Male Infertility

male fertility health

THE SERVICE WE PROVIDE

After nearly 3 decades in Sydney, Fertility Health continues to offer extensive support to infertile men through: a comprehensive program integrating Chinese medicine treatment for natural fertility, increasing pregnancy rates during ART (Assisted Reproductive Technology) cycles, conducting clinical research, advising on best practice in ART and surgical intervention, and predicting a male factor in fertility.

  • We are the only CAM (Complementary and Alternative Medicine) centre in Australia to also conduct clinical research into sub fertile men. In her research, Jann Mehmet observed clinically and statistically significant outcomes for sperm count, motility, and morphology using acupuncture and Chinese herbal medicine (see Clinical Trials),
  • We have extensive experience complementing all Sydney based IVF (in vitro fertilisation) programs. After providing thousands of treatments each year with many couples undergoing IVF, ICSI (intra cytoplasmic sperm injection) or sperm extraction programs, the team has an excellent understanding of the ART industry,
  • We assess and predict ‘male factor’ impact on natural fertility and ART cycles. We use Chinese medicine 'patterns of disharmony' as well as interpretation of blood tests, semen analysis and scans to predict risk to the success of IVF and ICSI cycles as well as natural conception,
  • We offer detoxification and pre-conception programs for men and women, based on the latest research, a naturopathic style consultation, and assessment through traditional Chinese medicine,
  • We provide an advisory service explaining systematic reviews and meta-analysis and world's best practice related to ART procedures and natural fertility. We also collate data in our clinic on natural conception and best treatment strategies in ART and Chinese medicine,
  • Based on best evidence we recommend non invasive cost effective tests and treatments as the first option, rather than the last option, or not at all.

WHAT IS A MALE FACTOR?

A ‘Male Factor’ refers to any semen parameter that predicts compromised fertilisation potential. Assessment is frequently made only to predict fertilisation potential for ART cycles. Our team has the knowledge and experience to use semen assessment to predict a ‘male factor’ on ART and natural fertility cycles.

Predicting a male factor generally incorporates analysing sperm quality and quantity, and seminal fluid (the sperm environment). This relies on a semen analysis developed by the ART industry, in order to assess sperm fertilisation potential during ART treatment cycles (such as IVF and ICSI). The current semen assessment is somewhat problematic as it was not designed to assess a male factor impacting ‘natural conception’ (Windt and Kruger 2004).

The Fertility Health team believes it is important to assess the risk of ‘male factors’ on both natural conception and ART cycles when a couple is not conceiving.

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DIAGNOSIS AND ASSESSMENT at Our Centre

1. Most men want to know why they are infertile. Men with fertility issues often appear to be asymptomatic or without any obvious symptoms or history to explain their infertility. The Fertility Health team has developed a more thorough medical history assessment in order to shed light on causative factors. We find this is always very much appreciated.

2. We investigate ‘unexplained infertility’. Around 60% of couples that come to our clinic have been told there is no known reason for their infertility. We have found in 95% of cases there are three main reasons for this diagnosis: inadequate semen analysis testing and interpretation; female factors not diagnosed by standard blood tests and scans; and a combination of both (see Female Intertility - Unexplained Infertility).

3. We offer guidance and discussion on best practice on a range of associated tests and fields including: semen analysis, testicular biopsy and ultrasound, best IVF services, Gynaecologists, Urologists, Radiologists, and Donor programs.

4. We provide a second opinion on all semen analysis results. We regularly assess couples who have been given an inaccurate diagnosis because of minimal testing and poor interpretation of a report. Research suggests this is a common problem world wide (Franken, 2004b; Jequier and Ukombe, 1983; Menkveld and al., 1997; Morgenthaler et al., 1995; Mortimer et al., 1986; Neuwinger et al., 1990), and we have found this to be one of the most common reasons a diagnosis of ‘unexplained infertility’ is given to a couple.

5. We advise on the extra semen parameters to be tested to measure natural conception potential. In order to provide an accurate prediction of a male factor impact on natural conception, a more comprehensive analysis of a semen sample is needed than is generally provided, even by the top fertility clinics. While count, morphology, motility, and DNA fragmentation are important parameters to assess, we also recommend the testing of several other less routinely reported parameters that will impact natural fertility.

