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.
One of the chief concerns couples have is the about the safety of the procedures that fertility specialists use to help them achieve pregnancy, such as IVF (In vitro fertilization). Most of us in the field know that serious complications to the mother-to-be can occur but are quite rare. A recent study with the lead author from Emory University looked through nationwide database of IVF clinics across the country over the past 12 years, and confirmed that while IVF does entail risks for women, those risks are quire small.
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.
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.
This is one of the most common questions patients ask their fertility doctors and/ or their OBGYNs. Fortunately the short answer is no and this is backed up by large research studies. While their purpose may be to prevent pregnancy, the contraceptive effect of the pill wears off rather quickly. In some women the return to normal cycles and fertility can take a number of months, but usually there is not much of a delay. In other women, such as those with ovulation disorders such as PCOS, coming off the pill may actually increase the chances for conception. If your cycles have not regulated themselves 6 months after stopping the pill or they are becoming less regular over time after then and you’re trying to get pregnant, it’s probably not the pill, and it’s time to discuss this with your GYN or fertility specialist.
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.
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.
With stories of 45 year celebrities having babies (and sometimes even twins and triplets) with high tech treatments, most people think that age is not a barrier to successful treatment. When using donor eggs from a young egg donor, that is definitely true. The chances for success with donor egg ivf is excellent, even for women in their late 40’s. However that is not the case in women using their own eggs. Pregnancies in women undergoing fertility treatment without the use of a donor over 45 are very unusual. A recent report from Florida describes a 46 year old woman who is reported to be oldest woman to conceive from IVF with her own eggs. Is this a major breakthrough? Not really. The main determinant over whether a fertilized egg will develop into a healthy baby is whether the embryo is genetically abnormal. Genetically normal embryos are common in 25 year olds but pregnancy rates are never 100%. Likewise, the vast majority of 45 year olds’ embryos are abnormal, and so the pregnancy rates would be expected to be quite low but not exactly 0%. When confronted with these odds, most couples would chose not to try.