Varicoceles are a collection of varicose veins around the testes much more commonly on the left and are present in between 4 and 22% of all men. However if men with primary infertility are examined then between 21 and 41% have varicoceles and men with secondary infertility have an even higher incidence. Varicoceles may run in families and may worsen with time.
The association between varicocele and male infertility has been hotly debated for the last 50 years. Recently the world of science has changed its view and is now saying that repair of a varicocele which is of moderate to large size is a useful exercise in men with fertility issues.The choice of repair either surgical or radiological is also up for debate.
Varicoceles are thought to impact on sperm health by increasing the temperature of the testes. The increased pressure in the veins may cause reflux of toxic adrenal and renal metabolites into the testes along with chronic vasoconstriction of arterioles. This leads to under perfusion, stasis and hypoxia, and subsequent dysfunction of the spermatic epithelium . There is also evidence that DNA damage to the sperm is higher in men with varicoceles and that this reduces after ligation.
So what does this all mean? Men should be examined for the presence of varicoceles particularly when their semen analysis is abnormal or their DNA fragmentation level is raised.
Tuesday 13 November 2012
Saturday 23 June 2012
Selecting Great Sperm
We are excited to be getting a technology called IMSI up and running in the next few weeks. IMSI stands for Intracytoplasmic Morphologicall Selected Sperm Injection. In an normal ICSI cycle the embryologist selects the sperm for injection at a magnification of 400x however IMSI is where sophisticated optics allows a magnification of 7000 to 8000x therefore enabling a much better look inside the sperm to select sperm without vacuoles within the nucleus. A recent meta analysis suggested that both implantation and pregnancy rates may be improved over conventional ICSI by 2 to 3 times with reduced miscarriage rates.
As yet it is not clear who may benefit from this technique possibly men with 2 previous failed ICSI cycles, poor embryo quality or poor sperm morphology or high levels of DNA fragmentation. The technique is time consumptive for the lab staff and will add about another $750 of cost.
We expect to offer IMSI by mid July and will announce its introduction on our website. It will be available initially through our Auckland Clinic only.
As yet it is not clear who may benefit from this technique possibly men with 2 previous failed ICSI cycles, poor embryo quality or poor sperm morphology or high levels of DNA fragmentation. The technique is time consumptive for the lab staff and will add about another $750 of cost.
We expect to offer IMSI by mid July and will announce its introduction on our website. It will be available initially through our Auckland Clinic only.
Sunday 10 June 2012
What to eat during an IVF cycle
I had always assumed that women knew what was a healthy diet and that they followed the general principles when going through an IVF cycle because they knew this would increase their chances of conceiving and also that their child would have improved lifelong health outcomes. However recent work has shown that women often eat poorly during their IVF treatment with many not having enough folic acid, iodine, carbohydrate or protein in their diet, with many still consuming caffeine and alcohol along with too much fat, salt and convenience foodc.
So this is a blog about what women should be eating when doing IVF treatment. Firstly, adequate folic acid supplementation which means 0.8mg daily and if a woman has a BMI above 30 then she should be taking 5 mg folic acid. The folic acid story is really confusing as many of the pregnancy supplements don't have the correct dose. The next absolute is to remove caffeine and alcohol from the diet, caffeine can be difficult as is present in a number of beverages not just coffee, such as tea, green tea, chocolate. coke and energy drinks. The NZ Ministry of Health Guidelines suggest women who are pregnant should be eating 6 serves of fruit and vegetables, two servings of lean protein, six servings of bread and cereals (preferably wholegrain), three servings of dairy (low fat yoghurt, trim milk), drink plenty of fluids, choose and prepare foods low in fat, salt and sugar. Here are the Ministry of Health Guidelines . So eat well!
