughly 50%, in older women the risk is over 80%.

Treatment options

What are the options for fertility in patients diagnosed with cancer? The best choices are available to those that have not yet initiated treatment and involve cryopreservation. During treatment, the risk of problems rises, and after treatment, there may not be adequate recovery of fertility to achieve pregnancy.

Cryopreservation allows cells to be stored with great stability for long periods of time. The record time from sperm cryopreservation to pregnancy is 28 years; there probably is no real limit to the time that cells can be stored. To store cells requires technology that reduces the formation of ice crystals, which disrupt cells, and prevents the rapid rise in salt concentration that occurs as water freezes. Cryopreservatives and management of temperature changes (slow freeze or vitrification) are used to reduce the risk of these problems.

Male

The option for fertility preservation in men is straightforward, cryopreservation of sperm. Sperm is obtained by masturbation and frozen in multiple vials in liquid nitrogen. 2-3 sperm samples can be obtained per week, with 2-4 vials stored per ejaculate; two weeks worth of donations could yield 8-24 vials of sperm. Costs vary widely, but would range from $1500-$3000 for processing and 3 years of storage.

Testicular sperm extraction is an option for individuals with azoospermia. Testicular tissue cryopreservation remains a theory that has not yet produced a human pregnancy. It has been proposed as an option for preservation of fertility in children, but has yet to be proven in clinical practice.

Female

Women have the option of cryopreservation of oocytes or embryos. For women without a partner, oocyte cryopreservation holds promise as a means to preserve fertility potential without committing to a specific sperm source or partner. For women with a partner or sperm donor, embryo cryopreservation is a proven technology.

To create cryopreserved oocytes, Follicle Stimulating Hormone (FSH) is administered over a ten day time period to stimulate ovarian follicles. The oocytes are retrieved under sedation with a needle guided by ultrasound and then stored in liquid nitrogen.

Newer techniques of oocyte vitrification secure good pregnancy rates for those with good oocyte quality. Traditional oocyte cryopreservation is performed using a slow freeze technique, but more rapid vitrification procedures optimize results. The trick with cryopreservation is to lower the temperature while avoiding ice crystals that disrupt cell membranes and proteins. Vitrification, an ultrarapid freezing process utilizing a minimal fluid volume, reduces the risk of these problems and optimizes cell quality.

For those women with a partner, or that are willing to commit to a specific sperm donor, embryo cryopreservation is an excellent option. After stimulation and retrieval, oocytes are inseminated and cultured in an incubator for 1-5 days, followed by cryopreservation. The embryos can be thawed and transferred at a later date, after clearance from the oncologist. Embryo cryopreservation is the best established of the fertility preservation techniques, with years of experience in its applications. Good pregnancy rates can be anticipated.

Ovarian tissue cryopreservation, the cryopreservation of whole pieces of the ovary, as opposed to cells, remains experimental. Complex tissues are more difficult to cryopreserve than cells, though rare success has been reported.

Cancer recurrence

Is there risk to the use of fertility drugs in patients with cancer? It does not appear in studies to date that breast or ovarian cancer risk is affected by use of fertility drugs. Studies indicating an increased risk are balanced by other studies indicating a reduction in risk. Studies to date have been limited, and treatment decisions still must be individualized.

Does pregnancy increase the risk of cancer recurrence? In theory, certain types of cancer could be aggravated by the hormones of pregnancy, but studies have not confirmed an overall risk. Certain types of cancer are less common in women that have delivered a pregnancy. Treatment decisions must be individualized, as future studies gather more information.

Pregnancy

Certain cancer treatments create organ toxicity that must be evaluated in considering patients for pregnancy. Heart output is limited in patients that have received doxorubicin. Uterine irradiation is associated with miscarriage and pre-term labor.

Children

Children born after fertility preservation procedures do not carry any increased risk for birth defects. There are hereditary syndromes that can be associated with cancer that could be transmitted to children, but there does not appear to be any other increased risk for cancer or genetic disease in children of cancer survivors.

Patients contemplating conception must consider life span expectations as part of their decision on whether to conceive. Such considerations are not, however, a reason to withhold treatment, and are ultimately the individual and family should decide.

Philip E. Chenette, MD

Resources:

www.fertilehope.org Fertile Hope

www.livestrong.org Lance Armstrong Foundation

www.cryobank.com California Cryobank

www.PacificFertilityCenter.com Pacific Fertility Center

Sperm are clearly sensitive to environmental conditions. It is possible, through changes in lifestyle and activity, to improve sperm health. The studies available to evaluate environmental effects are unfortunately limited, but they offer insight into sperm sensitivity and ways to optimize their performance.

Temperature The scrotum where sperm are produced is 2 degrees lower than core body temperature. Raising the temperature by a few degrees results in a decline in sperm count and motility. Men suffering from cryoptorchidism, where the testicles are located above the scrotum, closer to central body temperatures, frequently suffer from low sperm counts. Infertile men tend to have a higher scrotal temperature⁽¹⁾, a characteristic that seems to be genetically determined⁽²⁾.

Common illnesses and every day activities can be sources of an increase in scrotal temperature. Acute fever associated with illness causes a significant decline in sperm quality⁽³⁾. In one study, total sperm count decreased within two weeks after a fever and required 79 days to return to normal. The DNA component of these sperm showed high levels of DNA fragmentation. Researchers in France installed temperature sensors to nine volunteers, and recorded scrotal temperatures while driving⁽⁴⁾. Scrotal temperature increased gradually over several hours, peaking 2.5 degrees higher at three hours. Another study showed that scrotal temperature was lowest while standing naked, and highest while clothed, seated, with legs crossed⁽⁵⁾. Higher scrotal temperatures have been associated with use of a laptop computer⁽⁶⁾. A group in Germany looked at scrotal temperatures with a variety of underwear⁽⁷⁾. As expected, tight underwear increased the temperature more than loose or no underwear. The effect was most pronounced while walking and less noticeable while sitting, since sitting temperature was somewhat elevated regardless of type of underwear worn.

The common sense approach is to avoid activities which can increase scrotal and testicular temperature, use loose-fitting underwear, and provide adequate ventilation to the scrotum. Exposure to hot tubs or saunas should be avoided. Take showers rather than baths, because heat conductance is lower when the testicles are not immersed in hot water. Sitting or driving for extended periods should be minimized.

Stress The effects of stress on sperm are complex. Under conditions of extreme stress, sperm counts decline. Analyses of prisoners awaiting sentencing have shown complete suppression of spermatogenesis on testicular biopsies⁽⁸⁾. A study of semen characteristics after the Slovenian war in 1991 showed a reduction in sperm count and motility, and a reduction in the proportion of male children born⁽⁹⁾. In 1995 a strong earthquake of magnitude 7.2 on the Richter scale occurred in Kobe, Japan killing 5,502 people. Sperm motility declined immediately, with low motility lasting for months⁽¹⁰⁾. The sperm of a man who lost his home and his father had still not recovered 10 months after the earthquake.

Stress associated with fertility therapy affects sperm and sexual function. Sperm parameters may decline in patients undergoing in vitro fertilization⁽¹¹⁾. Male fertility patients have a higher incidence of erectile dysfunction, ejaculatory disorders, loss of libido and a decrease in the frequency of intercourse⁽¹²⁾. One study of infertility patients showed an increase in burnout in male patients⁽¹³⁾.

Unfortunately, studies of the effect of stress reduction on sperm are rare,^(14)(15) so the treatment of stress has not been conclusively shown to improve sperm parameters⁽¹⁶⁾. In spite of the lack of clear data, stress reduction therapy is recommended for fertility patients and may reduce problems with sexual dysfunction.

