Lat­est news on the IVF front

A pro­ce­dure to help men with low sperm counts is one of the ground­break­ing new treat­ments for in­fer­til­ity

YOU (South Africa) - - CONTENTS - BY MARELIZE POTGIETER

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.

HOME PLAN

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.

AR­TI­FI­CIAL IN­SEM­I­NA­TION

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.

Sur­ro­gacy

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.

POSED PIC­TURE

In­tra­cy­to­plas­mic mor­pho­log­i­cally se­lected sperm in­jec­tion (IMSI) is a lab­o­ra­tory tech­nique used in in-vitro fer­til­i­sa­tion treat­ments.

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