So this is a blog about what women should be eating when doing IVF treatment. Firstly, adequate folic acid supplementation which means 0.8mg daily and if a woman has a BMI above 30 then she should be taking 5 mg folic acid. The folic acid story is really confusing as many of the pregnancy supplements don't have the correct dose. The next absolute is to remove caffeine and alcohol from the diet, caffeine can be difficult as is present in a number of beverages not just coffee, such as tea, green tea, chocolate. coke and energy drinks. The NZ Ministry of Health Guidelines suggest women who are pregnant should be eating 6 serves of fruit and vegetables, two servings of lean protein, six servings of bread and cereals (preferably wholegrain), three servings of dairy (low fat yoghurt, trim milk), drink plenty of fluids, choose and prepare foods low in fat, salt and sugar. Here are the Ministry of Health Guidelines . So eat well!
Sunday 27 May 2012
Monday 7 May 2012
Birth Defects and IVF
There has just been an article published in the New England Journal of Medicine concerning this issue which is why I thought the subject deserved a blog. This paper showed an association between babies born from assisted reproductive technologies having a slightly increased risk of birth defects. What was important about this study is that it also looked at couples who had fertility issues but who managed to conceive spontaneously. This is valuable as we all want to know is this observed association due to the drugs and the lab processes involved in an IVF programme or is it due to the possibly suboptimal sperm and eggs which are causing a couple's infertility. This new study showed a similar increase in birth defects in couples with infertility who then conceived without treatment. This is a new finding.
They also found that the increase in birth defects was in children born after ICSI but not IVF. Children born from frozen and then thawed embryos showed no increase in birth defects even when they were from ICSI cycles. Possible explanations for this include a reduced chance of a suboptimal embryo surviving the thawing process or the absence of ovarian stimulating drugs.
It is really important that all people going through fertility treatments are aware of these findings and can make real informed decisions about their options going forward.
They also found that the increase in birth defects was in children born after ICSI but not IVF. Children born from frozen and then thawed embryos showed no increase in birth defects even when they were from ICSI cycles. Possible explanations for this include a reduced chance of a suboptimal embryo surviving the thawing process or the absence of ovarian stimulating drugs.
It is really important that all people going through fertility treatments are aware of these findings and can make real informed decisions about their options going forward.
Saturday 21 April 2012
IVM or IVF without drugs
We are excited to start In Vitro Maturation at Fertility Associates. This is a technique in which immature eggs are removed from the ovaries and matured in the lab, injected with sperm and the resulting embryos replaced in the uterus. The technique is best suited for women with polycystic ovaries who have difficulties with standard stimulation drugs. It means that women do not have to use the hormone injections or risk ovarian hyperstimulation syndrome.
It has been around for a while but pregnancy rates have been modest so not many IVF units have been interested in pursuing IVM. There have been improvements in culture processes in the lab and a better understanding of physiology mean that pregnancy rates have looked better.This is why we were keen to get started with IVM.
We don't know yet about the results of the first cycle but are are delighted to be continuing our history of firsts in NZ with reproductive technologies.
If you'd like to know more about IVM, please email Fertility Associates on info@fertilityassociates.co.nz
It has been around for a while but pregnancy rates have been modest so not many IVF units have been interested in pursuing IVM. There have been improvements in culture processes in the lab and a better understanding of physiology mean that pregnancy rates have looked better.This is why we were keen to get started with IVM.
We don't know yet about the results of the first cycle but are are delighted to be continuing our history of firsts in NZ with reproductive technologies.
If you'd like to know more about IVM, please email Fertility Associates on info@fertilityassociates.co.nz
Wednesday 14 March 2012
Ureaplasma and Miscarriage
Two studies have suggested that a male infection with ureaplasma may increase the risk of miscarriage after ICSI treatment. Ureaplasma is a bacteria which may grow in the reproductive tract. It is notoriously difficult to grow in the lab and so is seldom tested. There are no symptoms. We performed a study looking at how common ureaplasma was in our population. We asked all men having a semen analysis if they were happy to be tested for this.18% of men were positive. The study was tricky to do as we needed to taxi the samples to the lab immediately.
At Fertility Associates we have decided to ask all couples starting IVF to take a single dose of azithromycin (an antibiotic) as a precautionary measure. Many IVF clinics world-wide give prophylactic antibiotics to the man and woman prior to IVF treatment, so the concept is not new. Although ureaplasma may impact more on the outcome of an ICSI cycle, we decided to treat all people doing IVF as well, as there are some circumstances when ICSI may be required because of sperm quality on the day of egg collection.
