Husband Has Severe Varicocele: Surgery or IVF?

Question:

My husband has a severe varicocele on the left. The sperm count is 0.8 million in total and has 5% motility after 1 hour. What should be our first option: should we do varicocele repair first or should we go for IVF/ICSI?

Thank you for your help in advance. S. from Illinois.

Answer:

Hello S. from Illinois,

The severely decreased sperm count is probably not from the varicocele but other factors. Several studies have shown that removing the varicocele make little difference, and so nowadays it is not recommended. Many Urologists will recommend it and do the procedure because that is the only treatment they can offer. I think most infertility centers will recommend proceeding directly to IVF/ICSI. That is what I recommend. Besides, if your husband goes through this surgery and the semen analysis is still abnormal, you will still have to go to IVF with ICSI.

Why not go to your infertility clinic directly and get pregnant? :)

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Testicular Biopsy To Determine Absence of Sperm Prior To TESE & IVF

Question:

Dear Dr. Ramirez,

My husband was born with exstrophy of the urinary bladder (in 1965 before some of the advances in that area), and as a result has had numerous surgeries, etc. He believes he used to have normal ejaculation before a major surgery in 1990; he does not now (none at all). A number of years ago (before we were married), he had a fertility test that involved opening the testicles (I don't remember what it was called), but the doctor failed to find sperm. His current urologist thinks he should give it another try. Which leads to my questions:

1. Is it likely to succeed (my husband said it was extremely painful)?

2. If they do find some sperm, do we need to be ready for IVF immediately? (This is a big issue for us, since IVF is much more expensive than something like IUI with donor sperm, so we'd need to save up for a while. Also, I don't want to have to take fertility drugs unless absolutely necessary, which would be the case with IVF.)

Thank you so much. I've gotten a lot out of reading your answers to other questions.

Answer:

Thank you for the compliment and for your question.

I think that the testicular biopsy would be a good thing to do. The Urologist needs to make sure that all quadrants of the testicle are biopsied to check for sperm. Of course, if the first biopsy shows sperm then he doesn't need to continue further. Because of this, it would be best that an andrologist, a sub-specialist urologist who treats male infertility and sexual disfunction, were present to examine the sperm immediately. It is not necessary for the test, but can avoid all the extra biopsies.

The biopsy is important because this is going to determine if sperm can be harvested from your husband's testicles, which can then be used to inject into your eggs via IVF. That would lead to a genetic child for your husband. Since testicular sperm is not the same (i.e. not activated) as sperm that is ejaculated, it cannot be used in conjunction with an IUI. You would need to do IVF with TESE and ICSI, which can be expensive, so you have to decide if it is important for you to have a child with your husband's genetics. If it is not important, certainly IUI with donor sperm is cheaper.

Fertility drugs are given with IVF to maximize the number of eggs that are retrieved and fertilizable. This is necessary because not all the eggs that a woman has are good eggs. There are no known long-term side effects, problems or complications with taking the fertility drugs, so you don't need to worry about that. The biggest problem is the cost, and the fact that they are injections.

Finally, you don't need to proceed with IVF immediately after the testicular biopsy is done. The testicle can be rebiopsied at the time of the egg retrieval. In fact, they need to coincide. We usually do the TESE under conscious sedation so that it is more comfortable for our patients, because we use conscious sedation for the egg retrieval as well.

I hope that helps. Good Luck to you and your husband.

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

When is IVF used instead of IUI for Male infertility?

Question:
I was wondering when ivf is used instead of iui to start when male infertility is involved. What do the stats have to be (count, motility, etc) in order to say iui isn't an option?
　
What are the stats for iui and ivf. Do most women get pregnant using ivf?

Answer:
Hello Bill from the U.S.,
　
IUI and IVF are completely different treatments with significantly different pregnancy rates.
　
IUI is a "natural" treatment option in that the body has to do the same natural processes in order to achieve pregnancy. As such, the highest pregnancy rates are 24% per cycle and drop significantly after four attempts. IUI is mainly used when an ovulation induction/timed intercourse treatment fails or if there are "mild" sperm abnormalities. IUI accomplishes one of the steps required for pregnancy. It gets the sperm into the tube to await the egg, but also helps by timing ovulation better. Usually, it would be indicated with any of the following:
1. Count between 10 -20 million
2. Motility between 30-60%
　
IVF is not a natural treatment option because almost the entire process is taken out of the body. The only "natural" parts of the process are ovulation induction in the ovary, embryo hatching in the uterus and implantation. Because of these remaining "natural" processes, there is not a 100% pregnancy rate. Pregnancy rates are very dependent on the age of the eggs. In under 35 year olds, pregnancy rates are now up to 70+% per cycle attempt and go down from that age group. At 43+, it is 25% per cycle. With IVF, the ovaries are stimulated to growth many eggs, the eggs are aspirated from the ovaries, fertilization then occurs in the laboratory where the sperm are added or injected into the eggs, the fertilized eggs are allowed to grow into embryos and the embryos are placed back into the uterus. IVF accomplishes 6 of the 9 steps required to produce a pregnancy. Hence, it has a higher pregnancy rates. In terms of male factors, except for no sperm, IVF can be accomplished with any level of sperm abnormalities and is directly indicated when the findings are severe i.e. less than the above parameters including morphology less than 30%. TESA (trans-epididymal sperm aspiration) is a new technique for men that don't show any sperm in a semen analysis, but have sperm production within the testicle. In this procedure, sperm can be extracted directly from the testicle and used to inject directly into each egg. You only need enough sperm for the number of eggs that a present. So, even if a semen analysis shows no sperm, there is still the possibility of a genetic child with this technique.

If there is no sperm on semen analysis, and you can't afford IVF/TESA/ICSI or don't mind not having a genetic child, then IUI can be done with donor sperm. Donor sperm usually costs approximately $500 per specimen, so the overall treatment cycle would cost approximately $3000 per month of trying.
　
I hope this answers your question.
　
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.blogger.com/www.montereybayivf.com
　
Monterey, California, U.S.A.
　
for additional information check out my blog at http://womenshealthandfertility.blogspot.com/ check me out on facebook and twitter with me at @montereybayivf