One example is the semen pH. Many reports do not document the semen pH, and yet elevated pH predicts a male factor even when all other parameters are excellent. Occasionally the semen pH is reported but overlooked in the interpretation and yet the treatment of elevated pH does not require expensive or invasive intervention, neither do the other parameters that are overlooked on semen testing.

6. We offer our opinion on the most rigorous laboratory in Sydney for semen analysis. Not all laboratories are equal or reliable. For example, it is our experience that currently in Sydney there is only one clinic sufficiently rigorous to assess a male factor. Importantly, we still need to request extra tests even from this clinic in order to more rigorously measure a male factor impact on natural conception.

7. Our team researches natural fertility and thoroughly reviews the health profile of the whole person.

This is the cornerstone of true holistic medicine and traditional Chinese medicine is one of the forerunners of this form of assessment and treatment. We refer to it as ‘treating the root and branch’. A metaphor that describes treating the ‘cause’ and the ‘symptoms’ of a disease. If a disease of either the ‘root’ or ‘branch’ is not fully assessed, the results will be compromised (in this case, semen quality and quantity).

8. We understand the many different categories of male infertility.

We complement our classically trained Chinese medicine diagnostic skills that incorporate ‘patterns of disharmony’ with rigorous scientific scrutiny, research, and clinical experience.

9. We believe male infertility needs more research, so we thoroughly investigate all potential factors within every category of male infertility. For example, while scientists believe environment and genetic factors are responsible for declining sperm quality, in more than 60% of infertile men there is no known cause for their sperm abnormalities (McLauchlan, 2004). Our team believes there are many complex factors related to male infertility that are routinely not investigated, so we investigate all potential factors with each client because we want to help provide answers and contribute to the research.

10. We add specific and appropriate questions to our medical history questionnaire. Most men do not know why they have developed a fertility problem. Unless specific questions are asked, answers will not be found and a comprehensive diagnosis cannot be made.

11. We discuss further testing options when appropriate, including blood tests, ultrasounds, and testicular biopsies.

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CHINESE MEDICINE TREATMENT SUPPORT

1. We offer detoxification and pre-conception programs for all men, based on the latest research, a naturopathic style consultation; and traditional Chinese medicine.

2. We provide nutrition and dietary guidance. based on naturopathy, Chinese Medicine diet therapy and best available evidence-based research.

3. We are aware of simple non-invasive solutions. Sometimes the reasons for infertility are not complicated, however simple solutions confirmed by inexpensive tests may not always be explored by some practitioners.

4. We provide both naturopathic and Chinese medicine assessment and treatment. Our Chinese medicine practitioners have been attending advanced naturopathic training workshops for nearly 3 decades.

5. We have a dispensary with over 300 single herbs. We mix on site our own Chinese medicine formulas with tailored modifications based on classical Chinese herbal medicine theories and strategies in treating disease. Our treatment involves absolute tailoring of our formulas to each man’s constitutional requirements (see Acupuncture and Chinese Medicine). We do not cater to a ‘one size fits all’ treatment strategy.

6. We are familiar with the array of formulas and products on the market. We select those that best assist in improving sperm count, motility, morphology, DNA fragmentation, sperm antibodies, varicocele, testicular infection, heavy metal contamination, detoxification, and other related sub categories.

7. We are experienced in treating a range of complex and chronic diseases, that may compromise the success of the fertility treatment. Scientists believe that general health and wellbeing can be a blueprint for testicular health (Franken and Kruger, 2004b). We agree that testicular health and general health may compromise sperm quality. For example, an azoospermic man will require specific herbs to assist with sperm production and quality, however if this man also has chronic diarrhoea and this is not addressed, the herbal remedies will be of little benefit to sperm quality.

Similarly, if a man with high DNA fragmentation has a history of chronic sinus infection with copious production of nasal mucus, or has a chronic cough or wheezing or night sweats or testicular pain or high blood pressure, these health problems will need to be addressed before the underlying problem of infertility, and increasing sperm count and quality, is effectively addressed. Doing anything less may not be effective.

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COMPLEMENTING SYDNEY-BASED IVF PROGRAMS

We provide acupuncture and Chinese herbal medicine treatment during ART cycles to increase pregnancy rates caused by female or male factors influencing infertility. We also provide an advisory service on best practice in Sydney on a range of surgical and ART procedures.

