Infertile patients cannot afford to wait for treatment while their eggs get older.
Dr. Sherman Silber, Infertility Center of St. Louis, is offering free video consultations for patients who need to plan now for their treatment while stay-at-home orders are in place. He is talking to and evaluating patients in their home via to comply with social distancing measures.
Dr. Silber is discovering that patients actually prefer this method of telemedicine consultation over the conventional office visit. Patients have conveyed that “it is so much more convenient and less stressful” to have a free telemedicine personal consultation than to take a day off from work to travel to the doctor’s office and sit with other nervous patients in the waiting room.
The COVID-19 pandemic is thus changing much of the way we will do things in the future, and for the better. "Our patients are surprisingly much happier with this approach. Of course, at some point we need to perform hands on treatment. But with this new manner of seeing patients, we can come to the right diagnosis and treatment plan for most patients more efficiently, quickly, and painlessly, with no loss of personal one-on-one communication.” This is a very welcome new era of telemedicine that has been forced on us by the current difficult times.
There has been a great deal of publicity and public concern about the burgeoning infertility epidemic in this country and in the world, the billion dollar infertility treatment industry, and the various abuses associated with the infertility industry. People that we actually know as former colleagues have possibly done some really terrible things. These atrocities and the public fear over them have been given a great deal of appropriate media attention in recent years. On a more positive note, I would like to acquaint you, in this very brief capsule, with some of the incredible advances that have been able to help the vast majority of even “hopeless” infertile couples have children. Many of these recent advances we have been fortunate enough to have developed, or helped develop.
I. MALE INFERTILITY A. Low Sperm Count: Incredibly low sperm counts just don’t make any difference anymore. Along with our Belgian collaborators we have developed a method in the last three years of picking up an individual’s sperm one at a time, selecting one that looks good and normal, and no matter how poor its motility and even if it’s the only single sperm in the ejaculate, it can be injected into the wife’s egg with a normal fertilization and pregnancy rate. Thus, men with the lowest sperm counts imaginable are basically completely fertile with this technique. (It is called “ICSI“, short for intra-cytoplasmic sperm injection).
B. Zero Sperm: Those with zero sperm are fertile too. If a man is obstructed for many years, we are able to use microsurgery to restore normal fertility to them. We developed that original microsurgery technique 22 years ago. But, what about men who have no sperm production at all? We find that even in these men with “no sperm production,” if you look carefully in the testicle, you will almost always find an occasional sperm or sperm precursor in the testicle. We can inject these early sperm cell precursors into the wife’s eggs and once again, get a normal fertilization and pregnancy rate, the same as with a fertile man.
C. Finding the Gene for Male Infertility: We have located and mapped the gene that causes male infertility on the long arm of the Y chromosome. Various mutations and errors in this gene, or related genes, will result in various deficiencies of sperm production resulting in male infertility. Thus, every new generation of male offspring we are able to help come into being with the sperm injection technique is likely to perpetuate the same male infertility problem that their father had been mutated with. These couples don’t seem to mind this warning because they figure that if they can have a child with the technology now available, then certainly their male offspring will also in the future be able to have a child with this technology.
II. CYSTIC FIBROSIS (CF) Cystic Fibrosis (CF) is the most common genetic abnormality in the human race and at least 40,000 people in this country suffer from it. Every one in 1600 births is a baby with Cystic Fibrosis, and perhaps more chillingly, 4% of every person you meet or know is a carrier for Cystic Fibrosis. It is the most common childhood disease producing gene error in the human population.
With modem medical treatment, most people with Cystic Fibrosis can now survive to adulthood and lead a relatively normal life as long as they receive proper and continual treatment. But they can’t have children.
A. Now CF Men Can Have Children: The reason these men can’t have children is related to the fascinating and peculiar genetic organization of humans. The same gene that is required to allow these people to have normal lung and pancreas secretions is the gene that directs the formation in the developing fetus of the vas deferens. Two seemingly unrelated functions are controlled by the same gene. Thus, all men with Cystic Fibrosis have congenital absence of the vas deferens on both sides and are sterile. Their sperm production is completely normal but the sperm simply can’t get out. All of these men with Cystic Fibrosis can now have children because we simply operate microsurgically to retrieve sperm from the epididymis, sperm that would normally never fertilize the wife, and inject those sperm directly into the wife’s eggs. We have many couples now with frank Cystic Fibrosis, who thought they could never have children, who are carrying a normal family.
B. We Can Now Prevent Future Children From Having CF: We can insure that their children are genetically normal and do not have Cystic Fibrosis. If both husband and wife are carriers, we are able to test the embryos by biopsying one of their cells, doing a gene scan on this one single cell of the embryo, and then in eight hours find Out which of the embryos tested are normal and which would be children with Cystic Fibrosis. We can then choose to replace only the normal embryos and freeze the genetically diseased embryos for possible future transfer if there ever is a genetic cure. This “pre-implantation ?” is accomplished by the same delicate micromanipulation (ICSI) techniques that are employed for injecting sperm from infertile men into the egg.
III. FEMALE INFERTILITY AND AGE The female’s infertility now has absolutely no impact on her ability to get pregnant with modem techniques (except for one factor–her age). The negative effect of her age has nothing to do with her uterus or any other aspect of her body or health, but only has to do with the age of her ovaries. Eggs from young women when transferred to older women result in completely normal pregnancy rates even in women, as you know, as old as 60 or 65. Eggs from older women, however, have extremely low pregnancy rates when transferred to young women. Furthermore, even beautiful normal embryos derived from women who are over forty have extremely low pregnancy rates, because of the high degree of genetic abnormality found in these older eggs Thus, we have completely solved the problem of male infertility which was considered to be the number one obstacle three years ago for couples getting pregnant, and we have completely solved all female infertility except for one: and that one is the mere fact of getting older.
