Wisdom from Wisot Wednesdays, Round 17!

Reprint from Redbook’s Fertility Diaries

Hello, everyone, and welcome back to our weekly Q&A with top fertility expert Dr. Arthur Wisot. We've got so much in store this week: Four great questions, an answer to last week's pop quiz ("What are the three reasons that it seems like the conception rate is 100% on prom night in the back of the pick-up truck?"), and a question from Dr. Wisot to all of you! If you've got a question for Dr. Wisot, just leave it in the comments section and we'll get to it next week. And now, for the disclaimer: "My answers to questions on this blog do not constitute medical advice, but are merely meant to create an educational forum for consumers. It is always best to discuss these issues with your health care provider." The good doctor's answers are below, in bold:

Question #1: We've been trying for two years and never once had a positive pregnancy test. Recently we went through extensive testing — I am completely healthy/normal however, we were diagnosed with male factor infertility. He's seen a urologist and received a clean bill of health. We've been to an RE and were told that given his SA, we should "Do not pass go, go straight to IVF/ICSI." I've come to terms with the path ahead of us, however despite my RE's frequent reassurance that "It only takes one!", I feel like I need another opinion on his stats to fully understand our chances of a successful pregnancy: SA #1 (WHO Methodology) Total Count: 208 million A - 0% B - 15% C - 4% D - 81% Total Motility - 31 million Kruger Morphology Normal - 3% Head Defects - 44% Acrosomal - 5% Neck Defects - 31% Tail Defects - 17% SA #2 (WHO Methodology) Total Count: 98.9 million A - 0% B - 21% C - 18% D - 61% Total Motility - 20.8 million Kruger Morphology Normal - 1% Head Defects - 44% Acrosomal - 3% Neck Defects - 28% Tail Defects - 24% His counts are high, but the motility and morphology numbers freak me out. Should we be concerned with chromosomal abnormalities or possible DNA fragmentation? As our start date to cycle approaches, I worry that there simply won't be enough "quality" sperm to choose from. Can you help me understand what criteria the lab technicians look for when selecting sperm for ICSI? Thank you.

Answer: Fertility treatment works best when we are correcting a problem, if that's possible. Here the problem is the motility and morphology. If they don't move well, they have much less chance of reaching the egg. If they are misshapen, they have much less chance of penetrating the egg. Fortunately, the speed and shape have nothing to do with the chromsome makeup of the sperm. So IVF with ICSI is a treatment that can overcome this problem. If you are young, you could try some IUIs, but I would usually not recommend spending too much time before moving on.

Question #2: Due to my husband's cancer treatments, he is unable to have children (based on a semen analysis in 2000). When I started my IF treatments in 2007 (no birth control since 2000), we did not do another semen analysis and used donor sperm. I'm now considering IVF (15 failed IUIs, medicated and not). Can we consider utilizing my husband's sperm? What's the minimum an RE will want to see in order to use his sperm?

Answer: The minimum number of viable sperm needed is equal to the number of eggs you produce. That's easy. The bigger question is whether the chemotherapy drugs may have damaged the sperm beyond their numbers, ability to swim and their shape. You should consult with his cancer doctor to get information on exactly what and how much of the drugs he received and what potential damage they could have caused beyond the obvious.

Question #3: Hi, Dr. Wisot! A few weeks ago, in your answer to my questions about embryo defragmentation, you mentioned looking at strategies to improve egg (or embryo) quality. What are some of the strategies you've used in situations with low ovarian reserve, lots of fragmentation in the embryos? Thanks for your thoughts!

Answer: Unfortunately I can not get into the details of prescribing and protocols here. Each fertility center has its ways of dealing with poor embryo quality. In the lab, procedures like co-culture, assisted hatching and defragmentation may be used. There can be modifications to the stimulation protocol. You may want to get an opinion from your doctor about what strategies he/she would suggest and then get a second opinion from another outstanding center. This is a difficult issue to resolve and it can't always be fixed.