Read more about Ureaplasma and Azithromycin in our Fertility Facts sheets here
At Fertility Associates we have decided to ask all couples starting IVF to take a single dose of azithromycin (an antibiotic) as a precautionary measure. Many IVF clinics world-wide give prophylactic antibiotics to the man and woman prior to IVF treatment, so the concept is not new. Although ureaplasma may impact more on the outcome of an ICSI cycle, we decided to treat all people doing IVF as well, as there are some circumstances when ICSI may be required because of sperm quality on the day of egg collection.
Read more about Ureaplasma and Azithromycin in our Fertility Facts sheets here
Saturday 25 February 2012
Fertility and Cancer
Fertility and cancer are subjects that many would not associate with each other but increasingly as cancer treatments are improving, then survivors are living with the consequences of their cancer treatments and for some this means infertility. There are an increasing number of options which are being offered so this blog is an overview of all of the options and what may be coming in the future.
So, I am going to separate the options for men and women. Men first. Freezing of sperm has been successful since the 1950s and in NZ sperm freezing prior to chemotherapy, surgery or radiotherapy is free. Men need however to be told about it ! The sperm may not be of good quality and ICSI may be required into the future. Occasionally no sperm is seen in the ejaculate and then sometimes testicular retrieval of sperm is offered. Studies have shown that less than 10% of men will request that this sperm is used into the future, as some will have normal fertility and some will not choose to parent, but at least if there is sperm frozen, then those men have the option.
Prepubscent boys are in a more difficult space. Those boys have not yet developed mature sperm producing cells in their testes and there is much debate whether testicular tissue should be stored in the hope that technology will develop so this tissue may produce usable sperm. At present in New Zealand this is not offered.
For women the choices are harder. The first option is to get on with the cancer treatment and then consider choices such as donor egg treatment or surrogacy in the future. For some women who are receiving radiotherapy to their pelvis, their ovaries can be moved away from the field of radiotherapy. Other women have the time to undergo a round of IVF treatment prior to starting chemotherapy and the eggs or embryos frozen for their future use. For others, then storage of ovarian tissue may be an option. This is where a part or whole ovary is removed, sliced into fine pieces and then frozen. The frozen tissue may then be thawed and replaced into the woman's pelvis. So far 19 pregnancies have been reported from this technology, so still early days. There are also some concerns around the chances of some cancer cells being present in the ovarian tissue.
There has also been some interest in a group of drugs called gonadotrophin-releasing hormone analogues as they may have a protective effect on the ovaries if used during chemotherapy. There are conflicting reports as to how useful these drugs may be and further studies are awaited. For girls, the only option is ovarian tissue storage.
All people who are facing cancer treatments and who have not completed their families should be given the option of a consultation with a fertility specialist so they can make some informed decisions, as once the cancer treatments have commenced, then it may be too late to preserve fertility.
So, I am going to separate the options for men and women. Men first. Freezing of sperm has been successful since the 1950s and in NZ sperm freezing prior to chemotherapy, surgery or radiotherapy is free. Men need however to be told about it ! The sperm may not be of good quality and ICSI may be required into the future. Occasionally no sperm is seen in the ejaculate and then sometimes testicular retrieval of sperm is offered. Studies have shown that less than 10% of men will request that this sperm is used into the future, as some will have normal fertility and some will not choose to parent, but at least if there is sperm frozen, then those men have the option.
Prepubscent boys are in a more difficult space. Those boys have not yet developed mature sperm producing cells in their testes and there is much debate whether testicular tissue should be stored in the hope that technology will develop so this tissue may produce usable sperm. At present in New Zealand this is not offered.
For women the choices are harder. The first option is to get on with the cancer treatment and then consider choices such as donor egg treatment or surrogacy in the future. For some women who are receiving radiotherapy to their pelvis, their ovaries can be moved away from the field of radiotherapy. Other women have the time to undergo a round of IVF treatment prior to starting chemotherapy and the eggs or embryos frozen for their future use. For others, then storage of ovarian tissue may be an option. This is where a part or whole ovary is removed, sliced into fine pieces and then frozen. The frozen tissue may then be thawed and replaced into the woman's pelvis. So far 19 pregnancies have been reported from this technology, so still early days. There are also some concerns around the chances of some cancer cells being present in the ovarian tissue.