Exercise The risk of developing male fertility problems appears to increase with the intensity of exercise. Intense exercise, such as endurance running, will lower levels of luteinizing hormone (LH) and testosterone.^(17)(18) Studies of semen characteristics have shown variable results. DeSouza⁽¹⁹⁾ developed the concept of a training volume threshold, in which running more than 100 km or 62.14 miles per week was associated with decreased levels of testosterone and sperm motility.

A detailed prospective study comparing competitive cyclists and triathletes with sedentary controls⁽²⁰⁾ was unable to show any suppressive effect of competitive exercise on FSH, LH, or testosterone levels. Although those with the highest levels of training had higher levels of circulating testosterone at baseline, these levels did not change with training. Competitive cyclists developed lower sperm motility during competition, however, motility values returned to normal following competition.

The best advice regarding exercise and sperm is moderation. While attempting conception, it is not advisable to undergo high intensity sports training. Good nutritional standards should be always be maintained when following an exercise program. An existing maintenance exercise program may be continued without concern for its effects on sperm.

Diet is a difficult topic to study in isolation, so fertility data is limited. A recent study of beef consumption showed that maternal consumption⁽²¹⁾ of beef resulted in lower sperm concentrations in sons. The proportion of men with low sperm counts was three times higher in the sons of women that consumed high levels of beef. Lifestyle, pesticide exposure, and xenobiotics (chemicals found in organisms that are foreign to them) were all considered potential factors. Heterocyclic amines (carcinogenic chemicals formed from the cooking of muscle meats), which are estrogenic, may also play a role⁽²²⁾.

Alcohol has long been associated with male reproductive dysfunction. Impotence, infertility, and male secondary sex characteristics are all affected by chronic alcohol use. Testosterone levels are lower, sperm production is reduced, and FSH and LH levels are affected⁽²³⁾. A study of chronic alcoholics demonstrated low levels of pituitary and testicular hormones, and significantly decreased sperm concentration and morphology⁽²⁴⁾. Sperm chromosomes are altered in men that consume alcohol⁽²⁵⁾.

Little data exists on the moderate consumption of alcohol. Data from the Ontario Farm Family Health Study did not show an adverse effect of alcohol consumption⁽²⁶⁾. In another study, alcohol or cigarette consumption did not alter sperm parameters, but when patients both smoked and drank alcohol a significant reduction in seminal volume, sperm concentration, percentage of motile spermatozoa, and a significant increase of the nonmotile viable gametes were detected⁽²⁷⁾.

Smoking tobacco affects sperm parameters, with reduced sperm counts, motility, and morphology reported in several studies⁽²⁸⁾. Whether these changes affect the male fertility remains uncertain. According to ASRM, “The effect of smoking on male fertility is … difficult to discern. The available data do not conclusively demonstrate that smoking decreases male fertility… Few studies have or can address the question, because of the confounding effects of partner smoking habits and fecundity. Although sperm concentrations, motility, and/or morphology are often reduced compared to results observed in non-smokers, they often remain within the normal range. Nevertheless, to the extent that the zona-free hamster egg penetration test reflects the ability of sperm to successfully fertilize a human oocyte, the available evidence suggests that smoking may have adverse effects on sperm function.”

Caffeine studies have revealed inconsistent effects on sperm, with at least one study showing no effect⁽²⁹⁾. Caffeine has been used as a sperm stimulant, increasing the motility prior to insemination. There does not appear to be any substantial adverse effect of caffeine on sperm.

Common Medications The list of medications with effects on sperm is long, and worthy of review. Noteworthy medications are the SSRI anti-depressants (Cipramil, Lustral, and Effexor were the reported medications), which were associated with near-azospermia in a case report⁽³⁰⁾. Ibuprofen (Advil, Nuprin) does not seem to cause adverse effects on sperm⁽³¹⁾.

Vaginal lubricants can interfere with sperm. FemGlide, Replens, and Astroglide lubricants demonstrated a significant decrease in motility, whereas Pre-Seed did not affect motility or DNA integrity⁽³²⁾.

Treatments for erectile dysfunction may have an effect on sperm motility. A significant increase in sperm progressive motility was observed after sildenafil (Viagra) administration as compared with baseline; in contrast, a significant decreased motility was observed after tadalafil (Cialis).

Antihypertensive drugs have numerous effects on sperm. Beta-blockers and diuretics have been associated with impotence. Calcium channel blockers (nifedipine, Procardia) have been associated with infertility⁽³³⁾. If you are on heart medications, review them with your physician.

Reports on the effects of marijuana use on sperm are conflicting. Early studies had poor controls, later studies showed reductions in testosterone and sperm quality⁽³⁴⁾ while other studies showed no effect on testosterone levels in chronic heavy smokers⁽³⁵⁾. A recent study revealed a direct effect of THC, the active ingredient in marijuana, on sperm motility and fertilization capacity⁽³⁶⁾. The conclusion of the study was that “the use of THC as a recreational drug may impair crucial sperm functions and adversely affect male fertility, especially in those who are already on the borderline of infertility.”

Conclusion Sperm are a biological substance, produced in a complex interplay of genetic predisposition, specific temperature and pH, and in association with specific cells and secretions. If the system is insulted, problems will often arise. The sheer numbers of sperm in an ejaculate provide a wide margin for maintaining fertility even after such insults occur, but repeated attacks on the reproductive system can ultimately result in male fertility problems.

Philip Chenette, MD

References:

