BABY BLOOMERS: SESSION ONE - FERTILITY TREATMENT FOR HIM
On 17 June 2009 the ‘’Baby Bloomers’’ GP professional development sessions in Reproductive Medicine kicked off with an evening devoted to male Infertility. On this, the first of three evenings, Greenslopes specialists Dr Clare Boothroyd and Dr Peter Campbell discussed the diagnosis and treatment of male infertility and the problems associated with vasectomy reversal; whilst Scientific Director Dr Steven Fleming delved into the minutiae of identifying the best sperm in the IVF laboratory.
Over 30 registrants attended the first three sessions, which were both informal and interactive allowing participants the opportunity to explore their own experiences in general practice. A summary of key messages from these lectures is outlined below.
Dr Clare Boothroyd: Androgen replacement, living long-term with male factor infertility and preserving male fertility
Dr Clare Boothroyd began her presentation by highlighting major risk factors for male infertility. These include: maldescent of the testes, family history of male infertility, cigarette smoking, the taking of marihuana, the IBS drug (sulfasalzine) and potentially heavy alcohol consumption. However research into aetiology and understanding of male infertility has not made great advances over the last thirty years with the advent of successful treatment using assisted reproductive techniques. Fortunately men’s health is now getting the attention it deserves and hopefully this will change in the future. Prevention of mumps orchiditis with vaccination, measures to reduce sexually transmitted infections such as chlamydia and early orchidopexy are important means of prevention of male infertility.
Dr Boothroyd reported that overall ~10% of cases are treatable (for example pituitary disease or hyperprolactinaemia), but it is considered that ~90% of males require treatment through a fertility centre. Diagnosis, however, can be difficult with less than perfect tests for serum testosterone or even semen analysis.
A recent comparison of semen analysis tests revealed that tests performed at fertility centres are more reliable than those from a general pathology laboratory. Dr Boothroyd also highlighted the need for patients to be referred onto fertility centres quickly, if the female partner is 35 years or older.
Diet and vitamins
The vitamin supplement for men, Menevit™ is marketed to support sperm health in men trying to conceive a pregnancy. However Dr Boothroyd reported that a critical review of the small randomised controlled study investigating the use of Menevit™ by men whose partners were undertaking a cycle of IVF or ICSI showed no significant benefit over placebo. Further studies are needed before Menevit™ can be recommended routinely. Other studies suggest an organic diet can improve male fertility, but these results and other studies into folic acid are also inconclusive.
Long term implications of male infertility
Dr Boothroyd emphasised that having a low sperm count was associated with an increased risk of testicular cancer – perhaps a doubling or trebling of the risk. As testicular cancer is a rapidly growing but eminently treatable tumour Dr Boothroyd stated that all men with male factor infertility should be examined and advised to perform regular self examination. The place of routine ultrasound of the testes in male factor infertility remains uncertain but some studies have suggested nearly 10% of men with male infertility have microlithiasis of the testes.
Dr Boothroyd recommended the Andrology Australia website, for comprehensive up-to-date information on all aspects of infertility and fertility treatment.
Dr Peter Campbell: Fertility after Vasectomy
Greenslopes Specialist Urologist, Dr Peter Campbell, described the surgical implications of vasectomy surgery. He reported that this straightforward operation has a success rate of 98%, with 7% of men opting for vasectomy reversal at a later date. Despite being a routine operation, patients need to be aware of the possible side effects: 30% of men suffer chronic pain after surgery, and there is also a 1 in 2,000 chance of recanulisation of the tubes.
Dr Campbell noted that vasectomy reversal has a small failure rate partly due to scarring, caused by diathermy. This makes reversal more difficult and the surgeon has to cut back along the tubes to find patent ends before attempting to rejoin them. Reversal success rates drop after 7 years from the time of vasectomy (i.e. if the time interval from vasectomy to reversal is greater than 7 years). Most reversals are, therefore, performed on men under the age of 35 years; men over 40 years often need to consider surgical sperm recovery and ICSI. Also men whose partners are under 35 are good candidates, while those whose partners are over 40 might prefer IVF with ICSI.
For further information visit: www.campbellurology.com.au
Dr Steven Fleming: Bypassing male factor infertility
Dr Steven Fleming began his session by discussing the main factors affecting male fertility (age, sperm defects, spermatic cord occlusion, immunological factors, ejaculation disorders, DNA fragmentation and chromosomal or gene defects). He then introduced the techniques used in the laboratory to bypass problems of male factor infertility. Using the well-established procedures of intrauterine insemination (IUI), in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI), it is now possible to overcome the majority of causes of male infertility.
If sperm are not present within the ejaculate, they can be recovered using fine needle aspiration of the epididymis, a procedure known as percutaneous epididymal sperm aspiration (PESA). Alternatively, they can be recovered from the testis, using a procedure known as testicular sperm aspiration (TESA). If necessary, an open surgical procedure - known as testicular sperm extraction (TESE) - can be used, to identify and biopsy larger quantities of seminiferous tubules.
However it is known that in certain circumstances sperm quality is reduced (i.e. with paternal age) and this is associated with DNA damage in the nucleus. Various techniques are therefore being developed and trialled to select the most intact and functionally superior sperm. For example, under high magnification the size/density of the sperm head can denote intact DNA, adherence of sperm to factors found on the outside of the egg can be used to isolate sperm that are more mature, and electrophoretic membrane separation can be used to isolate those sperm with intact DNA, that are believed to be the most negatively charged.
As mentioned there are also genetic causes of male sub-fertility, and these include micro-deletions on the Y chromosome. Using molecular genetics these causes can now be identified using molecular probes.