SCIENCE PULSE    Male Factor Infertility

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

 Philip Chenette, MD has spent over a decade specializing in the treatment of patients with complex infertility diagnoses, especially in women with decreased ovarian reserve and women over 40. As a member of the International Society for Stem Cell Research, he is working to apply the concepts of stem cell therapy to help couples have healthy children. His expertise is recognized by peers who select him as “Best Doctor” in national surveys. (See www.BestDoctors.com)

PFC SPOTLIGHT    My Journey to PFC Egg Donor Agency

Who am I?
Hello my name is Elizabeth Zeiter and I was born and raised right here in Northern California. I come from a family of doctors and health professionals, so naturally I had a desire to study medicine too. The summer before college I attended a National Youth Leadership Forum on Medicine where I confirmed my interest in the medical field. That fall, I began my life journey on the road to become a doctor at the University of California at Davis. For two years I studied math and science. At the end of a stressful second year, I knew that I needed a break, so I decided to take a quarter off and explore my other passion. I have always been drawn to people and their cultures. My new schedule consisted of history, sociology, anthropology and international relations classes. This gave me an opportunity to learn and understand the many backgrounds and traditions of the diverse people with whom I lived with and attended classes. It was at this point that I decided to go down a different path. I received a Bachelor's degree in International Relations. My last year of college I began an internship with the American Cancer Society promoting a breast cancer early detection program with the Latina community of Yolo County. I was hired full time right out of college and worked until the grant funding ran out. I took advantage of my time off and decided to travel and explore Europe.

How I found PFC?
Back from Europe, fresh and ready to join the work force again, I began an optimistic hunt for a job. I knew that I wanted a position that would both satisfy my passion for medicine and love for humanity. So I went from job interview to job interview and no luck. I decided to temp for a while and continue to job hunt. I stumbled across a position at PFC. I did not know much about IVF, IUI and egg donors, but it sounded interesting. After meeting Dr. Ryan and Dr. Schriock, I knew that this was the place for me.

My Experience at PFC?
My experience at PFC has been very rewarding. I am surrounded by compassionate people working towards our one goal, helping patients build a healthy family. As Program Manager of the Egg Donor Agency, I have the opportunity to work with both egg donors and recipients. My position allows me to learn a great deal about medicine and technology and permits me to share my compassion for humanity with people from all over the world who desire to expand their family. Most importantly, I am at a job where I leave at the end of the day with a big smile because I have made a difference in someone's life.

On a more personal level?
If I am not at PFC, I am taking off on a new adventure somewhere around the world to places I have never been before. I also love to volunteer my time to various charities and enjoy participating in group trainings for full and half marathons that raise awareness and money for a variety of special causes.

• Elizabeth Zeiter is Manager of Pacific Fertility Center Egg Donor Agency which is located in the same building as our fertility center. Ms. Zeiter facilitates the egg donation process for current and prospective egg donors and is readily available to answer donor and recipient questions regarding the egg donation process. She assists recipient patients with the process of choosing an egg donor, as well as coordinates communication between the Egg Donor Agency and the medical clinic.

CONCEPTION HEALTH    Preconception Health

While many factors leading to female factor infertility are out of a patient's control (genetics, for example), there are several measures patients can take that will help optimize their chances of conception.

At the forefront is receiving routine gynecological care. During the preconception phase, it is important that the patient have an up-to-date Pap smear and mammogram. Furthermore, the patient should undergo testing for infectious diseases (Hepatitis C, Hepatitis B, syphilis) and immunization status for varicella and rubella and hormones which can affect ovulation (prolactin and TSH). Any fibroids or polyps the patient has should be evaluated to make sure they wouldn't adversely affect the chances of conception. Also, the patient should be taking essential prenatal vitamins as prescribed by her OB/GYN.

 Certain behavioral factors should also be assessed and, in some instances, eliminated prior to trying to conceive. Smoking and drinking should be eliminated and exercise should be moderated. Incorporating a regular exercise program along with a balanced diet is recommended. The diet should include lean proteins, a colorful variety of fresh fruits and vegetables, combined with a limited intake of processed and fatty foods.

Women who are extremely thin or very heavy should seek the help of a nutritional counselor to attain a healthy weight without fad or crash diets. Embarking on a new, strenuous exercise regimen or crash diet just before attempting to become pregnant is not recommended. Medications being taken for preexisting medical conditions should also be evaluated to ensure they won't compromise a pregnancy.

If the patient requires a fertility specialist, it is recommended the following tests be performed prior to seeing a specialist. This will streamline the diagnosis process and expedite them on their path to proper treatment. This includes testing of the ovarian hormones, follicle stimulating hormone (FSH), Estradiol; a semen analysis (for the male partner) and an HSG (dye study) to assess tubal patency.

Age is a critical factor in the outcome of infertility treatment and it is important for patients to be more proactive the older the patient gets. At Pacific Fertility Center (PFC), our guideline for patients is to seek help from a fertility specialist after: 1 year of trying for women less than 35 years of age; 6 months of adequately timed intercourse or inseminations for women ages 35-39; 3-6 months of trying for women over 39.

Again, time is of the essence when it comes to getting treatment from a reproductive expert, and, keeping that in mind, there are several tests that we do not encourage patients to take prior to seeing an infertility specialist based on their limited usefulness.

Ultimately, conceiving through assisted reproductive technology (ART) is a team effort involving the patient, OB/GYN, and fertility specialist, with the process beginning several months before the patient steps foot in an IVF clinic.

For more information go to www.infertilitydoctor.com/infertility/prep.php.  Eldon Schriock, MD

FROM US TO YOU    PFC at ASRM and More

  Pacific Fertility Center Team
Left to Right: Front: Philip Chenette, MD, Isabelle Ryan, MD, Carolyn Givens, MD
Back: Joe Conaghan, PhD, Carl Herbert, MD, Eldon Schriock, MD

Pacific Fertility Center at ASRM—Pacific Fertility Center supports continuing education and encourages all employees to stay abreast of the latest research and developments in the ever-changing field of infertility.

In late October, Eldon Schriock, MD, Carolyn Givens, MD, Joe Conaghan, PhD, Karen Volpe, RN, and others attended the 2006 American Society for Reproductive Medicine (ASRM) Annual Meeting in New Orleans. Look for our comprehensive ASRM Round-Up article in an upcoming Fertility Flash that will highlight some of the exciting topics that were covered during the meeting.

From the Incubator—Did you know? The first reported birth using donor sperm in an artificial insemination in the United States took place all the way back in 1890.
(Source: Alan O. Trounson & David K. Gardner. Handbook of In Vitro Fertilization, 2nd Edition. 2000; 10.)

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-- Best regards from all of us at Pacific Fertility Center.