1. Zorgniotti, A.W. and Sealfon, A.I. (1988) Measurement of intrascrotal temperature in normal and subfertile men. J. Reprod. Fertil., 82, 563–566.
2. Hjollund, N., Storgaard, L., et al. (2002) Correlation of scrotal temperature in twins: Brief Communication. Human Reproduction, 17(7):1837-1838.
3. Sergerue, D.E.S.S., et al., (2007) High risk of temporary alteration of semen parameters after recent acute febrile illness. Fertil Steril, In press.
4. Bujan L, et al. (2000) Increase in scrotal temperature in car drivers. Human Reprod 15, 1355–1357.
5. Mieusset, R. et al., (2007). Effect of posture and clothing on scrotal temperature in fertile men. J Androl. 28(1):170-175.
6. Sheynkin, Y., et al., (2006) Increase in scrotal temperature in laptop computer users. Human Reproduction. 20(2):452-455.
7. Jung, A., et al. (2005) Influence of the type of undertrousers and physical activity on scrotal temperature. Human Reproduction. 20(4):1022-1027.
8. Steve, H. (1952) Der ein Fluss de nerven System auf ban und Fatigkeit des Geschlechtorgane des Menschen. Theim, Stuttgart.
9. Zorn, B et al., (2002) Decline in sex ratio after 10-day war in Slovenia. Human Reproduction.17(12):3173-3177.
10. Fukuda, M, et al. (1996) Kobe earthquake and reduced sperm motility. Human reproduction. 11(6):1244-1246.
11. Clarke R.N., et al., (1999) Relationship between psychological stress and semen quality among in vitro fertilization patients. Human Reproduction. 14(3):753-758.
12. Lenzi, et al. (2003) Stress, sexual dysfunctions, and male infertility. J Endocrin Invest. 26(3 Suppl):72-6.
13. Sheiner, et al., (2002) Potential association between male infertility and occupational psychological stress. J Occup Environ Med. 44(12):1093-1099.
14. Pook, M, et al. (1999). Coping with infertility: distress and changes in sperm quality. Human Reproduction. 14(6):1487-1492.
15. Tuschen-Caffier B, Florin I, Krause W, Pook M. (1999) Cognitive-behavioural therapy for idiopathic infertile couples. Psychother Psychosom 68:15–21.
16. Campagne, D.M., (2006) Should fertilization treatment start with reducing stress? Human Reproduction. 21(7):1651-1658.
17. Wheeler, G. D., et al. (1991) Endurance training decreases serum testosterone levels in men without change in luteinizing hormone pulsatile release. J. Clin. Endocrinol. Metab. 72: 422–425.
18. Arce, J. C., et al. (1993) Subclinical alterations in hormone and semen profile in athletes. Fertil. Steril. 59: 398–404.
19. De Souza, M. J., et al. (1991) Gonadal hormones and semen quality in male runners. A volume threshold effect of endurance training. Int. J. Sports Med. 15: 383–391.
20. Lucia, A, et al. (1996) Reproductive function in male endurance athletes: sperm analysis and hormonal profile. J Applied Physiology. 81:2627-2636.
21. Swan SH et al (2007) Semen quality of fertile US males in relation to their mothers’ beef consumption during pregnancy. Human Reproduction. 22(6):1497-1502.
22. Cho E, Chen WY, Hunter DJ, et al. (2006) Red meat intake and risk of breast cancer among premenopausal women. Arch Intern Med 166:2253–9.
23. Emanuele, MA et al. (1998) Alcohol’s effects on male reproduction. Alcohol Health and Research World. 22:195-201.
24. Muthusami, KR et a;, (2005) Effect of chronic alcoholism on male fertility hormones and semen quality. Fertility and Sterility. 84(4):919-924.
25. Robbins, WA, et al. (2005) Effect of lifestyle exposures on sperm aneuploidy. Cytogenetic & Genome Research. 111(3-4):371-7.
26. Curtis KM, et al. (1997) Effects of cigarette smoking, caffeine consumption, and alcohol intake on fecundability. Am J Epidemiol. 146(1):32-41.
27. Martini, AC, et al. (2004) Effects of alcohol and cigarette consumption on human seminal quality. Fertility Sterility. 82(2):374-377.
28. Vine MF. (1996) Smoking and male reproduction: a review. Int J Androl.19:323–337.
29. Klonoff-Cohen, H, et al. (2002) A prospective study of the effects of female and male caffeine consumption on the reproductive endpoints of IVF and gamete intra-Fallopian transfer. Human Reproduction. 17(7):1746-1754.
30. Tanrikut C, Schlegel PN (2006) Antidepressant-associated changes in semen parameters. Fertil Steril. 86(3):S14.
31. Robinson, N, et al. (2005). Regular Use of Ibuprofen Does Not Affect Semen Analysis Parameters, Need for ICSI, or ART Clinical Pregnancy Rate. Fertility and Sterility (84): S14.
32. Agarwal A, et al., (2007) Effect of vaginal lubricants on sperm motility and chromatin integrity: a prospective comparative study. Fertil Steril. In press.
33. Hershlag A, et al. (1995) Pregnancy following discontinuation of a calcium channel blocker in the male partner. Human Reproduction. 10(3):599-606.
34. Kolodny RC, et al. (1974) Depression of plasma testosterone with acute administration. In: Braude MC, Szara S editor. The pharmacology of marijuana. New York: Raven Press; p. 217–225.
35. Mendelson JH, et al. (1974). Plasma testosterone levels before, during and after chronic marihuana smoking. N Engl J Med. 291:1051–1055.
36. Whan, LB, et al., (2006) Effects of delta-9-tetrahydrocannabinol, the primary psychoactive cannabinoid in marijuana, on human sperm function in vitro. Fertil. Steril. 85(3):653-660.

My husband and I have a long history together. We met in high school, and after 10 years of marriage, we were ready to have a family. My sister had experienced trouble getting pregnant, so as a result I worried that I might have the same problem.

My worries were partially confirmed when my husband and I unsuccessfully tried to conceive. In our case, we discovered we had the unlucky combination of both male and female factor infertility. At that point we were under the care of our gynecologist. On our doctors’ recommendation, we went through IUI near the end of 2003. It was a nightmare for a lot of reasons. I reacted poorly to Clomid and did not conceive.

While I was still trying to conceive, my sister was happily on her way to having a family. She had gone to the next level of care: an expert reproductive endocrinologist at Pacific Fertility Center. We were of course delighted to hear the news of her pregnancy, but at the same time frustrated because we were still not pregnant. We had always thought that once we were ready to have a family, we would be able to get pregnant easily and naturally.

After our disastrous IUI cycle, we tried again naturally, but to no avail. Frustrated and tired, we took a break. After a while, I spoke with my sister Alison, who referred us to Dr. Herbert at Pacific Fertility Center. He was wonderful and had great bedside manner. He was positive and upbeat despite our combined infertility diagnosis. We went straight to IVF with Gonal F and Repronex. Unfortunately, my body didn’t respond well.

I really appreciated Dr. Herbert during this discouraging time. He was frank with us and indicated that my follicles were not looking good. Without good follicles, the ability to retrieve a reasonable number of quality eggs was in question, so we did not continue our IVF cycle. Dr. Herbert was very flexible; he listened, explained our options and didn’t dictate what we should do. He suggested IUI as a way to salvage the IVF cycle and much to our surprise, we became pregnant! When I got the good news that my husband and I were going to be parents for the first time, I was “over-the-top” happy calling everybody I knew. In addition, on our first ultrasound, we saw two beating hearts. We not only were pregnant, but also were pregnant with twins!

The irony is that after my sister Alison had twins, I too envisioned having twins. During our initial OB ultrasound, Dr. Herbert indicated that he saw two heartbeats. We had a scare at one point as we thought I had experienced a miscarriage. However, I had just had some bleeding and passed a blood clot. I appreciated Dr. Herbert during this time, as he remained calm at all times. Much to our delight, I gave birth to a healthy, beautiful set of twins (Justin and Eva) who are now over a year old.

I thoroughly enjoyed my experience at PFC. They were great from a logistical standpoint, and were great about getting all of the paperwork out of the way quickly. I appreciate the nurses—Anne was awesome and whenever we called she was very kind and understanding. I loved going to appointments as it was such as positive experience. Additionally, I appreciate PFC for their professionalism. Dr. Herbert was so experienced and knew what he was doing the whole time; I trusted him a lot. I truly love our children. It is wonderful for my sister and me to be able share experiences as we learn about the joys of parenthood firsthand. It is sweet irony indeed.

Leslie

Leslie’s journey to a successful pregnancy was a bit unconventional but contains several important messages for you, our patients. The stimulation of her ovaries during her first IVF attempt did not progress as we had hoped. There were fewer follicles and some were large and others small (follicle disparity). Had this been her final attempt on very high doses of medication, we might have proceeded on to egg retrieval. However, we felt the stimulation was suboptimal and we expected to improve this process in another cycle by changing the medication regimen. As Leslie and her husband were diagnosed with unexplained infertility, we also felt she might conceive by ovulating the few larger follicles which were present and using intrauterine insemination. Fortunately we were correct, and Leslie now has two wonderful children. These conversions from a planned IVF cycle to IUI cycle can produce pregnancies as often as 10% of the time as long as there are no other fertility factors like tubal damage or severe sperm problems and the age of the woman is not advanced (less than 38 years). Leslie’s story is a good example of persistence in spite of initial disappointment, of using all the options available in the most effective manner, and of “keeping the faith”. We hope Leslie’s story can be an inspiration to others who may face similar disappointments on their journey to parenthood.

