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 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.
There are plenty of reasons to quit smoking. The health effects of smoking are well known and well documented, not just on your fertility, but a whole number of health issues including heart disease and cancer. Now, there's yet another reason to quit smoking if you are pregnant or trying to get pregnant. Cigarettes may actually affect a woman's male offspring's sperm quality. As reported in Human Reproduction, the male offspring of pregnant mice exposed to high levels of cigarette smoke had sperm with lower counts, lower motility and more abnormally shaped sperm (low morphology), and these male mice took longer longer to impregnate female mice who in turn gave birth to fewer mouse pups. So, what does this all mean? While we don't yet know if this is true in humans (or even 100 % sure it is true in animals), exposure to tobacco smoke could not only harm your fertility (among other things) but also could harm your unborn son's chances of fathering children. This is another good reason to quit.
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.
Like most Reproductive Medicine practices, we perform what we refer to as "Third Party Reproduction" meaning we use donor sperm, donor eggs, gestational carriers for couples who need these procedures. One of the problems with the use of an egg and sperm donors or surrogates and gestational carriers, is that using them can be rather pricey. A lot of effort is required to make sure all parties involved are protected medically and legally, and so many patients may be tempted to do this at home without medical intervention. This story of a "Turkey Baster" do it yourself surrogacy from the UK illustrates why it is so important not to try this at home.
One of the most fascinating things about practicing Reproductive Medicine in an ethnically and religiously diverse area is learning to understand the value systems that our patients bring to the table when they come to seek out fertility treatment. Some faiths such as Roman Catholicism reject Assisted Reproduction as a separation between reproduction and intimacy and others such as Judaism encourage it emphasizing the importance of the biblical commandment "to be fruitful and multiply." Sunni Islam permits assisted reproduction but forbids the use of donors or gestational carriers. The most fascinating and perhaps most paradoxical is that of Shia Islam, the predominant religion in Iran. Most of the world views the Islamic Republic of Iran as one of the most brutal and intolerant in the world, yet when it comes to Assisted Reproduction, it is actually one of the most open minded. As pointed out in an Op-Ed in the Pittsburgh Post Gazette, Iran's Shiite theocracy allows relatively unrestricted access to ART and IVF, including the use of egg and sperm donation, a practice forbidden in most of the Middle East. Iran, in fact, now has over 70 clinics, luring patients from Sunni countries that forbid the use of donation.
Researchers in Germany used very tiny tubes called nanotubes to control the motion of sperm. They used sperm mainly because the sperm are able to propel themselves. Today there is no real application for this even though this is fascinating. In the future, however this could represent a way to help fertilize eggs or even deliver drugs such as chemotherapy to their target. Here's the video: http://www.youtube.com/watch?v=O9fJx1Y7vaQ
Researchers at the National Institutes of Health, looked at the effects of obesity on sperm quality. They determined that men who were overweight (high BMI) or has a high waist circumference had significantly lower sperm counts and significantly low semen volumes than men of normal weight. Other semen parameters such as motility (percent swimming), morphology (percent normal shaped) and DNA fragmentation (proportion of sperm with normal DNA) interestingly were unaffected.
Many IVF and fertility practices such as ours use a procedure called PICSI to help certain couples where we are concerned that there may be a problem with sperm quality even when fertilization is succesful with ICSI. PICSI relies on placing the sperm on a field hyaluronic acid and having the embryologist determine whether sperm are able to bind to it. Sperm which are immature or otherwise abnormal are less likely to bind to the hyaluronic acid, and so sperm which do bind to it are used for the injection into the egg for ICSI. We and others have found that it may help certain couples who have failed ICSI cycles or had miscarriages from ICSI cycles. However, to date there are no large studies yet showing how effective it is, so researchers at the University of Leeds in the UK have initiated a large study to determine this.
Patients are always asking me are there dietary changes they can make to enhance their chances for pregnancy. In the case of men with low sperm counts, the answer is often no. However, researchers from Harvard School of Public Health looked at men's diet and the quality of their sperm in a study presented at the American Society for Reproductive Medicine (ASRM) meeting. Interestingly, they found that men who consumed lots of processed meats such as bacon and sausage had poorer quality sperm and those who consumed lots of dark meat fish such as salmon and tuna had better quality sperm. While these findings are preliminary; the study size is small and the data has not been published yet, this does suggest that nutrition may play a real role in male infertility.
Assisted reproduction and particularly advances in fertility preservation procedures such as egg freezing has made it more likely than ever that men and women will have offspring born after they are deceased. A woman who freezes her eggs (or a husband his sperm) before chemotherapy may not survive the cancer. So what happens when those eggs or sperm are used to help the surviving partner or some one else conceive? This article in the NY Times explores the legal and financial issues that might arise.