Over 2 decades ago, ICSI (intracytoplasmic sperm injection) revolutionized the treatment of male infertility. The ICSI procedure involves injection of a single sperm into each egg at the time of IVF (in vitro fertlization). Before the development of ICSI, couples with sperm issues, what we call "male factor," had very low fertilization and pregnancy rates, even when undergoing IVF. Now a days, because of the use of ICSI, poor sperm quality is a very unusual reason for an IVF cycle to be unsuccessful or to blame for poor fertilization. Over concerns about potentially poor fertilization, many fertility centers have chosen to use ICSI routinely to ensure optimal fertilization even when the male partner's sperm is perfectly normal. At Princeton IVF, our philosophy has always been to allow fertilization to happen "naturally" in the dish when there is no history of sperm issues or poor fertilization. While ICSI had been shown to be quite safe, we feel that a more natural selection process makes more sense and research in the past has suggested that ICSI is only beneficial in male factor patients. A recent large-scale study recently published in the Journal of the American Medical Association has borne this out. ICSI when used in IVF cycles used in couples without sperm issues had lower fertilization and lower implantation rates than non ICSI cycles.
Could a cure for real cure for infertility be on the horizon? Today many causes for infertility can currently be successfully treated such fertility issues caused by damage to fallopian tubes, ovulation disorders, endometriosis and low sperm counts or motility. These treatments currently available to us include fertility drugs, insemination, surgery and IVF. However, there are still issues in assisting women have very few or no eggs left or men who produce no sperm at all. This is a particular problem for women since women produce all they eggs they will in a lifetime while still in their mother's womb, and by their mid 40s have hardly any normal eggs left. These couples can be successfully treated only with the use of donor eggs or sperm. While these donor procedures are often quite effective, the children who result from these pregnancies do not carry the DNA of one or both of the parents. This is a problem since most couples who seek out the help of a Reproductive Medicine specialist want their own genetic children. With our current state of reproductive science this may not be possible.
One potential way around this would be using stem cells in the lab using cloning technologies. A group of scientists at the Weizmann Institute in Rehovot, Israel and Cambridge in the UK have brought us a little closer to this cure, figuring out how to more efficiently get these stem cells to grow into cells that will eventually develop into eggs and sperm. Their findings were recently published in the journal Nature.
The researchers have yet to take the next step; producing eggs and sperm from these stem cells. While it may become technically feasible, besides the technical issues, there are ethical concerns, perhaps even greater than when IVF when first introduced to overcome before this proceeds. IVF was enormous breakthrough when it was developed, but it is still merely a replication of natural conception, albeit in a laboratory dish. If this next step is even possible, it could bring reproduction to entirely new level. These technologies may make it possible to have genetic children without ovaries, without testes and without age limits, shattering our concepts about parenthood, even more so than it is today. It is not clear if society is ready for this yet.
In recent years, endometrial scratching, irritating the endometrium (lining of the uterus) to help in making the womb more receptive for pregnancy has emerged as a new and unsual way to help couples get pregnant. Recently, a group from Turkey presented data at the American Society of Reproductive Medicine meeting suggesting that performing an endometrial biopsy prior to IVF can improve pregnancy rates in women undergoing IVF by about 20%. In fact over the years, seeming against common sense, there have been a number of studies suggesting that a biopsy and/or hysteroscopy may improve the chances for IVF success. At Princeton IVF, we have been using this technique for years, first in patients who failed cycles without any good explanation and then routinely in all our IVF patients. Although no one is quite sure why it helps, it is likely that the repair process from endometrial trauma helps to make the uterus more receptive to embryos.
In women who suffer from infertility, their difficulty in conceiving is sometimes a sign of underlying health issues. For instance, it will know that women who suffer from infertility have a higher rate of pregnancy complications, even if they conceived without treatment. One of the most common causes for infertility, polycystic ovarian syndrome (PCOS) is often associated with underlying metabolic problems and women with PCOS are more likely to develop medical problems such as diabetes, high blood pressure and heart disease. However, what is less clear whether this is also true in men. A recently published study suggest that men with fertility issues and sperm abnormalities may be more likely to have other seemingly unrelated medical problems.
And why might this be important? Unless you are a Spanish farmer raising swine, or unless you live in Spain and are in the market for pork or ham, it should not matter. But is you work in the fertility field or are trying to get pregnant, it may be an issue. The concern over what is going on with Spanish pigs, is really about why the pigs were having trouble reproducing. It turns out that back in 2010, there was a marked drop in fertility in pig farms across difference regions of Spain. Investigators at first had trouble figuring our where there problem was. The one common thread in each of these farms was that all of the farms used plastic bags from the same manufacturer to collect semen for insemination. A researcher at the University of Zarazoga, Cristina Nerín, then analyzed the bags and found that an ingredient in the plastic bags was the cause of infertile Spanish pigs. The scary part is that this chemical (and similar compounds) are found in plastic products that are used to package foods and beverages we eat every day. The good news is that the pigs of Spain and happily producing lots of piglets again. However, there is likely more to come on this topic in reproductive medicine and potentially in other areas of medicine as well.