Carl Herbert, MD

I had been trying to get pregnant for six months and didn’t want to wait any longer. In the past, my husband had gone through chemotherapy, but when we decided to begin our family, we never contemplated that his medical history would make conceiving a challenge.

Once we were ready to take the next step, our urologist recommended Pacific Fertility Center. Patients he referred to PFC had been successful, so we were very hopeful that they might be able to help us. We lived a distance from the center and had to make the 6-hour drive each way for treatments. We were determined to get the best care available.

Our cycle began way back in August of 2005. Initially we worked with Dr. Paul Turek, an urologist from UCSF in conjunction with PFC in cases like ours. He performed testicular mapping, looking for pockets of live sperm. Since only one pocket was found, Dr. Turek recommended my husband undergo FSH injections 3 months prior to our cycle, to increase sperm production. Fortunately, this experimental protocol worked better than expected and we were able to avoid invasive surgical removal of sperm. It only takes one good sperm to fertilize an egg and he was able to find more than enough.

In order to get my eggs to fertilize with my husband’s sperm, I went through IVF including FSH injections. The needles intimidated me, but I was able to get past that fear. Everything turned out OK and I made it through the procedure really well. During my retrieval they collected 20 eggs.

As it turns out, after fertilization with ICSI, we had 8 grade 1 and 2 embryos. Three of the embryos were transferred and the other five were frozen. To my pleasure, I became pregnant with a single baby girl. This was an amazing experience, especially considering the odds were not hugely in our favor. Once we got the good news, we were in an elated state of shock – we had been through a lot and finding out we were finally pregnant was wonderful news! I had an extremely easy and natural birth in May of the following year.

All in all the experience was quite a whirlwind; my husband and I had a lot of ups and downs. The assumption we had when we first decided to try to get pregnant was it would be natural and uncomplicated. However, learning we had an infertility problem was a devastating experience. What empowered my husband and me was that we started doing research about our problem. The more we learned, the more comfortable and less intimidated we felt. I would highly recommend this. In retrospect, the biggest ups and downs were when we got the reports on the good or the poor sperm samples. When they found sperm they could use, we could hardly contain our excitement.

I appreciate the care Dr. Isabelle Ryan provided. I liked her a lot and I have heard nothing but good things about all the PFC doctors. Dr. Ryan knows what she’s doing and was able to explain all the options available to us. Joe Conaghan, the lab director, was spectacular. He was able to find sperm in a sample that our local doctors could not. Being from a rural area, we didn’t have local access to PFC’s level of care and state-of-the-art technology. I absolutely trust PFC and have recommended them to others. If we decide to have another child, we will definitely come back. We love our little baby girl so much and every day is a new adventure. We can’t imagine our lives without her!

Susie & Steven D.

Male factor infertility is quite common, contributing to 40% of infertility diagnoses. Treatment is designed around the particular type of problem and can be remarkably effective. For those with male factor infertility, the initial course of action is to review personal health habits. Stress, poor diet, and alcohol use have all been correlated with male factor infertility. Alcohol use, in particular, has been shown to have a dose-related effect on sperm; the more one drinks, the poorer the reproductive outcome. High temperature exposure from hot tubs or hot baths (immersion in hot water), or heavy exercise, particularly bicycle riding, have been correlated with male factor infertility as well. Resting a laptop computer on one’s lap has also been implicated in raising testicular temperature.

Diagnosis of male factor infertility starts with a semen analysis. The semen analysis should be performed on an ejaculated sample collected on at least two occasions 2-7 days following abstention from sexual activity. Measurement of the sperm count, motility, and volume can reveal production problems as insufficient or poor quality sperm are released from the testes. Table 1 lists the standards for assessing a semen analysis (Source: The World Health Organization, 1992).

Additional tests to evaluate sperm quality include the detailed or Krueger morphology. This entails viewing individual sperm cells under a high-powered microscope. This is a strict test that reveals abnormalities in the shape and size of the sperm heads, mid-pieces, and tails. A normal morphology is present when over 14% of sperm are normal.

Survival of the sperm on extended testing is also a useful diagnostic test. The sperm survival test, or SST, is a method for testing the lifespan of the sperm. At 24 hours, sperm survival should be over 40% (i.e. 40% of the sperm sample should survive); conversely, lower survival rates correspond to lower pregnancy rates.

Additional testing for male factor infertility includes a physical exam, blood tests for FSH, prolactin, and testosterone, and an ultrasonography of the collecting tubes of the male reproductive system. In some cases, an assessment of DNA fragmentation can give an index of sperm quality as well.

One condition we encounter at our clinic is azoospermia, which is the absence of sperm in the ejaculate. This can occur from birth defects, injury or infection, or rare endocrine abnormalities. In azoospermia, a high FSH level indicates testicular failure. Insufficient levels of testicular hormones lead to an increase in the release of pituitary gland FSH to compensate. High levels of testicular hormones are often accompanied by testicular atrophy (small testicles). Testicular biopsy may confirm the clinical findings.

Men with testicular failure (and very low sperm counts) should be tested for Y-chromosome microdeletions and abnormal karyotypes, or chromosomal count. Microdeletions may be transmitted to offspring, resulting in fertility problems for boys born after treatment.

The most common abnormal karyotype is Klinefelter Syndrome, where the male has three or more sex chromosomes, instead of the normal two. Such chromosomal defects can have effects on children born after treatment, and men should receive genetic counseling and risk assessment prior to treatment. Men with testicular failure may still have partial sperm production. Detailed assessment with microscopic surgery may detect a sufficient amount of sperm to use with in vitro fertilization (IVF).

Obstruction is another type of male factor infertility, as potentially normal sperm cannot move from the testes to the ejaculate. Men with a normal FSH may have an obstruction in the vas deferens or any of the other collecting tubes that gather sperm from the testes. Men with congenital absence of the vas deferens (CBAVD) may be carriers of cystic fibrosis, and should be tested. Surgical obstruction, or vasectomy, is readily repaired. Microsurgical techniques, and an experienced surgeon, will increase success rates. The procedure may be attempted for many years after an initial vasectomy. More unusual obstructions can result after infection of the epididymis. Ejaculatory duct obstruction can be treated with a cystoscopic procedure. Obstructions can sometimes be repaired, but often a simple needle aspiration procedure (percutaneous epididymal sperm aspiration, PESA) will yield enough sperm to achieve fertilization with IVF.

The key treatment when working with low sperm numbers, whether in the ejaculate or obtained by needle aspiration or biopsy, is to perform in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI). ICSI is when a highly trained embryologist uses micromanipulators to inject an individual sperm into an egg, optimizing for fertilization.

ICSI has become a common procedure, resulting in many pregnancies worldwide for men that otherwise could not have children. Sperm with a variety of abnormalities, ranging from low counts, to extremely low motilities, can be suitable for use. The DNA of the sperm is tightly compacted in ways that protect it from injury, even when the other components of the sperm do not function well. Injecting the sperm into the egg can bypass the barriers separating sperm and egg.

Another condition we encounter which can lead to abnormal sperm parameters is the presence of a varicocele. A varicocele is an enlarged vein along the upper part of the scrotum. The blood carried in these veins may elevate the scrotal temperature, and possibly carry toxic materials into the testicle, affecting sperm production. Only varicoceles that are palpable are thought to contribute to infertility. Ultrasound is sometimes used to confirm an uncertain diagnosis, but there is doubt whether subclinical varicoceles are associated with infertility. Varicoceles can be repaired, or various fertility treatments attempted, including sperm wash and insemination, and in vitro fertilization. The decision of treatment depends on both male and female factors, such as age, tubal disease, and ovulation disorders.

