In the News...

I wanted to bring to your attention a couple articles that caught my eye recently. I found them pertinent to our discussions here and I hope you take the time to read them.

The first one is "How Older Parenthood Will Upend American Society" by Judith Shulevitz, which appeared in The New Republic:

It's a sobering read about how the graying of American parents is affecting the makeup of many generations to come. This article covers many aspects on this topic. The main one that jumped at me was the paradigm shift that has come as a result of the correlation between significant rise of children born with mental and physical disabilities (genetic mutations, autism, schizophrenia, etc.) and the increased age of the respective fathers. It appears that the proverbial ticking clock may no longer be limited to women, but now men need to become much more aware of when they choose the finally have children.

The other highlight for me was the obvious, nonetheless painful reality of the brevity of human life -- "A woman who is 35 when her child is born is more likely than not to have died by the time that child is 46." Many couples that I know undergoing IF treatments are in their mid-thrities. Somehow it feels completely normal -- after all, many are educated, professional men/women, who wanted to accomplish certain things before being surrounded by diapers. I wonder how it will affect the sociological conversations for the next generation in terms of caring for older parents at a younger age and future healthcare entitlements for the rest of us "older parents" (with dwindling numbers of babies, who will care for us and how will our care be payed for?).

The article does raise the question of IF treatments and its effects on the wellbeing of the next generation and the lack of regulation of this industry.

Which leads me to this next article: "Are Infertility Doctors Turning into Predatory Bankers?" by Peter Ubel, which appeared in Forbes:

This brief article covers the murky waters of the for-profit IF treatments (the more patients an RE has the more money he/she makes, thus possibly offer more treatments than necessary) and the kickbacks REs receive from referring patients to loan companies that are supposed to help pay for the exorbitant IF treatments.

This reminded me of two important topics that I always bring up: 1) Sadly while we look to our REs as these heavenly beings who are going to make our dreams come true, in the end, it is a business transaction. So if you are not getting 100% of your RE/clinic, you can always take your hard earned money elsewhere. And 2) we MUST continue to advocate for our cause and press our lawmakers to get insurance companies to provide greater/full coverage.

Male Factor Infertility (MFI) Follow-up

I've already shared with you the basics of male factor infertility (MFI) in an earlier entry (benchmarks, tests, general options), but a recent discovery is worth revising this topic.

According to this article in Scientific America, researches have managed to decode the human genome of a single sex cell. Unlike other cells, sperm and egg cells contain only a single set of chromosomes. This discovery will enable scientists to decode the genetic makeup of your partner's sperm. The hope is that it may finally give some answers to those suffering from "unexplained infertility" and will hopefully become part of the standard testing done during RE visits.

This sequencing of a full genome from a single sex cell, like the sperm (and maybe some day the egg), is expected to become available for infertility lab uses within the next five years. In the meantime, there a few options that are worth mentioning:

• PICSI: While ICSI is commonly used in fertility clinics, surprisingly PICSI is not as prevalent. In essence, PICSI is a sperm selection method that allows embryologists to select sperm beyond just their appearance (remember morphology and motility of the sperm?) and then be ICSIed (yes, I used it as a verb!). This method entails placing the sperm in a dish that contains Hyaluronan. This is a substance found in the cells around human eggs -- and in other tissues. The theory is that mature and most importantly sperm with good DNA will bind to the Hyaluronan, hence be selected for ICSI. For what it's worth, we used this method at our last IVF cycle at CCRM. 

• SCSA: This is another test available, perhaps closest to this new discovery, that allows us to find out more about the DNA of the sperm. SCSA (Sperm Chromatic Structure Assay) is a sperm DNA fragmentation test. In other words, it looks to find any "breaks" in the DNA of the sperm, which can be one of the reasons behind recurrent miscarriages -- sperm and egg meet, embryo is formed but quickly dies because of fragmented DNA. Now the question is, is it worth doing this test if ultimately even if the results came back positive for high fragmentation you (a) would continue to try using your partner's sperm, or (b) you would not consider using donor sperm? Those were the questions posed to us when we inquired about it with our RE. There may be value in testing if you are near the end of your rope and need to find closure.

