In this session, Professor Suks Minhas, Consultant Urologist and Andrologist at Imperial College London, explained how the process of sperm collection looks like, how semen is analysed, what surgical sperm retrieval techniques are used and when are they indicated.
From the point of view of COVID-19, we know that potentially it could affect your testes. I’ve certainly had some patients who have had COVID-19 and then develop testicular problems now we don’t know the full association. However, if you look at studies that have been done in hospitalized patients, there is quite a lot of testicular damage, and undoubtedly, we think it does probably affect it. The studies that were recently done showed about 90% of patients had very low sperm counts or no sperm after they’d had COVID-19, but again this wasn’t very well controlled in the studies. There are many other factors the patient’s been in the hospital also had various drugs, and we don’t know whether it was other effects or whether it was a COVID-19 itself that was causing uh the fertility problem.
No, I think if the sperm sample analysis is normal, and you’re dealing with infertility, that’s the kind of unexplained group we’re talking about. We wouldn’t necessarily do FSH and LH tested in that group as we thought it was a hormone problem, but that’s usually if the sperm count is abnormal or there’s no sperm. We’ve got to remember that a third of patients are of unknown fertility, you can have normal semen analysis and still cannot conceive. The question is, why is that? I think more and more we realize that it’s DNA damage. About a third of these patients may have DNA damage, so it’s not just about what sperm looks like on a semen analysis. It’s also about sperm integrity in terms of DNA integrity which has become much more of a novel tool that we use now in testing because there are factors that cause DNA damage.
DNA is like a ladder, and if you get a break of that ladder normally, the egg we think can repair the DNA fragmentation or damage it. As men get older, the DNA damage increases as when we get older, the egg is less able to repair the DNA, that’s the theory. There is evidence within the literature, so there tend to be environmental factors, infections, varicoceles, dietary factors, the imbalance between oxidants and antioxidants, but again the evidence for all of this is a little unclear.
One of the issues is that overall what you’ve got to look at are factors called sperm DNA damage. There may be environmental factors, we know that it may be a factor involved in embryo formation and also miscarriage, implantation failure in patients who are trying to have IVF treatments. I co-chair a group called the European Association Guidelines Committee, we have put together some guidelines as to when we should measure sperm DNA and how we should go about that. In those guidelines, we’ve suggested that for patients who have unexplained fertility with normal semen analysis or those that might have failed IVF treatments, doing DNA fragmentation would be worthwhile testing and looking at.
I’m talking in the context of freezing sperm before operations. I always say to patients when I see them, and they come to me for sperm retrieval that we’ve done studies, others have done studies, and they showed no difference of using fresh or frozen sperm taken from the testicle or epididymis. The 5% represents all patients in those groups where we found that the sperm just did not survive the thawing process. We think that’s probably a cryopreservation process invariably, however it’s because of poor quality sperm that is frozen.
The problem is that when you face surgery on someone who has no semen or has obstructive age sperm, you’ve got to take what you’ve got, so what we try and do in those circumstances is to try and circumnavigate that is that if we find sperm on one side in operation it’s not very good we stop, and we hope that would be good enough for ICSI treatment, but then we leave the other testicle as a backup for the future to perhaps using fresh on the day.
Overall, 5% is very low, you could argue should every single patient have a synchronous cycle of ICSI with a sperm retrieval that logistically is a bit of a nightmare, it’s very difficult to arrange. That’s the kind of reason why can you mitigate that? Not really, that’s the problem, and that’s just the issue of the cryopreservation but also freezing poor quality sperm in the first place.
That’s the theory. Some studies suggest that in theory, the younger the patient, the better ability of the egg or ovum to correct the DNA damage or repair it. That’s one of the theories that are some research is going to be done. Nobody quite knows, although we kind of look at DNA fragmentation as this kind of normal biomarker, we also need to remember the female partner’s age, the quality of her eggs as well because we so often ignore that, and our focus tends to then go to the sperm and focus a lot on the sperm. I think we’ve got to be a little careful, but that’s a theory, and there is some evidence back in that all.
I don’t think anybody knows the answer to that, and I think that in terms of COVID-19, we know it seems to affect the testis. Giving the vaccination before in the context of prevention or transmission, the evidence for trans generational transmission, in other words, to an embryo fetus, is very extremely limited and isn’t there. I think it’s too early to say this, but I can tell you many studies are done about this at the moment. What’s interesting about vaccination not for COVID-19, but Human papillomavirus (HPV), that’s the wart virus, is that there are thoughts about whether vaccination reduces HPV expression, which might affect IVF outcome. There is evidence, of course, that coving can affect the testis, but again the evidence is quite controversial and needs to be more robust.