In closing, it is important to remember that infertility is not just a “female” issue and that men should engage in lifestyle habits that will not compromise their fertility. Furthermore, advancements in assisted reproductive technology (ART) have given men with infertility diagnoses newfound hope in their quest to build a healthy family.

– Philip Chenette, MD

ICSI Overview: Intracytoplasmic sperm injection (ICSI) is a technique used in the IVF laboratory to inject individual sperm into eggs. The procedure was developed in Belgium in the early 1990′s (Palermo et al., 1992) and it revolutionized the treatment of male factor infertility. Prior to ICSI, men with moderate and severe fertility issues had little or no chance of having their own genetic children. ICSI has so revolutionized the treatment of infertility that it is used in the majority (55.6%) of assisted reproductive technology cycles in the United States (CDC National Summary and Fertility Clinic Reports, 2003).

When IVF is performed without ICSI, it is common to incubate individual oocytes in a petri dish with about 100,000 sperm. Usually these sperm have been obtained by processing the semen in such a way as to be able to isolate sperm that look normal and swim energetically. Only the best 10% of the sperm in a normal semen sample are used, and in the petri dish, these compete for the honor of fertilizing the oocyte.

When ICSI is employed, individual sperm are isolated and forcibly injected into the oocyte by an embryologist. The oocytes have to be incubated in the enzyme hyaluronidase to remove the cumulus cells that surround them (naturally, these cells would be dislodged by the many sperm that try to penetrate the oocyte). Prior to injection, the sperm may be processed (as above) but often there are so few sperm available that processing is minimal. Once selected, the sperm is immobilized by breaking its tail. This is accomplished by dragging the injection needle across the tail until a visible kink or break can be seen. The immobilized sperm is then aspirated into the needle, which is pushed through the shell surrounding the oocyte and then through the cell membrane. The elasticity of the oocyte membrane is such that the embryologist must be rough with it to get through. Piercing the membrane is usually achieved either by poking it several times or by aspirating the membrane into the needle until it breaks. Once the membrane breaks, the sperm can be dropped inside the oocyte.

Technically, ICSI is one of the most difficult procedures to perform in the IVF laboratory and it requires a talented embryologist to do it well. As well as being responsible for choosing “the sperm”, the embryologist must work quickly and be firm enough to break the sperm tail and oocyte membrane while not being so aggressive as to kill the oocyte. ICSI has been so successful as a technique that it is now widely used in cases where there is no male factor infertility. In fact, of all the ICSI cases performed nationally in 2003, only 53% had a male issue (CDC, 2003). While ICSI is absolutely indicated for low sperm counts, decreased sperm motility, abnormal sperm morphology (size and shape) and surgically retrieved sperm, its use has expanded to include cases with anti-sperm antibodies, previous low fertilization with IVF, low oocyte numbers, frozen-thawed sperm and ejaculatory dysfunction such as retrograde ejaculation. In addition, ICSI is being widely used for patients having preimplantation genetic testing because it avoids DNA contamination during embryo biopsy by the many sperm that are usually attached to the shell of the embryo.

ICSI Risks: In assessing the risks of ICSI, we must first look at the procedure itself. In piercing the cell membrane, our greatest concern is in avoiding the area within the oocyte where the DNA is located. This is done by orientating the oocyte such that the polar body (a small packet of discarded DNA) is placed at the 12 or 6 o’clock position and the needle inserted at 3 o’clock. The polar body is the most practical indicator of where the oocyte DNA is located since it is created by the division of the oocyte’s total DNA just prior to ovulation. However, the DNA may not always be in the assumed place so a theoretical risk of damage exists, and chromosome breakage has been observed as being higher in ICSI-derived embryos when compared to conventional IVF embryos (Bergere et al., 1995; Edirisinghe et al., 1997).

In addition to DNA disruption or damage, the physical and biochemical disturbance that occurs could be significant. The injection procedure could introduce foreign material into the oocyte such as culture medium, seminal fluid with or without bacteria (Michelmann et al., 1998), viruses (Brossfield et al., 1999), or in theory, even prions (Lacey & Dealler, 1994) or foreign DNA.

Following the ICSI procedure, the fertilization process is known to be different than with conventional IVF with atypical decondensation of the sperm head resulting in delayed replication of the male genome. This is thought to result from the injection of the intact sperm into the oocyte since such sperm retain their acromosomal cap and perinuclear theca, both of which are normally lost as the sperm penetrates the shell of the oocyte. There is marginal evidence that the sperm sex chromosome is preferentially located in the anterior head and therefore might be impacted by the delayed decondensation caused by retention of the cap (Luetjens et al., 1999).

Currently there is no evidence that the miscarriage rate is different between ICSI and IVF pregnancies, and the incidence of prematurity and low birth weight babies (7.6% and 10.3% respectively for ICSI) is similar to that for IVF in large studies (Wisanto et al., 1995; Aytoz et al., 1998), but slightly higher than rates found in natural pregnancies. These outcomes have been confirmed in a large US-based study (Schieve et al., 2002) showing overall lower birth weight and higher perinatal mortality in children conceived with the help of reproductive technologies, but no significant differences between ICSI and IVF.

In the mid 1990′s ICSI had become a routine procedure in the world of assisted reproductive technology (ART) and was being widely used. However, reports surfaced indicating that the resulting children had a high incidence of chromosomal abnormalities (In ‘t Veld, 1995; Van Opstal et al., 1997). The immediate response from the ART community was a flurry of scientific papers refuting the findings, but ultimately the conclusions of the studies were confirmed by large scale, prospective systematic follow up studies on the ICSI children. Instrumental in these studies was the Brussels University where ICSI was invented. Thorough pre- and postnatal testing showed an abnormal karyotype in 2.6% of the ICSI pregnancies (Bonduelle et al., 1999) and in a subsequent study, 3% showed a chromosomal abnormality (Bonduelle et al., 2002). Novel chromosome abnormalities increased threefold (1.6% in ICSI vs. 0.5% in the general population) and these were mostly comprised of sex chromosome aneuploidies with a smaller number of autosomal structural anomalies. Inherited chromosomal abnormalities increased fourfold in ICSI pregnancies (1.4% compared to 0.3% in the general population) and this was related to the higher rate of existing chromosome abnormalities seen in the parents (mainly the fathers). It is important to point out that the incidence of these sex chromosome aneuploidies and structural abnormalities is inversely related to the number of sperm in the ejaculate and is therefore higher in ICSI fathers (4.8% vs. 0.5% in the general population), and interestingly also higher in ICSI mothers (1.5%: Van Assche et al., 1996). The structural chromosome abnormalities include deletions of sections of the Y chromosome in some men with low sperm counts which will be passed directly to sons created by ICSI.

We are fortunate that the children of ICSI are being widely followed and many solid studies have appeared and continue to appear on the incidence of congenital abnormalities (these are problems that cause impaired function and require medical or surgical intervention). The most common abnormality appears to be hypospadias (a urological condition where the urethra opens under the penis instead of at the tip, and which is correctable with minor surgery) which is increased in ICSI births (Wennerholm et al., 2000). However, when evaluating these cases, the increased risk for congenital abnormalities is often reduced or eliminated when confounding factors (maternal age, infertility, multiple pregnancy, familial and pregnancy history) are factored in (Ericson & Kallen, 2001). Nonetheless, it does appear as though ICSI and IVF children do have an increased odds ration (2.77 and 1.8 respectively) for malformations that need medical or surgical intervention in early life when compared to naturally conceived children (Bonduelle et al., 2005).