With every discovery we seem to be coming closer to finding some answers for the millions of couples struggling with unexplained infertility and MFI. 

But like technological advances, scientific advances are very quickly replaced with other more promising discoveries. 

Would any of the above sperm selection options give you the closure you would need to stop pursuing infertility treatments if you found out that your partner's sperm just doesn't seem to make the cut?

Taking It Like a Man: Coping With MFI

MFI was one of the many issues that was preventing us from having children. Unlike what I expected, DH handled it rather well. Sure his ego was bruised and he experienced lots of conflicting emotions (especially when I brought up using donor sperm), but he made it clear that we were partners on this journey and that he will do what ever he can to make it happen for us. He made some dietary and lifestyle changes (no laptops on the lap, lots of multi-vitamins designed to help sperm production and quality). Most importantly, he showed-up; he was always by my side, he changed his meetings around in order to take care of me post egg retrieval, heck, he even came out to Denver with me so that I wasn't alone during that cycle. I asked him to briefly share what the experience was like through his eyes and what advice he had for other men. You can read his thoughts below. 

I realize that not all partners are going to be as resilient in the face of this news, so here are a few suggestions on how to help him cope (and keep your sanity): First, give him some space and don't nag. Men, as we well know, are not the most communicative creatures. They need to internalize things first, and that process takes a while. His silence should not prevent you from doing your own research and feeling pro-active. I certainly was the researcher in our case and when DH was ready, I would share with him everything I found out that day. I promise you that he will eventually be more apt to talk about it, but I guarantee you that he will shut down even more if you nag him. When he is finally ready to talk, share with him some of the options that are out there, along with blogs written by other men who are also experiencing MFI. He might say he doesn't have time, but I promise you that he will check them out when he's ready.

Secondly, when he is finally ready to talk, remember what you want to hear from people when you share with them your journey through infertility; you want to be heard, you want to feel comforted and the slightest callous comment is like a dagger through your heart. Well, behind that tough exterior, your partner feels exactly the same way, so while you might have to initiate the conversation, let him take it from there and air-out his frustration and insecurities. Also, consider seeing a therapist together. Sometimes, it helps to have a third-party facilitate -- a therapist's office is neutral ground and a place where you can truly listen to each other. RESOLVE offers a list of mental health professionals, which I encourage you to check out, even if you end up going by yourself to better communicate with your partner about his infertility issues. 

Lastly and perhaps most importantly, remember why you wanted this baby in the first place: you are happily married or in a loving relationship with your partner and you want to create a family TOGETHER. Sure you could get knocked up faster alone, using the sperm of a medical student who likes rock climbing and plays the piano, but this 23 year old is not going to be there for you when you're overwhelmed by parenthood. Again, it's about togetherness. So make a conscious effort to make time to stay connected. Go out to a romantic dinner (and don't talk about infertility!), meet for drinks after work, and make sure you remain physically connected. Having gone through the period of sex-on-demand, it's hard to reconnect sexually and leave the heavy baggage of infertility at the door. Especially if you're dealing with MFI, your partner may be feeling inadequate or "less of a man," if you will. It is partly your responsibility to show him that you still desire him and that you love him just as much as you did before you found out about his infertility. So, time to buy some lingerie and make reservations somewhere nice!

MFI is hard on everyone, but especially on your partner, so become his rock and let him lean on you. 

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Typically infertility is seen as a woman’s burden to bear, but if your experience is/was anything like mine, it’s plenty hard on men too. Sure, we’re not the ones with the burning maternal instincts. Nor are we the ones having needles shoved into every square inch of our bodies and begin to look like a bruised pincushion. We are, however, often times the ones who have to shove those needles in there. A task I personally found horrific, shoving a metal spike into my soul mate’s flesh EVERY day and watching her wince in pain, all because she wanted that baby so badly -- not fun.

But that’s almost the easy part compared to the coping and humiliation. Coping with the fact that the one thing your wife wants more than anything else in the world (including you) is a baby and you can’t seem to give that to her. The guilt and the pressure that swells inside of you borders on hate. You hate your wife for adding pressure (as if you needed any more), you hate the situation and most of all you hate yourself. This penis of yours that used to give you so much pleasure is now the bane of your existence.

