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Fertility preservation for male patients – why, when and how?

Melvin H. Thornton, MD
Reproductive Endocrinologist at Global Fertility & Genetics, Global Fertility & Genetics

Category:
Fertility Assessment, Lifestyle and Fertility, Male Factor

male-fertility-preservation
From this video you will find out:
  • What is sperm freezing?
  • How does sperm freezing work?
  • What does the cryopreservation process involve?
  • Are there any risks involved in sperm freezing?
  • What is the difference between semen and sperm?
  • How does cancer treatment affect sperm and male fertility?
  • What are the effects of cancer treatment such as chemotherapy/ radiation therapy on sperm?
  • What are the strategies for fertility preservation in men with cancer?

What are fertility preservation options for men and when are they indicated?

In this webinar, Dr Melvin H. Thornton, Reproductive Endocrinologist at Global Fertility & Genetics, has talked about fertility preservation for men, when should it be indicated, how it’s done and why.

What are fertility preservation options for men and when are they indicated? - Questions and Answers

Do you recommend hormonal treatment before sperm retrieval TESE in a man with non-obstructive azoospermia with FSH 2 (UI/L) and LH 2 (UI/L), and normal testosterone 350 ng/dL and estradiol 13 pg/ml?

If someone who has a low sperm count is not due to obstruction, what is the recommended treatment? Typically, we try to see if we can increase sperm counts on a more natural level. You may have heard of medicines called Clomiphene or Letrozole, which are typically used for women to increase their egg numbers in a fertility cycle. We also use the same kind of medications for men to try and increase their sperm counts. It’s not unusual to see a male be placed on Clomiphene or Letrozole to increase the sperm counts.

The most important thing to remember is that in the sperm cycle, it does take 74 days on average to make sperm, so if you’re going to initiate that type of treatment, you have to get at least three months to see if the sperm has improved. If it hasn’t improved, in many cases, the reproductive specialist may say, let’s go another three months to a total of six months. If there’s no improvement in the sperm numbers, they will have a testicular aspiration or testing procedure.

Is there a time limit for using the sperm if it’s frozen?

There is no time limit. Many case reports have shown that men have frozen sperm for over 20 years, and they’ve had healthy babies, so there’s no time limit for using the sperm if it’s frozen. It’s just a matter of choice whenever you’re ready to start your family building journey.

Medically, there’s no time limit, but what’s important I did not mention is that here in the U.S., freezing sperm may cost between 700- 800 US dollars, and then on an annual basis, the storage fees may be about 1000 dollars per year. Sometimes people look at those numbers, and they have to put a time limit on how long they’re going to store sperm just because of the cost, but medically it can be frozen indefinitely. There is a cost of storage fees, some sperm banks will give 3 to 5 years of storage for sometimes 2 or 3 thousand dollars, so it all depends upon the sperm bank.

What causes DNA fragmentation, and is it curable?

Typically, it’s going to be oxidative stress. Oxidative stress comes from diet, the best way to treat that is with a good male multivitamin or antioxidants or a good diet. I always push my clients on fish oil, and fish oil has shown to decrease DNA fragmentation. Other things that can cause DNA fragmentation are environmental, such as smoking, poor diet, all those things can lead to DNA fragmentation, but it’s reversible by using antioxidants.

If the report between testosterone and estradiol is more than 10, is it necessary or correct to recommend Letrozole?

If one medication doesn’t work, then they will always go to a different medication. If you start with Clomiphene, then you try that for 3 months, if that doesn’t work, you’ll switch over to Letrozole, unless someone has side effects or has a contraindication where they can’t take it. We recommend either one, and it depends upon preference and what you’re looking to accomplish. They’re both equally effective as far as improving sperm in men.

How do you recommend Letrozole?

Typically start with Clomiphene. Most people using Clomiphene are taking 25 milligrams every other day, and the dose of Letrozole is 5 milligrams every other day as well.

Above what value of LH or FSH do you recommend injection with gonadotrophins?

It’s not a value of FSH or LH, here in the U.S., we tend to start with the least invasive treatment, which is the oral medications Clomiphene and Letrozole and then move to the more invasive such as injections with gonadotrophins. The problem here in the U.S. is that gonadotrophin injection therapy may run about a thousand dollars per device with a pin, which tends to be very expensive. We try to start with the most cost-effective treatment, which is the oral medication, so we don’t use it directly, we use it mostly in couples or men who have not had success with the oral medication.

Are there any risks involved with freezing sperm?

There’s no risk involved in freezing sperm.

We had one round of egg retrieval in Ukraine for a donor, and we winded up with one healthy embryo out of 7 blastocysts. In the second round of stimulating with a different donor, we winded up with 5 healthy embryos out of nine blastocysts. What could be the problem? The first donor was 24 and from Ukraine. The second stimulation was done in Georgia, and the donor was 30 years old from Georgia. All embryos were tested.

