THE NEW YORK TIMES
May 5, 2008
by Laurie Tarkan
But for a semen specimen, most men are practically ignored when couples go to fertility centers. And depending on the infertility specialist offering treatment, that is either a good thing or a bad thing.
Some urologists say they can treat a man with low sperm count and increase pregnancy rates, helping patients avoid costly and invasive in vitro fertilization. Reproductive endocrinologists and scientists, on the other hand, say that most male fertility treatments have not been shown to improve pregnancy rates and put patients through unnecessary risks and expense.
It is a debate that has been raging for at least 50 years in various forms surrounding almost every aspect of male infertility and its treatments, but all this changed in 1992.
In 1992 an advance in I.V.F. called ICSI, for intracytoplasmic sperm injection, provided fuel for the reproductive endocrinologists’ view that most men do not need fertility-enhancing treatments. In the procedure, pronounced ICK-see, a single sperm is inserted directly into an egg. ICSI revolutionized treatment for men with severely low sperm counts. Reproductive endocrinologists say that trying to improve sperm count in most men is not possible, and no longer necessary, because only a few healthy sperm are needed for ICSI.
Male problems are believed to be either solely or partly responsible in about 40 percent of all infertility cases. Urologists commonly blame it on varicocele.
Yet the research on surgical repair of varicoceles to correct male infertility has shown the repair of the varicele does nothing to improve sperm count.
“Whenever it has been studied in a controlled fashion, it’s been shown to have no impact on pregnancy rates,” said Dr. Sherman J. Silber, a urologist and the director of the Infertility Center of St. Louis. A former proponent of the surgery, he has stopped performing it. “Most urologists who specialize in infertility have a vested interest,” he said; the varicocolle surgery is all they do, and “that’s the moneymaker.”
“Couples put off I.V.F. for years, waiting for sperm count to rise, while the woman’s age increases from say 34 to 37 and her eggs are getting older,” Dr. Silber said.
For women in their mid-30s and older, time is of the essence. Based on national averages, the success of one cycle of I.V.F. using a fresh embryo drops from about 50 percent in women under 35 to about 20 percent in those 38 to 40. It drops further, to about 11 percent, in women in their early 40s. Most doctors would agree that if a woman is getting older, the couple should go straight to I.V.F. with ICSI, rather than seeking futile treatments to try to improve sperm count.