Question #4: Hi. Some background: I have a small prolactenoma that I take Parlodel for. Have had regular prolactin levels for one year now and have been TTC since April 08. Husband's sperm is normal, he is 34, I am 30. My question: Ever since going off the pill I have had a very short luteal phase. My doctor thinks I am ovulating due to OPKs thermal shift. But luteal phase is 2 - 6 days. My doctor says that is not a concern; do you agree? I have an HSG scheduled for this week and if clear, the doctor suggests Clomid. Thanks for your thoughts!

Answer: You need to get into this more deeply than following your cycles with a temperature chart. You do fit the definition of a luteal phase defect just by the length of your luteal phase. I would guess that you are not seeing a reproductive endocrinologist/fertility specialist. Clomid is one way to overcome this problem, but your cycles need to be monitored by ultrasound following your egg development, confirming the egg's release and progesterone monitoring in the luteal phase.
Before I get to last week's quiz answer, I would like to get your perspective on the reproductive aspects of the Octo-Mom situation. Has it affected your confidence in the specialty as a whole? Do you think we should legislate how many embryos may be transferred? I'd love to hear what you think. Next week, I'll share my perspective.

Pop quiz answer:

Last week's question was, "What are the three reasons that it seems like the conception rate is 100% on prom night in the back of the pick-up truck," while so many women struggle to have a child.

1. The girls are usually in the late teens, which biologically is the optimal age group for reproduction. (Please, don’t shoot the messenger.) Today, between education and careers, many women are putting off their childbearing until they are biologically more mature.

2. The guys are also at a peak of sorts. Most of the time they look at the post-prom hours with great anticipation. In fact, they frequently practice so they will give a stellar performance. They can regenerate their counts more quickly than their more mature counterparts. The increased, er, practice time improves motility and decreases DNA fragmentation so they are primed to perform magnificently from a reproductive point of view.

3. This is where the back of the pick-up truck comes in. Couples who are engaged in fertility treatment have sex, make love, have intercourse, or whatever you want to call it. In the back of the pick-up our two prom goers and have hot, steamy sex like two rabbits going at it, with similar results. There is no stress and the level of excitement improves the semen specimen further. The stress comes about two weeks later when she misses her period.

The point of all this is that one cannot expect fertility treatment to match the efficacy of this method. I’ve even had patients borrow a pick-up to try to regain their lost youth. But, believe me, it doesn’t work. What may help if you are not already at the point of IVF is to try to regain that spark that brought the two of you together and don't let the quest for a baby get in the way of what you once had. If you are having IUIs, try it the old-fashioned way after your IUI. Even if it is the IUI that ends up getting you pregnant, at least you’ll have had some fun trying.

Male Infertility: Intracytoplasmic Sperm Injection (ICSI)

Background

Male infertility accounts for the reason for the problem in approximately 40% of the 2.3 million couples experiencing infertility in the US. Traditionally, couples with severe male factor had three options: using donor sperm, adopting or electing not to have children. The plight of men with severe sperm problems having their own biological children was a strong force in the development of new approaches.

Treatment of male infertility often depends on the specific cause of the infertility and can include surgery, medical treatment and if those are not effective, microinsemination techniques. Microinsemination is laboratory assisted fertilization of an egg. Intracytoplasmic sperm injection (ICSI), a specialized form of microinsemination, was first developed by reproductive medical specialists in Belgium to help couples overcome male infertility problems associated with an inability of sperm to fertilize an egg. Since then, ICSI has been successfully used to treat many types of male infertility and is helping more couples realize their dream of having their own biological children even in the most severe cases of male infertility. Today, the technique is no longer considered experimental and is among our routine services.

The ART of Parenthood

There are several Assisted Reproductive Technologies (ART) that have been developed to assist couples in having children. Among them are: in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), egg donation, cryopreservation with subsequent thawing and transfer of embryos, and a growing number of microscopic techniques such as ICSI and most recently, preimplantation genetic diadnosis (PGD). These microscopic procedures are the most demanding and exacting part of ART.