Soon you’ll start jacking off into cups for analysis and popping pills to improve your “quality." Whatever the case, you will do what is necessary because all you want is for this to go away so you can get back to that life you both had intended on living.

Then, somewhere along the way, you lose yourself, forgetting that you are going through something too, and that your wife isn’t the only one who is suffering. But we are men, right? We’re supposed to be strong and fix everything and make this all better. But when you are this lost, how do you find your way back? Sad to say, but you have to put all of that on the backburner and go after this baby like it is the single most important thing in your life (because it should be). Literally everything hangs in the balance: your self-esteem, your focus, your marriage and your future. And I promise that if you do this, resolution will come. For some it may come as a successful IVF cycle or an adoption. While others may turn to donor sperm or living life as a couple, but as long as you have given all of yourself, leaving no stone unturned, you can look back and say, “I made this happen” and not “This happened to me.”

That’s what I did. At one point I literally took a month off of work and moved to Denver with my wife and dog so that we could go to the best IVF clinic on the planet. It even cost us tens of thousands of dollars of our own money, but one look at my son and it was worth everything. I never look back. And the best part is, I also feel like my marriage is infinitely stronger, because I showed her what I was willing to do for “us.”

Signed, Mr. Infertility Doula a.k.a. DH.

It Takes Two to Tango: Male Factor Infertility (MFI)

Infertility is a harrowing experience for a couple, but while as women we are able to talk about it (albeit within the comfort of anonymous chat rooms), men are often times much more isolated. Historically, being able to procreate often and with various partners is a big part of the male gender identity, so when the semen analysis numbers come back sub par, it's a very tough pill to swallow. And considering that 40 to 50 percent of cases of infertility are due to male factor, that's a lot of men who are silently suffering (2.5 million men every year!).

While some cases of MFI can be treated with lifestyle and dietary changes (you'll have to be patient with those as they take 3 months to see results), most cases are a result of the genetic malformation of the sperm. A basic semen analysis will give you a clear picture of where you stand. Most clinics and/or urologists go by the standards established by the World Health Organization -- below are the parameters:

• Normal seminal fluid volume (the amount of sperm in the sample) and concentration: 2-6 milliliters  in volume with a minimum of 20 million sperm per milliliter.  
• Sperm count should be greater than 40 million per sample.
• Motility (the number of alive and moving sperm) of at least 50 percent.
• Morphology (correct shaped sperm) of at least 30 percent. Most clinics go by a stricter Kruger test that requires that 12 percent of the sample must have perfect morphology.

In addition to the hard facts of a semen analysis, your partner should see a urologist who will check for physical (e.g. varicoceles) and hormonal abnormalities. He/She will suggest the necessary treatments to help alleviate the issues. Should the examination indicate Azoospermia (no measurable sperm in the semen), micro-surgery can retrieve sperm from the testes and the epididymis (technology is a beautiful thing).

There are a few paths that can present themselves as a result of these tests:

1. If your partner's semen analysis comes back within the ranges listed above or slightly below, you will most likely get the green light to attempt IUIs. 
2. But, if you are dealing with a more severe case of MFI, you will probably go down the IVF with ICSI road, where by the semen is cleaned and the best looking sperms are directly placed inside the oocytes. The 2008 SART member clinics results indicate that 64 percent of IVF cases involved the use of ICSI with 44.4 percent of those resulting in live births. Those are the kinds of numbers that give hope. A piece of practical information I'd like to impart is that if you are going to use your partner's already "fragile" sperm, use a fresh sample rather than a frozen one. Your success rate should be higher as a result of it (it's a different story if you're using donor sperm) -- this is purely anecdotal, but I have personally spoken to women who finally achieved success ones they started using fresh samples. 
3. A last option, and a difficult one to accept, is to use donor sperm (DS). This a low-tech and low-cost approach, but riddled with many emotional challenges for your partner (and for you) to come to terms with. I'll discuss it soon. Your clinic should be able to direct you to a sperm bank or have donor sperm profiles available to you. 

In upcoming entries I will discuss the emotional aspects of MFI; donor sperm; ICSI vs. PICSI and the bio-ethical conversations surrounding the use of ICSI.