Can science give us some new Signposts?

The whole subject of research into Male Infertility has been slow to develop, but for the first time in my long career, there is some light beginning to penetrate the gloom of failed ICSI cycles.

I have just returned from two exciting trips, the first from the American Urology Association in Chicago, and the second from Scientists in Ireland who have great experience in looking at the human microbiome in health and disease. So, What’s New?

Improving DNA Quality

At the largest annual International meeting of Urologists in Chicago, we reported our recent experiences with improved DNA quality of Sperm removed from the testicles, and how, in the future we might be able to predict more accurately, which men may benefit most from this approach.

Oxidative stress (OS) is thought to be the pathologic molecular mechanism underpinning the majority of known clinical, environmental and lifestyle causes of male infertility. It is associated with varicocele, genitourinary tract infection, prostatitis, obesity, tobacco smoking, endocrine imbalance and testicular dysfunction. It is something not to be easily dismissed.

There was general agreement about the adverse effects of oxidative stress on sperm function and quality, and that this is related to inflammatory processes in the genital tract.

Treating Varicoceles

Worldwide a consensus is developing about the need to treat Varicocoeles; I suspect that T

the American Guidelines, broadly in favour of treatment, will be strengthened.

Although varicoceles are frequently encountered in Urological practice, the effects of varicoceles on male infertility remain a subject of much debate. While the controversy of whether varicocele treatments improve natural pregnancy rates has been widely debated, it is now clear that they can have more far reaching effects on fertility potential in the male including effects on testosterone and sperm DNA fragmentation, with the potential to actually reverse azoospermia with varicocelectomy.

As a group of us suggested in a report published in April this year, the UK will have to update and improve their current unhelpful view.

The importance of Lifestyle

Nutrition, weight loss, exercise and the relationship of these lifestyle issues to levels of testosterone were reported and debated in several different contexts. The Americans have always had a more inclusive view of the importance of testosterone to male health in general, and I was pleased that for the first time in my career there was a comprehensive review of the uniformly bad and often disastrous effects of all forms of anabolic steroid abuse (ASA). In fact we do have worrying statistics about ASA from the UK; the office for national statistics reported that 4.5% of males were using steroids (other than on prescription).

The part that genetics may play

Until very recently we have lacked understanding of the fundamental mechanisms for men  ‘programmed’ to have low and sometimes zero Sperm counts. Researchers have now identified more than 1000 genes which may be responsible for the proper development of the testicles, and of the different cells which contribute to the ‘production line’ in the testicle. Through this branch of science, known broadly as ‘genomics progresses’, we will be able to modify the codes and messages which drive production, and get closer to being able to direct primitive cells to become useful ‘gametes’ which, despite hints in the media, we certainly cannot achieve in humans at present.

Low Sperm production – affect and treatment

A subject very close to our own current research was presented by the excellent group from Milan. The possibility that Sperm production can be affected by a collection of microorganisms (a microbiome) was convincingly reported in some early, but I suspect very important human studies.

A potential important advance in the practicalities of treatment came from Cornell in New York, where Scientists have developed a technique that can detect very small numbers of sperm, both in ejaculated specimens and from Micro Tese (the tiny tubules that are removed surgically). At present this is very early days, and data from only a few cases were reported.

The importance of Semen analysis

However this does underline the qualitative nature of almost everything we do. Semen analysis and to a certain extent ICSI itself is a craft, this is not in any way to belittle the many extremely talented practitioners of the art whom I rely upon almost daily, but it is clearly time to open our minds to technical and scientific innovations and to share these widely.

The notion that you cannot proceed with a cycle of treatment without “x” number of sperm was quite reasonable 10 or even 5 years ago. However, if we can now select good quality sperm, we may only need the same number as we have eggs.

Looking ahead

So our understanding is proceeding very rapidly. And treatment strategies, rather than universal reliance on IVF and ICSI, are now not just debated but are gaining worldwide acceptance.

But perhaps most importantly doctors and scientists are talking to each other worldwide… it’s certainly a ‘movement’ and perhaps even, a ‘revolution’.

Can science give us some new Signposts?
Jonathan Ramsayhttp://www.jonathanramsay.co.uk/
Jonathan Ramsay has developed a large practice in male fertility for over 30 years. He has been a Consultant Urologist at Hammersmith, Charing Cross and Chelsea & Westminster Hospitals since 1988 and is a visiting urologist to fertility clinics in Buckinghamshire, Sussex, and Central London.
Can science give us some new Signposts?