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A1. Yes, pregnancies can be obtained. This kind of problem was what ICSI was developed to treat.

A2. Yes, it may be possible to retrieve sperm from the epididymus ('cause some sperm are making it into the ejaculate), but retrieving sperm from the testicles may be tricky. When patients have testiclular failure, sperm are produced only in a few areas (foci) within the testicle. Obtaining tissue from the right area is more a matter of luck than anything else.

As long as there are sperm in the ejaculate, the prognosis is not so bad. Since your husband's problem seems to be getting worse, don't waste any time seeking treatment.

Best of luck.

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Thanks so much!!

One follow-up question: one of my husband's testicles seems much firmer than the other, could this indicate that the firmer side would be a better candidate in which to find foci where spermatogenisis is still occuring? Should my DH mention this firmness -observation to the "new" urologist at the appt this week or will it be easily determined during the exam?

We are moving ahead as soon as possible due to my husband's diagnosis. I hope to begin bcp in Feb and IVF/ICSI in early March.

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The new urologist will perform a physical examination of the testes and "feel" it for himself. And, yes, that is the more likely side for spermatogenic foci.

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Dr. Smith- Thank you so much for all the great information and timely responses to my questions. You ROCK!

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[quote author=Hoping For ICSI Miracle link=board=6;threadid=1901;start=0#14228 date=1137798569]
Dr. Smith,

We just got my husbands second SA results adn they look pretty dismal to my untrained eye. Summary:

200,000 total sperm (not concentration), motility 0% morphology 0% Kruger Strict Criteria (of the 50 sperm analyzed) Some poorly motile/ non-progressive sperm observed. Predominant abnormality was amorphous heads, acrosomal defects.

We are working with an RE to do IVF/ICSI and my cycle was delayed due to the SA results. My husband is going to a second urologist to discuss the potential for TESA/MESA. His diagnosis is testicular failure with low serum testosterone and elevated FSH/LH levels. His first urologist did not specialize in male infertility and put my husband on testosterone injections in December (in spite of the fact that this doctor was told that we were looking into ICSI and I asked whether the testosterone could impair spermatogenesis!) We discontinued these injections in late December and are hoping that the recent SA results may have been made worse by the testosterone injection treatment. We are now seeing a urologist with infertility specialty.

We have a healthy 2.75 year old DD conceived naturally and 2 prior m/c and my husband also conceived a son in 1992 from his first marriage. It looks like his condition has either arisen recently or progressed signifcantly since 2002.

My RE would procede with ICSI if the quality of the sperm sample on egg reteival day at least the same as this recent SA but there is no room for it to get any worse.

My question are:
1. Have you seen ICSI success with such dire SA results- assuming that I will stimulate well and get lots of eggs with which to attempt fertilization.

2. Is it likely that there would be sperm available to retrieve via TESA or MESA given my husbands serum androgen/hormone levels and testicular failure diagnosis?

Thanks!
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HI THERE!!!!!!
I have just come across your message and wanted to add something for you that MIGHT help you conceieve????
My husband and i are seeing an AMAZING Doctor in Toronto and he has a 74% success rate for conception in one treatment!
We have friends that have two children byu him in two years. He is just wonderful...the TEAM is!!
If you want the name of this doctor i would be happy to share it with you. We are currently attending and about to start IVF...
We too have been througha difficult time. THIS IS THE DOCTOR FOR YOU...I SWEAR!!!!!!
Please let me know if we can help with the information alone, and perhaps you can go from there???
All the best,
Judith

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I agree with the urologist that the chances of finding sperm, either ejaculated or testicular, remain good. From the information you have provided, it would be highly unusual not to recover some usuable sperm on the day of the ER.

