Latest news on the IVF front
A procedure to help men with low sperm counts is one of the groundbreaking new treatments for infertility
NOT so long ago doctors told him his chances of making his wife pregnant were zero. But the Irishman and his South African wife refused to take no for an answer – come hell or high water they were going to have a baby together.
They went searching for other opinions until they found Dr Amir Zarrabi, an expert in male infertility and urologist at Stellenbosch University’s medical faculty.
And what he said was music to their ears. The 40-year-old man had been told he’d never be able to reproduce because he has nonobstructive azoospermia (NOA), a condition in which ejaculate contains no sperm. But Zarrabi said he knew of a way to help.
But he warned them it would be a gamble because the procedure had never successfully led to a pregnancy in South Africa.
It was a chance the couple, who live in Qatar, were willing to take. They travelled to South Africa in April for the procedure – and now the 37-year-old woman is pregnant.
“Everything is going well,” Zarrabi says. “They’re ecstatic.”
The intricate procedure was first performed in 1999 by New York-based Dr Peter Schlegel. It involves making a small incision in the patient’s scrotum and temporarily removing the testicles.
Then, using a microscope, the doctor searches the tiny tubes of the testicles – each about a 20th of a millimetre wide – for sperm.
Zarrabi has done the procedure before but each time it has failed – either because he was unable to extract sperm or because the subsequent in-vitro fertilisation (IVF) of the egg cell failed.
“I explain it like this,” he says, turning to his computer and opening two pictures. In one illustration a whole lot of factory workers are hard at work on the factory floor, producing goods. The other picture features the same factory floor but there are only a few men standing around, producing nothing.
“Schlegel figured out the factory [the patient’s testicles] that doesn’t work looks like this,” he says, pointing to the second picture of the unproductive factory floor.
“Sure, it’s deserted, but here and there is a worker. That’s the case for up to 65% of all men [who suffer from NOA].”
The average man’s ejaculate contains about 15 million sperm cells per millilitre. During the procedure he performed on the Irishman, Zarrabi managed to find fewer than 10 sperm cells.
The harvested sperm cells were sent to a fertility clinic where they were used to fertilise the wife’s egg cell in vitro.
Zarrabi says the couple were desperate for successful results as it was the second time they’d had it done. The man had undergone the procedure in 2017 but, although Zarrabi had managed to extract sperm the IVF was unsuccessful.
“Few people are prepared to go through it a second time but this couple insisted.
“It takes determination from the man’s side as the risk of injury to the testicles is greater a second time,” he explains. He says injury can disrupt testosterone production in the testicles, which is why it’s critical they’re handled carefully to ensure blood flow isn’t interrupted. The operation has no effect on erections and the pain afterwards is manageable, he adds. And now the procedure, which costs around R45 000, is offering new hope to men with a similar problem. It’s likely it will soon become increasingly accessible as more doctors are trained to perform it.
FERTILITY rates are down worldwide, says Dr Lizle Oosthuizen, a fertility expert at Cape Fertility clinic in Cape Town. These days as many as 15% of SA couples run into problems. “It’s partly because people are waiting longer before they start trying to have a family,” she says.
Tertia Albertyn (49) from Cape Town knows how it feels to struggle with fertility issues. She was 31 when she married Marko (now 45), a branch manager for a logistics company.
They started trying for a baby right away but after six months of failing to conceive she consulted a fertility expert.
“Nothing was ever really wrong with me except my menstruation cycle was a bit irregular,” she recalls.
First they tried artificial insemination but three rounds later there was still no joy.
“The day I decided I wanted a child it was as if a switch had been flipped in my head and nothing could turn it off again. It was something I felt in my whole being.”
With her first IVF, none of the egg cells was fertilised. The second time there was a problem with the egg cells. But they kept trying. Again and again.
On her eighth attempt she fell pregnant with twins, but one of the babies died in utero and the other was born at 26 weeks. He lived only 10 days.
Doctors weren’t able to identify anything specifically wrong with her and each time the pregnancy failed there was a different reason.
After losing her son, Tertia wanted to try to fall pregnant again immediately. “But the doctor said I needed to wait. Three months later I was back, ready to try again.”
After her ninth IVF she fell pregnant with twins again. Adam and Kate (now 13) were born at 36 weeks.
“I remember they put the babies in my arms. I just wanted to be sure they were alive, then I fell into a deep sleep.”
Four years later at age 40 Tertia fell pregnant without any fertility measures and later gave birth to Max (now 9). “I call him my bonus baby,” she says. “It was a terribly difficult journey, emotionally and physically. The procedures are also expensive. But I was willing to walk over broken glass to have a baby.” Tertia previously worked as a communications officer at a computer company but her experience led her to starting her own business, Nurture, which facilitates egg donation and receiving.
Why do so many people struggle?