When I see patients, I always ask them, have you had COVID-19? I’ve seen patients who’ve got normal semen analysis previously because they’ve had kids, and then somebody comes up with very severe abnormalities, and I so ask them, have you had COVID-19 because I’ve seen patients who’ve certainly had been badly affected. The question is, of course, how long do you wait? Do you wait for six months and then repeat a semen analysis? I’ve had patients who had no sperm, who’ve had COVID-19, potentially had problems in the testis and then repeated the semen analysis of 6 months, and that’s what I’m waiting for, at the moment, because it’s too early to say.
I was only talking in the context of freezing sperm because of an isolated procedure. If you think about a patient who doesn’t have any sperm and ejaculate and doesn’t know if you’re going to get sperm from a testicle, there are two things you can either do. One is we’re either going to do an operation on your partner, we’re going to try and extract sperm, we find it, we’re going to freeze it. If we don’t find it, then, of course, you have an answer.
The alternative is saying to them, look, you could do a synchronous cycle of ICSI, and we extract the eggs from the female partner, the male partner has surgery on the same day. The problem is we know that in 50% of non-obstructive age of sperm, we won’t find sperm, so what that 50% of patients who’ve gone through a cycle of stimulation should do? Do they freeze the eggs? Do they have a donor backup? The context in which I was talking about freezing sperm is yes, once we found sperm on a fresh cycle, we want to freeze sperm, and on a frozen cycle, we would freeze sperm anyway, so we would freeze what we’ve got to use.
That depends. The problem is abnormal forms, it’s a controversial, difficult area with a huge amount of variance in reporting. You go to one lab, and they report no normal forms, you go to another lab, and they report normal forms, which is about 4%, and it is upsetting because you’re left in a situation where other parameters are normal. The question is, what do you do with these isolated abnormal forms, is it significant? Some drugs can cause abnormal forms, of course, there are congenital problems, such as globozoospermia, but as in isolation, you would normally expect all the other parameters to be abnormal if it was significant.
If you think about it, a sperm may look normal to one person, abnormal to another, strictly speaking, it shouldn’t be like that because it’s done with strict criteria called Kruger criteria, but it does happen. How do you report this? Take the abnormal forms out of the equation as a sort of factor that is confounding. You can look at the total motile count, which is the volume multiplied by concentration, multiplied by the motility percentage to get the total motile count. We think it’s probably a better indicator of fertility potential in patients.
The probability is that you don’t know whether somebody with 1% of normal forms is going to be fertile or non-fertile. The key about all of this is that the patient’s been trying. Remember, the definition of infertility is the inability to conceive after one year of unprotected intercourse. 75% of couples can conceive in a year, 95% in two years. If you do a semen analysis, you open up a can of worms in a way because if you do it pre-marriage, or you do it in 3 months in, and you find you’ve only got 1% per cent of normal forms that can have a huge psychological toll on both of you. Does that necessarily mean that you’re infertile? No, and so I think you’ve got to be a little careful about over-interpretation of what we term as isolated teratozoospermia.
Liquefaction is thought to be allowing the sperm to confer the motility of movement. Liquefaction is normal, it’s not something that I particularly have seen, if I’m honest, in many years of doing this. I think one of the issues is that liquefaction of sperm occurs due to an enzyme called PSA, which is produced by a Prostate-specific antigen, which is a mark for prostate cancer, and so it’s a protease or an enzyme that liquefies the ejaculated. That’s the process by which it occurs, if you stand in an ejaculate, it will liquefy, and you see it become runny effectively.
Its effects in terms of fertility are largely unknown in many ways, and a lot more work needs to be done in that area. Is it a concern? I would not see it as a major concern, because effectively, we don’t know what the role of liquefaction is in terms of sperm function, but we think it is involved in the sperm’s motility in terms of the female partner when it’s in the female genital tract.