Concerns have also arisen about developmental delays in ICSI children as a result of a single paper (Bowen et al., 1998) that had them scoring lower on the Bayley Scales of Infant Development at 1 year of age when compared to IVF and naturally conceived infants. However, a good number of solid papers have since been published indicating that this finding is not holding up and that ICSI children are performing normally in psychological testing as well as in their cognitive and verbal skills using the Bayley and other scales of intelligence (Bonduelle et al., 1998; 2003 Ponjaert-Kristoffersen et al., 2004; 2005).

Finally, it is worth asking if gene expression is normal for ICSI children and are problems likely to arise as the children get older? In looking at gene defects, there is emerging evidence that ART children might be at a higher overall risk for genomic imprinting errors when compared to naturally conceived children. Genomic imprinting is a process that silences one gene from a parent, specifically so that the gene inherited from the other parent can do the work. The classic example is placental growth, which is controlled largely by paternal genes. Maternal genes for placental growth are deliberately inactivated since it is considered a conflict of interest for Mom’s genes to be involved in the regulation of how much of her resources the fetus gets. Problems arise when an imprinted gene is defective, because the perfectly good copy of the gene from the other parent has been switched off and therefore cannot work. Diseases such as Beckwith-Wiedmann and Angleman’s syndromes result from not having a functioning copy of a gene and preliminary evidence suggests that these might be more prevalent in IVF children (Gosden et al., 2003). Abnormal spermatogenesis is associated with an increase in defective genomic imprinting (Marques et al., 2003), but it is probably too early to tell if imprinting errors will occur more frequently in ICSI children. Angleman’s syndrome for example occurs at most at a rate of 1/200,000 IVF births, so the impact of ICSI will be difficult to measure. Similarly, retinoblastoma (a type of cancer of the eye that is caused by a genetic defect similar to what causes imprinted diseases) has been reported as slightly higher in IVF children (Moll et al., 2003) but further studies will be required to substantiate this observation and to ascertain the specific risk of ICSI.

ICSI is an aggressively invasive procedure that deposits a single sperm, usually from an infertile father, into the oocyte of a woman who has undergone fertility treatments. The specific risk of ICSI in offspring is an increased incidence of chromosomal abnormalities which may be caused by the procedure or by the parents, or both. ICSI is a routine and overly used procedure and patients should be educated as to the risks. Of the studies cited here, none of the children examined were older than 5 years. The long term hazards of the procedure, if any, remain to be determined. See below for the complete bibliography.

– Joe Conaghan, PhD

Bibliography:

Aytoz A, Camus M, Tournaye H, Bonduelle M, Van Steirteghem A, Devroey P. Outcome of pregnancies after intracytoplasmic sperm injection and the effect of sperm origin and quality on this outcome. Fertil Steril. 1998 Sep;70(3):500-5.

Bergere M, Selva J, Volante M, Dumont M, Hazout A, Olivennes F, Frydman R. Cytogenetic analysis of uncleaved oocytes after intracytoplasmic sperm injection. J Assist Reprod Genet. 1995 May;12(5):322-5.

Bonduelle M, Wilikens A, Buysse A, Van Assche E, Wisanto A, Devroey P, Van Steirteghem AC, Liebaers I. Prospective follow-up study of 877 children born after intracytoplasmic sperm injection (ICSI), with ejaculated epididymal and testicular spermatozoa and after replacement of cryopreserved embryos obtained after ICSI. Hum Reprod. 1996 Dec;11 Suppl 4:131-55.

Bonduelle M, Aytoz A, Van Assche E, Devroey P, Liebaers I, Van Steirteghem A. Incidence of chromosomal aberrations in children born after assisted reproduction through intracytoplasmic sperm injection. Hum Reprod. 1998 Apr;13(4):781-2.

Bonduelle M, Camus M, De Vos A, Staessen C, Tournaye H, Van Assche E, Verheyen G, Devroey P, Liebaers I, Van Steirteghem A. Seven years of intracytoplasmic sperm injection and follow-up of 1987 subsequent children. Hum Reprod. 1999 Sep;14 Suppl 1:243-64.

Bonduelle M, Van Assche E, Joris H, Keymolen K, Devroey P, Van Steirteghem A, Liebaers I. Prenatal testing in ICSI pregnancies: incidence of chromosomal anomalies in 1586 karyotypes and relation to sperm parameters. Hum Reprod. 2002 Oct;17(10):2600-14.

Bonduelle M, Ponjaert I, Steirteghem AV, Derde MP, Devroey P, Liebaers I. Developmental outcome at 2 years of age for children born after ICSI compared with children born after IVF. Hum Reprod. 2003 Feb;18(2):342-50.

Bonduelle M, Wennerholm UB, Loft A, Tarlatzis BC, Peters C, Henriet S, Mau C, Victorin-Cederquist A, Van Steirteghem A, Balaska A, Emberson JR, Sutcliffe AG. A multi-centre cohort study of the physical health of 5-year-old children conceived after intracytoplasmic sperm injection, in vitro fertilization and natural conception. Hum Reprod. 2005 Feb;20(2):413-9.

Bowen JR, Gibson FL, Leslie GI, Saunders DM. Medical and developmental outcome at 1 year for children conceived by intracytoplasmic sperm injection. Lancet. 1998 May 23;351(9115):1529-34.

Brossfield JE, Chan PJ, Patton WC, King A. Tenacity of exogenous human papillomavirus DNA in sperm washing. J Assist Reprod Genet. 1999 Jul;16(6):325-8.

Centers for disease control and prevention. Assisted reproductive technology success rates. National summary and fertility clinic reports 2003 2005 Dec; United States Department of Health and Human Services.

Edirisinghe WR, Murch A, Junk S, Yovich JL. Cytogenetic abnormalities of unfertilized oocytes generated from in-vitro fertilization and intracytoplasmic sperm injection: a double-blind study. Hum Reprod. 1997 Dec;12(12):2784-91.

Ericson A, Kallen B. Congenital malformations in infants born after IVF: a population-based study. Hum Reprod. 2001 Mar;16(3):504-9.

Gosden R, Trasler J, Lucifero D, Faddy M. Rare congenital disorders, imprinted genes, and assisted reproductive technology. Lancet. 2003 Jun 7;361(9373):1975-7.

In’t Veld P, Brandenburg H, Verhoeff A, Dhont M, Los F. Sex chromosomal abnormalities and intracytoplasmic sperm injection. Lancet. 1995 Sep 16;346(8977):773.

Lacey RW, Dealler SF. Vertical transfer of prion disease. Hum Reprod. 1994 Oct;9(10):1792-6.

Luetjens CM, Payne C, Schatten G. Non-random chromosome positioning in human sperm and sex chromosome anomalies following intracytoplasmic sperm injection. Lancet. 1999 Apr 10;353(9160):1240.

Marques CJ, Carvalho F, Sousa M, Barros A. Genomic imprinting in disruptive spermatogenesis. Lancet. 2004 May 22;363(9422):1700-2.

Michelmann HW. Influence of bacteria and leukocytes on the outcome of in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). Andrologia. 1998;30 Suppl 1:99-101.