In the first scenario, the fact that you had a much better response to the second egg donor means that it may have been an egg issue with the first egg donor. I would imagine the first one could have been an egg issue, particularly if you had the same sperm with a different egg donor and got much better quality embryos 5 out of 9.

Statistically, in nature, 50% of fertilized eggs will become a blastocyst, and that 25% will lead to a healthy blastocyst. It all depends upon how many eggs you’re starting with, how many are fertilized, then you’ll see how many develop. Looking at the individual age of the egg donor, someone who is 30 and below, you’d expect to have at least anywhere between 30 to 40% abnormality rates, that’s what the data shows. With your second donor, you had an excellent outcome.

What are the contraindications for the administration of Letrozole?

That’s very minimal contraindications of using Letrozole. There are more contraindications with Clomiphene than you’ll see with Letrozole. If anyone has a history of migraines, anyone having a history of visual disturbances, you will stay away from Clomiphene, which affects those organs.

There’s no contraindication to using Letrozole unless, of course, they’ve had an allergic reaction to it the first time they took it or side effects that were unbearable the first time they took it, but there’s nothing as far as contraindications that stand out.

Could sperm DNA undergo impairment through in vitro handling (after collection)?

Typically, not because of the way the sperm is processed, you’re washing away the sperm that’s poor quality, so you’re left with a better quality sperm. There are new devices that are out there to separate the sperm a little better.

There’s something called a Zymote, which’s a new technology where only the sperm that have normal heads and tails can swim through, so you’re selecting up the sperm that are damaged with DNA fragmented DNA, but this routine handling of the sperm doing the IVF process does not cause DNA impairment.

In your opinion, Letrozole should be recommended to all men with non-obstructive azoospermia (NOA)?  

 I believe it’s a good option to use Letrozole or Clomiphene, I don’t have an issue with having everyone take Letrozole, I think it’s a good drug to improve sperm counts.

Do you have good results with Letrozole in cases of non-obstructive azoospermia (NOA)?

The results depend upon how responsive they are to the treatment, but in general, we’ve had good results with the Letrozole. When you talk about non-obstructive azoospermia, a good result doesn’t mean they go to a normal sperm count, a good result means that we can get them to the point where they have enough sperm to actually go through an IVF process or maybe have enough sperm for an IUI procedure.

 I am 51, and I did sperm freezing this year, do you recommend doing another round of freezing, say five years later, or is it not needed? 

I would say try to freeze another sample instead of waiting just because as you get older, the sperm quality and concentration will decline, so I would try to freeze as much as you can this year, and it all depends upon your goals in the future.

If you already have 7 or 8 samples of sperm frozen, that should be enough for any sort of treatment you desire inseminations or IVF, but if you’re going to produce more, I would do it sooner than later.

Authors
Melvin H. Thornton, MD

Melvin H. Thornton, MD

Melvin H. Thornton, MD is recognized as one of the world’s leading experts in egg donation and surrogacy. He is double board-certified in Reproductive Endocrinology and Infertility as well as Obstetrics and Gynaecology. Dr Thornton received his medical degree from Washington University in St. Louis, completed his internship and residency at the University of Southern California, and received additional training in advanced reproductive surgery at The Cleveland Clinic. He joined the faculty at Columbia University where he served as Medical Director and Director of the Egg Donation Program at the Center for Women’s Reproductive Care (CWRC).    Dr Thornton has been helping families achieve their dreams of having children for over 20 years. Dr Thornton has published more than 50 papers, written several book chapters, and presented over 100 abstracts at national conferences on topics related to infertility, third party reproduction, and women’s health. He has distinguished himself through his extensive research in the treatment of HIV serodiscordant couples and the relationship to infertility and fertility treatment. Although his interests include all aspects of the treatment of infertility, he is particularly recognized as being one of the world’s leading experts in egg donation and surrogacy.   He is currently an Associate Professor at Quinnipiac University and provides lectures in reproductive medicine and infertility to OB/GYN residents at New York Medical College. He is an excellent educator and gives board review lectures for OB/GYN, Family Medicine and Paediatrics residents preparing for their board examination.  He previously was a member of the ACGME Clinical Competency Committee for Obstetrics and Gynaecology at Columbia and currently sits on the ASRM Education Committee. He is a Castle Connolly National Top Doctor and was awarded the Top Doctors New York Metro Area Award in 2017, 2018, 2019, and 2020.  Dr Thornton enjoys spending time with family, fishing and playing golf.
Event Moderator
Caroline Kulczycka

Caroline Kulczycka

Caroline Kulczycka is an International Patient Coordinator who has been supporting IVF patients for over 2 years. Always eager to help and provide comprehensive information based on her thorough knowledge and experience whether you are just starting or are in the middle of your IVF journey. She’s a customer care specialist with +10 years of experience, worked also in the tourism industry, and dealt with international customers on a daily basis, including working abroad. When she’s not taking care of her customers and patients, you’ll find her traveling, biking, learning new things, or spending time outdoors.

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