ICSI fertilization rates with testicular sperm are lower than ejaculated sperm (about 60% versus 80%). This is attributed to the "maturity" of the sperm. Sperm are not fully mature when they leave the testes (or when extracted from testicular tissue). The spend additional time maturing in the epididymus prior to ejaculation. During epididymal transit, the sperm undergoes many changes, including a modification to the way the DNA is packaged in the sperm nucleus. This modification improves the "fertilizability" of the sperm. When the sperm are denied this maturation process and taken straight from the testes, the "fertilization" rate is lower.

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Thanks you Dr. Smith!! One more follow-up question: we just received teh results of a second serum FSH level and it is now in the "normal" range (11.3 mIU/mL) this compares to a level >25 mIU/mL last November. We have not had an opportunity to discuss this with his urologist yet. Do you have any thoughts as to why his level would have returned to normal? Is this just expected fluctuation in testicular failure cases. We are puzzled by this result.

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I'm going to defer to the urologist on that one. I suspect that FSH values are variable in the early stages of testicular failure. As a follow up to your previous post, I should mention that fertilization with epididymal sperm is equivalent to ejaculated sperm, so I imagine that the urologist will try for epididymal sperm first (if there are no sperm in the ejaculate on the day of the ER), before going to testicular tissue.

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Dr. Smith,
Thank you for your previous responses to my questions above. As an update, we completed the fresh IVF cycle with 19 eggs retrieved, 12 mature, 8 successfully fertilized with surgically-retrieved testicular sperm (ICSI). We transferred two day 3 eight cell grade A (low/no fragmentation) embryos. Negative pregnancy result, but otherwise a good cycle given my age (40) and the use of testicular sperm. We froze four more embryos at day 3: 8A, 8B, 6A, 6B and discarded the remaining two (high fragmentation). We are planning a non-medicated frozen transfer next month and will thaw all four and transfer all survivors. Given that we are planning to transfer all thawed survivors, is there any good reason to try to grow the day 3 embryos to blastocyst first? Also, would you recommend assisted hatching (there was no thickened zona layer prior to freeze)? What are the argument(s) against AH? Would you consider the increased risk of monozygotic twinning from AH to be statistically significant? What about the risk of physical damage to embryo?

Lastly, while I have your ear, could you explain 6 cell embryos? My understanding from biology courses (many years ago) is that all cells split simultaneously in early embryonic development, so embryos should go from 4 to 8 cell stage directly. I am puzzled by 6 cell embryos, not to mention the odd numbers, like 5 or 7 cell (post-division cell loss?)

As always, thank you for dedicating your valuable time to this invaluable forum.

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The advantage to thawing and waiting until the embryos reach the blastocyst stage would be in knowing that the transferred embryos had reached the point of development when they aquire the ability to attach and implant. Thawing Day 3 embryos and immediately transferring the survivors would not answer that question. I think that's an important question in your case as the percentage of embryos that reach the blastocyst stage is significantly reduced when testicular sperm are used. These embryos tend to arrest development at the compacted morula stage, immediately prior to the blastocyst stage.

The jury is still out on the benefits (or lack thereof) of AH on Day 3 embryos. We routinely hatch blastocyst stage embryos prior to transfer, as this mimics the timing of the natural hatching process. We have seen an improvement in implantation rate following AH of blastocyst stage embryos. The current thinking is that the indications for AH for Day 3 embryos is (1) >38 years old, (2) FET, (3) previous IVF failure. Since you qualify in all three categories, I'd say go ahead and do AH. There is no down side and, when performed by an experienced embryologist, no know risk to the embryos. The obseved increase in monozygotic twining attributed to AH has not been observed in other labs. Accordingly, I do not attach much credence to that report.

Contrary to what you learned in biology class (from that really cool time-laspe movie of starfish embryos dividing), mammalian embryos do not divide synchonously. It is the rule rather than the exception to see intermediate phases of division (e.g. 6-cell). Don't give it another thought; its normal. However, is also the stage at which genetically abnormal embryos arrest development, so if it stays at the 6-cell stage for more than 24 hours, game over.

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