Male Infertility & ICSI

Fertilization of the egg by ICSI, getting one sperm into one egg, is the starting point for embryo development. For many years the only approach available for fertilizing an egg in ART procedures was to imitate what occurs in fertile couples, incubating the egg with sperm. This approach is successful in fertilizing approximately 75% of eggs in men with normal sperm parameters. Microinsemination techniques were developed to improve the likelihood of fertilization in men whose sperm parameters are markedly abnormal. Male infertility can be associated with the production of low numbers of sperm, sperm that do not “swim” properly or do not swim at all, and sperm that are abnormal in shape. Abnormally shaped sperm have reduced ability to penetrate the egg.

Non-ICSI insemination can be a difficult process in men with abnormal sperm parameters for two reasons: the sperm must first reach the egg and then penetrate the egg. They may not have adequate numbers, motility or normal morphology to have a good chance of their sperm accomplishing these two tasks. ICSI overcomes these deficiencies by injecting a single sperm into an individual egg. ICSI makes a low number of sperm, “poor sperm motility” and “poor sperm morphology” no longer barriers to couples who seek to have their own biological children.

In some men, the tubes known as the vas deferens that transfer sperm from the testis are blocked or missing through a congenital abnormality, an accident, a disease or an irreversable vasectomy. In such situations, sperm may be obtained by a surgeon from the epididymis, the site where sperm are stored through a process called percutaneous epididymal sperm aspiration (PESA). In men with other severe problems, sperm can be obtained by testicular biopsy (TESE). ICSI makes it possible to use epididymal or testicular sperm to achieve a pregnancy. There is also the situation where, for unknown reasons, a man’s sperm does not penetrate the woman’s egg, even though the number, shape and motility of the sperm all appear normal. ICSI is also appropriate treatment in these situations.

ICSI - The Technique

ICSI requires only one sperm per egg to be effective. ICSI is a simple and elegant way to transfer that sperm directly into the egg. Using a microscope, the embryologist gently draws one sperm into a pipette. The tip of the pipette is then guided into the waiting egg. The egg is held steady at the end of another glass pipette. Then with a steady and measured forward motion, the sharpened tip of the sperm-containing pipette is inserted into the egg. Reversing the process that pulled the sperm into the pipette, the embryologist now ejects the sperm into the egg. And finally, the sharpened tip of the empty pipette is removed from the egg. After picking up the sperm, the entire ICSI technique takes the embryologist less than ten minutes.

ICSI - Does it damage the egg?

ICSI procedures are routinely done successfully without damaging the egg in most cases.

This is not surprising to embryologists for several reasons. First, the egg is many times larger than the pipette that is used to penetrate its surface. Second, the human egg is encased in a tough, elastic membrane that usually doesn’t crack, shatter or crumble.

Finally and most important, Mother Nature lends a hand: the egg has the ability to rapidly repair the small hole in its membrane made by the pipette.

ICSI - Are there any side effects?

Despite widespread use and acceptance, ICSI is still a relatively new procedure. Children born as the result of ICSI are still very young and have not yet reached an age to reproduce. Genetic reproductive abnormalities in the father can be passed on to male offspring. Currently there are reports of a small increase in minor birth defects and congenital abnormalities in babies born through ICSI. This is not surprising since it is usually being performed in couples in which the man has very abnormal sperm. In addition ICSI bypasses an important natural process of sperm penetration.

Theoretically, this could permit the transfer of certain conditions that have a genetic basis. Where a genetic basis for male infertility is suspected or known, the couple may also find it helpful to speak with a genetic counselor before choosing to use ICSI, as well as have genetic testing for abnormal chromosomes or microdeletion in the male (Y) chromsome.

Credits –

This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the Southern California fertility center, Reproductive Partners Medical Group. For more information on IVF and the many available fertility treatments please visit www.reproductivepartners.com.