There has also been some interest in a group of drugs called gonadotrophin-releasing hormone analogues as they may have a protective effect on the ovaries if used during chemotherapy. There are conflicting reports as to how useful these drugs may be and further studies are awaited. For girls, the only option is ovarian tissue storage.
All people who are facing cancer treatments and who have not completed their families should be given the option of a consultation with a fertility specialist so they can make some informed decisions, as once the cancer treatments have commenced, then it may be too late to preserve fertility.
Wednesday 1 February 2012
Donor Sperm
We have just launched a campaign to increase the recruitment of sperm donors. We have deliberately gone with an edgey feel so as to generate some hype and media interest. With slogans such as 'come one come all' and 'give it a shot' then there has been a pleasing amount of interest and after the first weekend 6 potential new donors contacted the clinic yay!
Our donor sperm programme has changed dramatically over the last 10 years. Now more than 90% of those on our waiting list are single or gay women with the number of heterosexual couples becoming very much the minority. This reflects the improvements that have occurred in the treatment of male infertility along with changing social trends seen in our society. Women in their 30s outnumber men and many have not been able to find a suitable life partner and are aware of their biological clock and are choosing to parent alone. We never have sufficient sperm donors to meet the demand and many women are forced to wait for more than a year before a suitable donor is able to be found.
Potential sperm donors need to be in good health, be aged less than 45 and have no known genetic disorders. They also are required to be identifiable and understand that most children born as a result of sperm donation will want to make contact with their donors at some stage in their lives.
Our donor sperm programme has changed dramatically over the last 10 years. Now more than 90% of those on our waiting list are single or gay women with the number of heterosexual couples becoming very much the minority. This reflects the improvements that have occurred in the treatment of male infertility along with changing social trends seen in our society. Women in their 30s outnumber men and many have not been able to find a suitable life partner and are aware of their biological clock and are choosing to parent alone. We never have sufficient sperm donors to meet the demand and many women are forced to wait for more than a year before a suitable donor is able to be found.
Potential sperm donors need to be in good health, be aged less than 45 and have no known genetic disorders. They also are required to be identifiable and understand that most children born as a result of sperm donation will want to make contact with their donors at some stage in their lives.
Thursday 12 January 2012
Fertility Tourism
We have all become travellers with cheaper airfares and now with the internet the whole world has become accessible and this has effected change in the fertility world. Many people are exploring options offshore when locally their needs are not being met.
Mostly people are travelling because they cannot find an egg or sperm donor. A few travel in the quest for surrogacy or because they perceive that better technologies may be available elsewhere.
With regards to sperm donation, then prior to the introduction of the HART act in NZ in 2004 then it was possible to go on line to most American sperm banks, select your favourite sperm donor profile (maybe 6 foot 2 inches, tanned with green eyes and a lawyer) and get the sperm shipped down. Now it is illegal to import sperm where the donor has been paid. So this means going there. However there are some real downsides to going to an overseas clinic for sperm donation and not just about the cost. The real downside is around losing the upside of the HART act, which allows the child to contact their donor into the future. The other huge drawback is that your donor may already have tens or even hundreds of offspring. It is also hard to know how well the donors have been screened for infectious and genetic diseases. Also many overseas clinics have a much more aggressive approach to multiple pregnancies. At Fertility Associates the current wait time for a clinic recruited sperm donor is around 10 months and for a sperm donor in an IVF programme it is only 3 months, so would I encourage offshore sperm donation? It's a no from me.