Moll AC, Imhof SM, Cruysberg JR, Schouten-van Meeteren AY, Boers M, van Leeuwen FE. Incidence of retinoblastoma in children born after in-vitro fertilization. Lancet. 2003 Jan 25;361(9354):309-10.

Palermo G, Joris H, Devroey P, Van Steirteghem AC. Pregnancies after intracytoplasmic injection of single spermatozoon into an oocyte. Lancet. 1992 Jul 4;340(8810):17-8.

Ponjaert-Kristoffersen I, Tjus T, Nekkebroeck J, Squires J, Verte D, Heimann M, Bonduelle M, Palermo G, Wennerholm UB. Collaborative study of Brussels, Goteborg and New York. Psychological follow-up study of 5-year-old ICSI children. Hum Reprod. 2004 Dec;19(12):2791-7.

Ponjaert-Kristoffersen I, Bonduelle M, Barnes J, Nekkebroeck J, Loft A, Wennerholm UB, Tarlatzis BC, Peters C, Hagberg BS, Berner A, Sutcliffe AG. International collaborative study of intracytoplasmic sperm injection-conceived, in vitro fertilization-conceived, and naturally conceived 5-year-old child outcomes: cognitive and motor assessments. Pediatrics. 2005 Mar;115(3): 283-9.

Schieve LA, Meikle SF, Ferre C, Peterson HB, Jeng G, Wilcox LS. Low and very low birth weight in infants conceived with use of assisted reproductive technology. N Engl J Med. 2002 Mar 7;346(10):731-7.

Van Assche E, Bonduelle M, Tournaye H, Joris H, Verheyen G, Devroey P, Van Steirteghem A, Liebaers I. Cytogenetics of infertile men. Hum Reprod. 1996 Dec;11 Suppl 4:1-24.

Van Opstal D, Los FJ, Ramlakhan S, Van Hemel JO, Van Den Ouweland AM, Brandenburg H, Pieters MH, Verhoeff A, Vermeer MC, Dhont M, In’t Veld PA. Determination of the parent of origin in nine cases of prenatally detected chromosome aberrations found after intracytoplasmic sperm injection. Hum Reprod. 1997 Apr;12(4):682-6.

Wennerholm UB, Bergh C, Hamberger L, Westlander G, Wikland M, Wood M. Obstetric outcome of pregnancies following ICSI, classified according to sperm origin and quality. Hum Reprod. 2000 May;15(5):1189-94.

Wisanto A, Magnus M, Bonduelle M, Liu J, Camus M, Tournaye H, Liebaers I, Van Steirteghem AC, Devroey P. Obstetric outcome of 424 pregnancies after intracytoplasmic sperm injection. Hum Reprod. 1995 Oct;10(10):2713-8.

Human semen is a complex mixture of cells and fluids produced by the various components of the male reproductive system. The objective of sperm preparation is to remove the vigorously swimming sperm from this mixture, leaving behind the dead, dying or otherwise poorly swimming sperm, additional cells, enzymes and other factors that comprise the seminal fluid. A sperm cell is incapable of fertilizing an oocyte until it has separated from the seminal fluid.

We use a variety of separation techniques in the laboratory that are tailored to the procedure that the sperm will be used for, and modified according to the quality and type of sperm sample we receive. The average man manufactures about 250 million sperm in a 24 hour period. From a single ejaculate, we will only use 100,000 sperm for each oocyte that we have to inseminate in an IVF cycle. But for an intrauterine insemination, we want to get as many motile sperm as possible into the female reproductive tract, so we will therefore be using a much higher overall fraction of the sperm. Alternatively, for men who have no sperm in their ejaculate and for whom we have to retrieve sperm surgically from the testicle, we want to biopsy the minimum amount of tissue that will give us one sperm for every oocyte that has to be inseminated.

There are two general methods that we employ for the vast majority of sperm processing in the laboratory. The first is a density gradient centrifugation procedure in which the sperm sample is gently spun through 1-3 columns of a viscous solution of saline coated colloidal silica particles. The layers of silica are created by delicately layering different silica particle densities on top of each other in a test tube, and then layering neat semen on top. This method takes advantage of the fact that living sperm are dense compact cells that pass easily through the columns, while dead or dying sperm that are less dense due to leaky membranes are trapped with other cells and debris in the interfaces between the layers. The second method for preparing sperm takes advantage of the sperm’s natural swimming abilities by placing neat seminal fluid in proximity to some culture medium and allowing the sperm to swim from one to the other. There are many variations in this technique including the swim-up (semen is layered under the medium), or the converse method called the swim-down, and the actual method used depends mainly on the quality of the sperm sample. The swim-up is primarily used for samples that have good numbers of highly motile sperm from which only a small fraction needs to be recovered. The swim-down technique works better when sperm are swimming weakly and need the help of gravity to separate from the seminal fluid. For an individual with vanishing numbers of sperm (say a few hundred) we may use a swim-out technique. Here, the sperm are placed in the center of a small drop of medium and an embryologist will wait with a needle at the edge of the drop, picking up the first sperm to get there. One of the big criticisms of the ICSI procedure, where individual sperm are injected into oocytes, is that the embryologist chooses the sperm. However, with the use of the swim-out procedure, there is some degree of “natural selection” as we choose the sperm that are quickest in getting to the edge of the drop. We also choose sperm that are the normal size and shape, and that are free from defects (such as a bent neck) if we have the luxury to do so. In rare cases we have to use every sperm we have, so there’s no “selection” whatsoever. In most of the cases where we’re processing samples that have normal numbers of sperm, the sperm isolated by density centrifugation or by swim-up will be “washed” once or twice before being introduced to the oocytes. This involves suspending the sperm in a volume of culture medium and then centrifuging gently so that the sperm can be concentrated and removed from the medium, while leaving behind any trace of the silica particles or seminal fluid that may have carried over from the first processing step. Although sperm can be damaged by centrifugation, these steps are necessary to ensure that the sperm are free of contaminants that could prevent fertilization.

There are many other methods used to process sperm samples but we use them so rarely that they are scarcely worth mentioning. For example, samples with a high amount of debris can be filtered through glass wool or processed by sedimentation to clean them up before they undergo any of the procedures already described. In addition, we can treat a semen sample with chemicals in certain situations, but this again only happens under somewhat desperate circumstances. If a semen sample is extremely viscous or clotted, we can digest it using the enzymes amylase or chymotrypsin. If none of the sperm are moving we can treat them with pentoxifylline or caffeine to try to stimulate movement. When performing ICSI, we need to know that sperm are alive, and movement is our primary indicator. We can try to stimulate movement using drugs, but for the sperm that are to be used to fertilize the oocytes, we prefer to go drug-free. Here, we place the sperm into a hypo-osmotic solution (regular culture medium that has more water than normal) and as water enters living sperm their tails coil. These we can then inject into oocytes.

For patients that purchase frozen sperm from a sperm bank, the bank will usually offer the option of buying the sperm processed or unprocessed†. Processed sperm, usually labeled “IUI sperm”, costs a little more since the sperm bank has already prepared it for use. Unprocessed or “ICI sperm” is essentially neat semen that has been frozen. Women who do their own inseminations at home buy this type of sperm and inject it into their vagina after it is thawed. If you buy ICI sperm with the intention of having an intrauterine insemination, we will process the sperm as above to remove the seminal fluid and dead sperm. ICI sperm cannot be placed into the uterus since semen contains many contaminants such as bacteria, but also because semen can cause painful uterine contractions.