But even this problem can be solved with donor egg transfers which have caused so much of the controversy in the last six months. These procedures must only be performed with the clear and unequivocal permission and knowledge of the donor. In an ethically sound, properly managed program, egg donation is an excellent altruistic opportunity for younger infertile women whose problems will be easily solved while going through an IVFprocedure to help, if they wish and so offer, an older woman who does not have eggs capable of resulting in a baby. The sense of community and helping one another that develops amongst these couples involved in an ethical, legal, and thoughtfully organized egg donor program is enough to bring tears to your eyes because of the bad publicity about immoral procedures that have been performed with egg donation. It might be well to show just how beautiful this procedure can be when being performed as part of a program with high integrity.
Let me make it clear about this problem of female infertility. Whether the woman has endometriosis, blocked tubes, scarring or adhesions, deformed uterus, fibroids, poor ovulation, or even if she is a carrier of a severe genetic disease, all these problems can be very easily handled with IVF and micromanipulation of eggs and sperm. The only problem we cannot solve except with egg donation is the problem of the aging ovary which is simply a consequence of couples having not been able to receive proper treatment at a younger age.
IV. WHAT ABOUT THE CHILDREN BORN FORM THESE HIGH TECH PROCEDURES? A. Vasectomy Reversal and Microsurgery: We now have over twenty years of experience with children born as a result of vasectomy reversal, a procedure which was thought in 1975, when we first introduced it, by many people to be immoral and dangerous. Not only is there no greater incidence of any abnormalities or problems in these children than in a routine population, but indeed it is quite remarkable the overall competence of such children. The emotional stability and competence of these children, now grown up, is consistently higher than one might expect in a normal population, and we suspect that may be related to the intensity with which these couples wanted these children.
B. IVF and ICSI Children: Detailed genetic testing and follow-up of children born from in-vitro fertilization procedures, frozen embryos, and sperm injection into the egg procedures (ICSI) again reveals no greater risk of genetic or other abnormalities. However, as mentioned under Male Infertility, we would expect that most of the male offspring of men with poor sperm production will also have poor sperm production because it is genetically transmitted on the Y chromosome. Without our intervention this mutant gene for male infertility would not proliferate in the male population. Because of our intervention in large numbers of cases which will only increase over the coming decade, we would anticipate that we will have a technology induced increase in the incidence of male infertility requiring further technology.
V. WHAT ABOUT THE FUTURE PROSPECTS? A. Egg Freezing and Embryo Freezing: We can freeze embryos with fairly good and successful results, but until recently, we could not freeze eggs well. The process of chromosomal reduction division, or meiosis, is so complicated that freezing the egg (which is always going through the process of meiosis) simply doesn’t result in successful pregnancies. Therefore, to preserve a woman’s reproductive potential against aging, we had to first fertilize her eggs, and then freeze them. The future would be bright indeed for women if while in their twenties, before they were certain about their family plans, we could successfully freeze their eggs and save them for such a future time when they were more ready to embark upon having a family. This would also be of extraordinary importance for women who would be undergoing chemotherapy for cancers that occur in young women such as lymphoma or melanoma. Now, through a new ovarian tissue freezing technique, we can preserve eggs prior to meiosis. The technology for successfully using these frozen, unfertilized eggs is still in development, but it is fairly safe to assume we will realize this ability in the close future.
B. Genetic Testing of Embryos: If a couple are both known to be carriers for genetic disease such as Cystic Fibrosis, Hemophilia, Muscular Dystrophy, etc., it is established treatment now that we can biopsy the embryos and place back into the woman only the healthy ones so as to prevent her from having children with such a disease. But this is relatively crude technology compared to what I can foresee in the next ten years when we’ll be capable of doing entire genome analysis in a quick and rapid fashion so that embryos can be routinely checked for any genetic defect for even such complex problems as breast cancer or heart disease or diabetes, Alzheimer’s disease or Lou Gehrig’s disease, etc. This will then pose the dilemma that if this technology were available earlier in the century there might not have ever been a Lou Gehrig or a Stephen Hawking. I won’t comment on the dilemma that this technology brings up, except that we will all be facing this issue because you can’t stop this technology from developing further.
C. Jurassic Park: From the information we have so far, it would be very likely that if we could get hold of the testicles of recently discovered anthropological finds of ancient men frozen in a glacier of the Alps, for example, it is very probable that the sperm that we could retrieve from such a man’s testicles, would be capable of impregnating a modern woman using the sperm injection techniques. Of course, we prefer our modern cryobiology aided techniques for sperm freezing and preservation. But this ICSItechnology makes it highly likely that even the most simple freezing will sufficiently preserve DNA in men who are many thousands of years old who would be able to bear children today.
D. Competence of Human Beings In Future Generations: The observation that children born from infertile couples who have been through a tremendous amount of pain, anguish and expense in trying to have a child, have a much lower incidence of problems than one would expect in a standard population, indicates that all of this futuristic technology might not be as frightening as it seems. The growing infertility problem might result in a future generation of children who are much more cared about, and therefore much happier and contributing individuals.
If you have any questions, you may call us at (314) 576-1400.