Overall, I think it is a good time for males and their partners struggling with the awful trials of male infertility. There are certainly more specialists but there are also more advisers, coaches and sometimes ‘self-made’ experts. Therefore, access to all of these people is better and, as a result, awareness of this increasing problem is much improved.
Although access to this range of advisers is easy, you do need to be careful. It is such a desperate situation for so many of you that you want an appointment quickly, but just pause for a moment – if there is a long waiting list, there is probably a reason for this. In my practice, we are trying to prioritise cases, particularly those with no sperm – azoospermia - for whom the wait can be intolerable, so please let us know if this is the case and send a bit of your history with the appointment enquiry.
So what is new?
The research programme looking at ways of predicting better outcomes for sperm retrieval by measuring the cell-free DNA in an ejaculated specimen is almost complete, and the results are promising.
We are now collecting a significant amount of data about a different type of sperm DNA damage called double-strand breakage, and it seems to me that this is a better predictor of overall male fertility than are the standard tests which look at overall DNA damage. The double-strand breakage may be particularly relevant in failed IVF cycles. It seems, and it is early in our studies, that this double-strand damage is a more reliable indicator of unexplained male infertility than are the fragmentation tests used for the last 20 or 30 years. I suspect that this is why it has been so difficult to prove the predictive value of many of these assays.
It also seems – and again, this is an early prediction – that it is possible to select sperm without this double-strand damage. So far, we are using microfluidics for sperm selection (those sperm without the double-strand damage). This technique is promising, but we need to be sure that we are selecting the right sperm and, more importantly, we need to know why this defect occurs. Although it seems that we can reduce the double-strand breakage, the real test of success will only come when we know that doing this in a cycle of IVF and ICSI actually improves the live birth rate and, in order to prove an association, one does need a vast amount of data, and of course this means the passage of time.
I must thank all of you who have signed the consent form to allow my colleagues at Examen and Ulster University to study their sperm in more depth, to try to understand the basis of this form of DNA sperm damage.
The next question is why the microfluidic sperm selection seems to favour sperm without double-strand breakage. We have just started to look at the movement of sperm in three dimensions to see whether these better sperm can be selected, in the future, by this sort of computer analysis.
And finally, what about surgical sperm retrieval or micro-TESE – can we do better, and why do we fail in 50% of cases? Better ‘vision’ does help and the newest operating microscopes now available at the Lister Hospital and at the Avenues do make the surgeon’s job easier. Better processing of the specimens retrieved from the testicle is an equally, if not more, important issue and AI imaging techniques are just beginning to help us with this. But the real question is: what has gone wrong with the spermatogenic process in azoospermia, and can we do anything for those men who have failed a surgical sperm retrieval?
Well, my friend and colleague Paul Turek, who always thinks ‘out of the box’, has suggested the use of Isotretinoin, or Roaccutane, in these cases because vitamin A metabolism is involved in spermatogenesis. We do have to be careful, because Roaccutane has side effects and six months’ or more treatment seems to be necessary. But we do have to use this treatment sparingly, because it is easy to offer ‘hope’ to desperate couples and, although there are some data, we are miles away from having evidence.
So if you contact us, and by ‘us’ I mean my painstaking and loyal PA Alison, then please give us some of your details so that we can do our best to prioritise your appointment. Alison always keeps a list of those waiting for cancellations, and I am pleased to say that we are now able to see most of the new referrals within four to five weeks, and often much more quickly.
With best wishes to all of you who are still on their journeys, and I look forward to helping as many of you as possible and to hearing of any successes so that we can update our records.