Women become less fertile as they age, and from 35 fertility levels dip sharply, Oosthuizen says. “The risks of Down syndrome and other chromosomal abnormalities also increase,” she adds. Other reasons for infertility include endometriosis, uterine fibroids, damage to the ovaries due to either STDs or a variety of medical procedures, early menopause, low-quality eggs, polycystic ovary syndrome, failure to ovulate or abnormalities of the uterus. But these days 50% of the time fertility issues lie with men, Zarrabi points out. The results of an international study conducted at the Hebrew University of Jerusalem last year revealed sperm counts have dipped by more than 50% in the past 40 years. This can be attributed to environmental factors such as exposure to
These days as many as 15% of SA couples run into fertility problems
(From previous page) chemical materials, poisons and heat and lifestyle factors such as diet, stress, smoking and obesity, the study reported.
Higher rates of infertility are being seen in younger men who cycle or play certain sports and use steroids, says fertility counsellor Lizanne van Waart from Wijnland Fertility Clinic in Stellenbosch, Western Cape. “Testicles don’t like being too warm so we often advise men to stay away from taking hot baths and to avoid nylon underwear and long hours cycling.”
Other reasons for male infertility include a lower sperm count, impaired sperm function, producing no sperm and erectile dysfunction.
HOW INFERTILITY IS TREATED
There are various levels of interventions when it comes to infertility, says Dr Marienus Trouw, a fertility expert at Pretoria Fertility Centre.
“When people haven’t been trying for long, the approach will be different. For example, you’d look at their lifestyle and perhaps advise the man to take a folic acid supplement.
“You’d also look at the family history and determine whether there are any congenital conditions.”
He tries to make a diagnosis as soon as possible so he can work out a structured plan for his patients.
“If someone has damage to her ovaries that can’t be corrected surgically I’d recommend IVF. Someone with endometriosis might be helped with surgery but there are severe cases of endometriosis where IVF is the recommended choice.”
The cause is unknown in about 30% of all couples who struggle with infertility, says Dr Johannes van Waart, founder of Wijnland Fertility Clinic.
He says he’d typically put these couples on the home plan first (see below). If unsuccessful, this would be followed by artificial insemination, and finally IVF.
The price of procedures varies among clinics, and also depends on whether you go to a private clinic or public hospital.
This is usually the first step but can also be prescribed when it seems the problem is that the woman isn’t ovulating. It involves giving the woman medication to stimulate the ovaries to release two ovarian follicles.
The doctor determines when the woman is ovulating and the couple are advised when sexual intercourse should take place.
The chances of success on the home plan are between 6% and 8% per attempt and the plan is usually followed for four to six months.
It costs about R2 000 to R2 500 for the month when ovulation is monitored. During the following months the patient doesn’t need monitoring and just continues taking the medication.
This is when sperm is injected directly into the uterus using a thin tube.
It’s preceded by follicle stimulation but instead of waiting for the woman to ovulate naturally, she’s given an injection that brings on ovulation within 36 hours.
The man donates sperm, after which the healthiest sperm cells are identified under a microscope then used in the procedure.
“We’re bringing a better-prepared sperm sample closer to the target – but fertilisation happens naturally,” Johannes van Waart explains.
Chances of pregnancy are about 15% per cycle but the success rate drops after three failed attempts.
It costs about R8 000 to R11 000 a cycle.
IN-VITRO FERTILISATION (IVF)
This process happens in a laboratory where sperm cells are put in a petri dish with an unfertilised egg cell.
Once the egg has been fertilised, it’s implanted in the woman’s uterus, hopefully resulting in pregnancy.
IVF costs vary greatly and depend on factors such as the clinic, the techniques used and whether the patient wants to store extra egg cells, sperm or embryos.
It can cost between R40 000 and R68 000 an attempt.
Donor sperm, egg cells and embryos
Procuring donor sperm, egg cells and embryos can be done through either a fertility clinic or an agency.
This option is usually considered when there’s an insurmountable problem with the man, woman or both, explains Lizanne van Waart.
The donation process is entirely anonymous and none of the parties is told the identity of the donor or the recipient.
It’s illegal to trade in gametes, sperm or egg cells and the only payment allowed is to compensate donors for their time and effort.
Procuring donor sperm costs about R3 000, while the costs involved in procuring and implanting an egg cell can be anything from R70 000 to R100 000.
The costs of obtaining an embryo and placing it in the mother’s womb can be around R30 000.
A fertility clinic or agency can help you find a surrogate.
Legally there has to be a medical reason for a woman to choose to use a surrogate and there’s a legal process involved in surrogacy, Van Waart explains.
“The parents need to have at least one genetic tie with the embryo – either maternally or paternally – and a clinical psychologist has to declare them mentally fit to undergo the process.”
The total cost of surrogacy, including implanting the embryo, is around R150 000.
Intracytoplasmic morphologically selected sperm injection (IMSI) is a laboratory technique used in in-vitro fertilisation treatments.