Egg donation is a little different. It is all about age in the world of egg donation so the younger the egg donor the more likely that a baby will result from her eggs. There are many countries where it is legal to pay egg donors (not in NZ or Australia) which has encouraged a thriving industry around young women effectively selling their eggs. There are some risks to the egg donor as a result of the egg donation process namely ovarian hyperstimulation syndrome, bleeding or rarely infection at the time of egg collection possibly resulting in infertility. Once again overseas egg donation often means that the process is anonymous, multiple pregnancies are more common and it is harder to be sure about the standards of the clinic. So if you are considering overseas egg donation I would encourage people to choose a reputable clinic, from a developed country and ask lots of questions. We have forged a relationship with the San Diego Fertility Centre as we know the doctors, have visited their clinic and are very satisfied with their standards of practice. Over the past year about 30 couples have travelled to San Diego and had egg donation and more than 70 % are now pregnant half with twins. The cost is huge around NZ$45,000 and any frozen embryos created cannot be imported back into NZ so more travel is required.
There is an argument around the exploitive aspects of egg donation but I think that is something that individuals need to resolve within themselves. My personal view is that provided a woman is 20 or more (so can vote, drink and fight for her country) and has been given appropriate information about the process of egg donation, counselling and the process is performed according to best practice, then compensation for egg donation is very reasonable.
Travelling for surrogacy is way harder as once the baby is born it is difficult or impossible to bring the baby back into NZ and arrange the adoption process.My advice is seek extensive legal advice before even considering this.
So if travelling overseas for fertility treatment is some you are considering, ask your local fertility specialists for advice, they will be able to give you a heads up around the process, good clinics and the legal aspects.
Mostly people are travelling because they cannot find an egg or sperm donor. A few travel in the quest for surrogacy or because they perceive that better technologies may be available elsewhere.
With regards to sperm donation, then prior to the introduction of the HART act in NZ in 2004 then it was possible to go on line to most American sperm banks, select your favourite sperm donor profile (maybe 6 foot 2 inches, tanned with green eyes and a lawyer) and get the sperm shipped down. Now it is illegal to import sperm where the donor has been paid. So this means going there. However there are some real downsides to going to an overseas clinic for sperm donation and not just about the cost. The real downside is around losing the upside of the HART act, which allows the child to contact their donor into the future. The other huge drawback is that your donor may already have tens or even hundreds of offspring. It is also hard to know how well the donors have been screened for infectious and genetic diseases. Also many overseas clinics have a much more aggressive approach to multiple pregnancies. At Fertility Associates the current wait time for a clinic recruited sperm donor is around 10 months and for a sperm donor in an IVF programme it is only 3 months, so would I encourage offshore sperm donation? It's a no from me.
Egg donation is a little different. It is all about age in the world of egg donation so the younger the egg donor the more likely that a baby will result from her eggs. There are many countries where it is legal to pay egg donors (not in NZ or Australia) which has encouraged a thriving industry around young women effectively selling their eggs. There are some risks to the egg donor as a result of the egg donation process namely ovarian hyperstimulation syndrome, bleeding or rarely infection at the time of egg collection possibly resulting in infertility. Once again overseas egg donation often means that the process is anonymous, multiple pregnancies are more common and it is harder to be sure about the standards of the clinic. So if you are considering overseas egg donation I would encourage people to choose a reputable clinic, from a developed country and ask lots of questions. We have forged a relationship with the San Diego Fertility Centre as we know the doctors, have visited their clinic and are very satisfied with their standards of practice. Over the past year about 30 couples have travelled to San Diego and had egg donation and more than 70 % are now pregnant half with twins. The cost is huge around NZ$45,000 and any frozen embryos created cannot be imported back into NZ so more travel is required.
There is an argument around the exploitive aspects of egg donation but I think that is something that individuals need to resolve within themselves. My personal view is that provided a woman is 20 or more (so can vote, drink and fight for her country) and has been given appropriate information about the process of egg donation, counselling and the process is performed according to best practice, then compensation for egg donation is very reasonable.
Travelling for surrogacy is way harder as once the baby is born it is difficult or impossible to bring the baby back into NZ and arrange the adoption process.My advice is seek extensive legal advice before even considering this.
So if travelling overseas for fertility treatment is some you are considering, ask your local fertility specialists for advice, they will be able to give you a heads up around the process, good clinics and the legal aspects.
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