On a given day in our laboratory, one embryologist is primarily responsible for processing sperm samples, and each embryologist is assigned to this task about once a week. Each sample has different characteristics and the individual doing the processing must make informed decisions on the best approach for recovering the sperm that we need. It is an interesting and demanding area of the laboratory, but we enjoy the challenge of maximizing the potential of each sample that we receive.

– Joe Conaghan, PhD, HCLD

† For more information on frozen sperm and the products sold by sperm banks, see the “How do I Buy Sperm?” article in the April 2005 newsletter.

Many of our patients are undergoing fertility treatment for male factor indications, and undergo insemination therapy. This may be patients who are using donor sperm from a sperm bank, or patients who are using their partner’s sperm, but the sperm has been frozen (partner out of town, or other indications). We are often asked if the success rates will be affected by the use of frozen versus fresh sperm. As well, we are asked if the number of inseminations performed per cycle will affect the success rates. There is a body of studies that have been done to address these specific questions, and our clinic’s interpretation of the literature is the following.

The first consideration addresses which type of insemination provides the best outcome when using frozen sperm. A number of studies have looked at this question, and when all the data from those studies are compiled and analyzed, results indicate that if an intrauterine insemination (IUI) is performed (sperm placed directly in the uterus), the odds are 2.5 times greater that a pregnancy will occur, than if an intracervical insemination (ICI) is performed (sperm placed at the entrance of the cervix) (5% vs. 14% monthly chance of pregnancy) (1, 2). When sperm are placed at the cervix, many of them are “lost” as they travel through the cervix and into the uterus, to then find their way to the fallopian tubes. This dilutes the actual numbers that make it to the egg in the fallopian tube, and therefore decreases chances of success. Performing 2 intracervical inseminations in one cycle (9% chance of pregnancy) did not bring success rates close to what one intrauterine insemination achieved (15% monthly chance of pregnancy) (2).

Next consideration addresses if fresh sperm is better than frozen sperm. Two studies have addressed this best, and indicate that the critical components that will provide comparable pregnancy rates are the performance of an intrauterine insemination (IUI), accurate timing of the insemination (relative to the ovulation event), and adequate concentration of sperm inseminated (called total motile count=TMC) (3, 4). The most accurate way to time the insemination is by using ovulation predictor kits (OPK), or by administration of an HCG injection to trigger the ovulation event. Ovulation predictor kits have been evaluated and the kit we recommend is the Clear Blue Easy ovulation kit. First detection of an LH surge is most likely to occur in the morning, and our recommendation is to do one test/day, in the morning (5). The best timing for an intrauterine insemination using frozen sperm is within 24-48 hours after a positive LH surge as detected by an Ovulation Predictor kit. In a well-designed study, using first positive OPK results to time insemination, 5% of total pregnancies resulted in cycles where the IUI was done within 24 hours of the positive OPK result, 90% of total pregnancies if within 24-48 hours, and 5% of total pregnancies if past 48 hours (5). Quite a few studies have evaluated the minimum number of inseminated sperm required to achieve an adequate pregnancy rate. Most indicate a total motile count between 6-15 million. This means that after thawing the frozen sperm specimen, the lab must recover between 6-10 million moving sperm. Most sperm banks provide a post thaw guarantee of 10-15 million/vial if prepped for an IUI (sperm already washed), or 15-20 million/vial if prepped for an ICI (unwashed sperm).

Next consideration addresses sperm washing techniques. There are a number of different laboratory techniques for washing and preparing sperm for insemination. As it turns out, there is no difference in pregnancy rates based on the sperm preparation technique. This holds for both the freezing technique and the post thaw washing technique (if ICI prepped) (6). This also applies if the sperm is pre-washed by the laboratory prior to freezing (if IUI prepped) (7). As long as an adequate TMC is reached post freeze-thaw, pregnancy rates hold steady.

The last consideration is: would one IUI per cycle reach adequate pregnancy rates, or would 2 IUI’s be better? Many studies have been done evaluating this question, and while individual studies may show different results, the majority of studies indicate that one IUI/cycle is adequate, and 2 IUI’s does not improve pregnancy rates, as long as the IUI is well timed, and the TMC inseminated is adequate (2, 8, 9, 10, 11).

In conclusion: We take guidance from the best published literature, and use the following guidelines for managing frozen sperm intrauterine insemination cycles at Pacific Fertility Center:

• Determine best timing of intrauterine insemination or IUI:
  First positive ovulation predictor kit (OPK) if OPKs are reliable, or HCG injection as administered according to our instructions.
• Do one IUI 24-48 hours after first positive OPK, or 24-48 hours after administration of HCG
• Do intrauterine insemination (not intracervical insemination or ICI)
• Assure insemination with adequate total motile count or TMC
  We will thaw sperm until we have a TMC of 10 million

If attention is paid to these management points during your treatment cycle, you should feel reassured that your chances of achieving a pregnancy is comparable to those if you were using fresh sperm.

– Isabelle Ryan, M.D.

Footnotes

1. Goldberg et al, Fertil Steril. 1999 Nov; 72(5):792-5

2. Carroll et al, Fertil Steril. 2001 Apr:75(4):656-60

3. Subak et al, Am J Obstet Gynecol. 1992 Jun; 166:1597-604

4. Bordson et al, Fertil Steril. 1986 Sept;46(3):466-9

5. Khattab et al, Hum Reprod. 2005 Sep;20(9):2542-5

6. Byrd et al, Fertil Steril. 1994 Oct;62(4):850-6

7. Wolf et al, Fertil Steril. 2001 July;76(1):181-5

8. Centola et al, Fertil Steril. 1990 Dec;54(6):1089-92

9. Lincoln et al, J Assist Reprod Genet. 1995 Feb;12(2):67-9

10. Khalifa et al, Hum Reprod. 1995 Jan;10(1):153-4

11. Matilsky et al, J Androl. 1998 Sept-Oct;19(5):603-7

Question: My wife and I have been trying to have a child for a while now. I have been told that she is “allergic” to my sperm. What are our best treatment options at his time?

Answer: Many people say that they are allergic to their partner’s sperm, and that can mean different things, depending on the testing done. True incompatibility with sperm is very uncommon. Some female patients may have had a blood test to see if they have “anti-sperm antibodies” circulating in their blood stream. A positive test result actually does not correlate well to a true problem of incompatibility and infertility, and therefore this blood test is no longer recommended as part of infertility testing. An uncommon, but more relevant problem would be if the MALE partner were making sperm antibodies against his OWN sperm. Men who are at risk of this are those who have had testicular injury (scrotal trauma) or testicular surgery (torsion, tumors, or other indications). Antibodies are also commonly found in men who have undergone vasectomy reversal, especially if the interval between vasectomy and vasectomy reversal is a long one.

The sperm has 3 parts: the head, midpiece and tail. If the male patient makes sperm antibodies against the sperm midpiece or tail, this is probably of no consequence. If he makes antibodies against the sperm head, then this can prevent the sperm head from fusing with the egg membrane, and progressing with the important steps of fertilization. The remedy for this condition is to proceed to IVF, and have the embryologist inject the sperm directly into the egg membrane and cytoplasm. This injection process is called ICSI (intracytoplasmic sperm injection), and will restore normal fertilization rates for that couple.

It therefore is important to be clear about the appropriate testing to be done, if one suspects a sperm incompatibility. The anti-sperm antibody test is done directly on the SPERM, and done in a laboratory which has the ability to do this specialized testing (usually an IVF or an Andrology laboratory). If you have a history that might place you at risk of making antibodies against your own sperm, please discuss this with your fertility physician.

– Isabelle Ryan, MD