I think you’re referring to hormone stimulation in the context of having azoospermia or having no sperm or hormone therapy. What can be done in some men, people argue, but gonadotrophins, which is FSH and LH stimulation to raise testosterone potentially, stimulate sperm production in that way. The other way of doing it is with anti-estrogens to stimulate FSH/LH gonadotropins to stimulate testosterone and sperm production. The evidence for this is quite limited, the problem is when people do trials, they use their patients themselves, and as I said, some patients produce sperm, and that can appear and disappear. Do they work? We don’t know that, and we’re doing a study at the moment, but because of the confidentiality reasons tell you the result of that, at the moment, it suffices to say that the data is quite mixed and very difficult to interpret. We’ve done a meta-analysis hopefully, in about a month, we’ll be able to share that data.
The only time I would be giving it anyway is to stimulate testosterone in the men who have low testosterone because then you’ve got kind of nothing to lose because remember these kinds of drugs are expensive and not without side effects. In fact, in men, they’re off label, we’ve got to remember they’re not licensed to be used in men, they’re licensed in women, so that’s where the difficulty and controversy about all of this come from.
If you look at results from ICSI, they seem to be superior to IVF treatments, and that’s the kind of argument that you know about that people use. The evidence for IVF treatments causing congenital problems is limited, I’m not an IVF doctor as such, but ICSI can be associated with other congenital problems, however, it’s weighing up results and what’s best, and that’s where the sperm count comes in that’s what the sperm is. Ideally, ICSI should be used for male factor infertility, and more and more, we tend to use these type of treatments as well as IMSI and other treatments for DNA fragmentation. It depends on the IVF unit, I suppose in many ways, this doesn’t seem to be any standardization of this, and that’s one of the problems, and I think that’s what needs to be addressed by the HFEA, so perhaps we are overusing ICSI in that setting.
Both, so they can extract the sperm and that way alternatively sometimes when they’ve got tissues still they can freeze the tissue. I’m not an embryologist, but that would be a more embryological question, but they could do it both ways.
In a sample, you will get dead sperm, that’s the natural cycle, so what causes non-vital sperm, in other words, sperm that’s not alive. In that context, you need to look at infections. I’ve seen that urinary tract infections Sexually transmitted infections (STIs).
You would normally see either infection, but if you have a congenital problem, you can sometimes get various disorders that can get immotile sperm. Some of these conditions are called Kartagener’s or Immotile cilia syndrome, which is associated with chest problems as well where the flagella or tails aren’t moving, and the sperm, in a sense, is alive but depends on how you define vitality it’s a general vital stain on the cells. The most common one we see is, in terms of infection, but again the thresholds that we use are controversial, various drug treatments potentially gonadotoxic or toxins to the testis can also cause this, but you would have normally seen very severe cases of this. If I see non-vital sperm, one thing I would be looking at would be how many white cells are in the ejaculate, white cells might indicate infection as well. I’d probably want to culture the sperm and also do some other infection tests to make sure there isn’t an ongoing infection causing them.
It is only a research setting that it’s done currently, but it can be done and the issue about Micro TESE is the question you need to ask yourself: why are you doing Micro TESE in the first place in this setting. There are two reasons why you do Micro TESE.
First is non-obstructive azoospermia, which obtains sperm, and then you freeze it and use that sperm for ICSI treatment. The other setting where you do testicular sperm extraction for men who are non-azoospermic, who have sperm and ejaculate is as a kind of treatment in patients who have raised DNA fragmentation or damage, where you want to try and bypass the DNA fragmentation. The argument being the testicular sperm in some studies have shown to have less fragmented DNA than ejaculated sperm. That’s been shown in some studies, so you can measure DNA fragmentation within testicular sperm and compare it and ejaculate it. The other context we sometimes can argue using would be in patients who might have sperm frozen, and they’ve had multiple cycles because there is an argument that freezing sperm can damage your DNA. They might want to do it to see whether they’re failing embryogenesis or failing IVF cycles using frozen sperm and if it is due to the DNA damage to the sperm. The problem is that its patients who have these kinds of problems, it’s like gold dust because again you’ve done an operation to extract that sperm, therefore it’s a test that you’ve got to be very careful about doing.
To answer the question directly, you can measure DNA damages in testicular sperm, you would normally do a testicular sperm extraction on the day of an ICSI cycle as a method to try and bypass or try and circumnavigate, mitigate the problem of sperm ejaculated sperm and its effect in terms of DNA damage. The argument being that testicular sperm has less fragmented DNA. You’ve got to be cautious about this because levels of evidence for this are extremely limited. We’ve written guidance on this and said that if you’re going to be doing this, ideally, it should be done in a research setting.