A recent study suggests that men who keeps their cellphones in their pants pockets, may have lower sperm motility. Researchers at the University of Exeter in the UK, found that men who kept cell phones in their pockets had lower sperm motility than those who did not, about an 8% reduction. Is this an issue? It remains to be seen whether this decrease really affects a couple's chances for pregnancy and truly causes infertility.
With some states choosing to legalize marijuana, we hear very little of cannabis' effects on health, and even less on its impact on reproductive health. We have know for years that pot smoking can cause chromosomal breakage, and so for those couples trying to get pregnant, many reproductive specialists encourage both partners to quit when attempting pregnancy. Now, some new data out of the UK shows men who use marijuana are considerably more likely to have abnormally shaped sperm, Interestingly, in the same study, alcohol and tobacco did not. Since even in normal men, it is normal to have some proportion of misshapen sperm, this finding in itself is not enough information to say that marijuana causes infertility. Still, why take the chance? This is just another good reason to quit if you are planning to start a family in the near future.
Apparently according to the NFL, it is. One of the players on the Indianapolis Colts was suspended after taking clomiphene, a fertility pill commonly used by Fertility Specialists, OBGYNs and Urologists to help women (and sometime men) coping with infertility. Even though he was using it to help his wife get pregnant, successfully I might add, the NFL considers Clomid a "performance enhancing drug." Most patients who have taken clomiphene, and put up with some its side effects would likely take issue with that assessment.
A recent study from the NIH suggests that couples who have high cholesterol levels may not just be at higher risk for heart disease, they may also have a harder time getting pregnant. Couples (who were not yet considered infertile) in which both partners or even just the female partner had high cholesterol levels on average took a longer time to conceive. These findings are not so surprising since ovulation disorders such as polycystic ovarian syndrome (PCOS) are among the most common causes for infertility, and many of these patients have underlying metabolic problems that place them at risk for heart disease and diabetes. So what does this mean? It does not mean couples trying to get pregnant should rush out and go on statins to lower their cholesterol. Cholesterol is the chemical from which sex hormones such as estrogen and testosterone are made from, so these drugs could potentially be harmful to your fertility. However, healthy lifestyle changes such as moderate excercise and avoiding processed high carbohydrate foods may help both cholesterol and fertility.
Most Reproductive Medicine specialists know that our overweight patients often need higher doses of fertility medications, whether that is pills (clomiphene or Femara), or injections (Follistim, Gonal-F, Bravelle or Menopur). When we do IVF cycles, we also add a medication to prevent ovulation such as Lupron, Ganirelix or Cetrotide, and for the most part, the doses are not adjusted based on a patients weight. It turns out that doctors in Colorado looked at one of these drugs, Cetrotide (Cetrorelix) and found that overweight women actually metabolize the drug faster, meaning that the currently used dosing may not be sufficient in these patients. So, what does that mean? If the cetrotide does not last in the system long enough, premature ovulation may occur, and your IVF cycle could be cancelled. It may mean that we need to use higher or more frequent dosing in heavier women.
There has been a lot of chatter about effects of BPA in the news, an additive in plastics bottles and their effects on reproduction. The NIH decided to look into plastics additives effects on female and male fertility, and they found something interesting. Men who were exposed to pthalates, additives used to softer plastics such as vinyl took longer for their partners to conceive than those who did not; 20% longer. Surprisingly, BPA exposure in either partner and phthalate exposure in women did not affect fertility. While this does not prove that these chemicals cause infertility in men, it is another piece in the unsolved puzzle about how that environment may be affecting our reproductive health.
One Australian Fertility Specialist says yes, the classroom is the perfect place to learn about this, as reported on Yahoo News 7. Surveys continually show that the public, both women and men understand very little about their own fertility, and this is perpetuated in the media by stories of miracle late life pregnancies. Many women understand very little about how their own reproductive systems work, and even less about the true effect of age and lifestyle choices on their ability to have a family. Most of us reproductive specialists see patients all the time whose infertility could have been prevented. This doctor in Adelaide sees education as a sort of preventative medicine for infertility and is advocating making fertility education a part of the school curriculum in his country, along side with contraception. Will it work? And could it happen here in the US?
The effect of infertility on a couples' relationship is well know to most of us in the the field of reproductive medicine. We have all seen our patients' marriages fall apart even in those couples who are successful. Now, investigators in Denmark have looked at couples who went through fertility testing and looked at divorce rates. They found that couples who went through testing but never conceived had a 3 fold chance of divorce as compared to those who had children. Does this mean having children can save a bad marriage? Probably not, but it does suggest that couples who are successful with treatment (or on their own) are more likely to have their marriages survive.