After nearly 3 decades experience working with every ART centre in Sydney and, with a research background following systematic reviews and meta-analysis, the Fertility Health team is able to discuss at length all issues related to male factor diagnosis and treatment as well as IVF and ICSI.

This includes: the diagnosis and treatment of varicocele, azoospermia biopsies, IUI (inter uterine insemination), post vasectomy reversal treatments, sperm antibodies, high sperm DNA fragmentation, sperm mucus hostility, and related topics.

We provide feedback on local specialists.

Standards and expertise may vary greatly from one Assisted Reproductive Treatment (ART) clinic to another so we offer discussion on world's best practice.

For example, some azoospermic men may require testicular biopsies or may already have had failed biopsies. Matching the most appropriate and evidenced based type of biopsy to each man’s condition, as well as selecting the most suitable specialist with sufficient expertise in this surgical technique, may greatly improve the chance of achieving a healthy pregnancy.

New and developing techniques may offer greater success than current procedures being offered at the nearest In Vitro Fertilisation (IVF) clinic. Our familiarity with the most up to date array of relevant systematic reviews and their conclusions and clinical recommendations may assist a client in asking the right questions in their search for the most progressive medical specialist for their condition.

We bring our own insights to the table in order to support best outcomes for IVF and ICSI.

We have meticulously recorded our Chinese medicine treatments during ART cycles for nearly 3 decades, and this provides us with a wealth of clinical experience and insight. Our team also monitors the results of Chinese medicine clinical studies supporting IVF and ICSI and offers these treatments during IVF cycles.

We complement ART cycles to increase pregnancy rates with acupuncture and Chinese herbal medicine.

Studies support the use of Chinese medicine to improve sperm count, motility and quality as well as fertilisation and pregnancy rates during ART cycles (Pei et al., 2005; Siterman et al., 1997; Siterman et al., 2000; Zhang et al., 2002).

We are committed to providing treatment options for natural fertility cycles.

The ART industry offers procedures such as IVF and ICSI that may bypass a male factor, however treatment options and research on natural fertility have not always been fully explored. We are dedicated to contributing to natural fertility treatment options and research.

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THE DIFFERENT CATEGORIES OF MALE INFERTILITY

Many different types of acupuncture strategies, Chinese medicine herbal formulas and vitamins are provided at our centre for infertile men, because the subject of male infertility is remarkably complex and all men will require different treatment plans. For example, a male factor may be caused by azoospermia, low sperm count, poor motility, poor morphology, retrograde ejaculation, sperm antibodies, post vasectomy reversal infertility, high DNA fragmentation, and varicocele just to name a few.

All of the above categories are well understood by our team, as different methods of treatment must be provided. For example, azoospermia is a totally different cause of infertility than that of varicocele or sperm mucus hostility and therefore requires a totally different treatment strategy.

A tailored treatment plan is also required within all categories of male infertility. For example, in 20 men with low sperm count, there may be 30 different patterns of disharmony in Chinese medicine requiring 30 different herbal prescriptions for low sperm count. An experienced and skilled diagnosis may make the difference between success and failure.

Similarly azoospermia caused by Klinefelter syndrome is totally different from obstructive azoospermia or azoospermia seen after a vasectomy reversal or testicular infection. We observe different patterns of disharmony in Chinese medicine (CM) for azoospermia and all patterns require different CM treatment intervention.

Significantly, this is often the reason why a very small percentage of men respond to antioxidants when most do not. Therefore experience in CM assessment requires understanding the complex nature of infertility and all its potential causes in order to provide a tailored treatment.

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AZOOSPERMIA

As the incidence of infertility increases world wide, we see a growing number of men in our clinic searching for answers and support for azoospermia. We have a lot of experience supporting azoospermic men and our anecdotal evidence is extremely encouraging.

What is Azoospermia?

Azoospermia is diagnosed after a semen sample has been analysed and there is no sperm detected in the sample. This diagnosis suggests that the couple are unable to conceive naturally.

This news often comes without warning and as a complete surprise because until a microscopic examination of a semen sample, one cannot know if there is live sperm or not in the ejaculate. The man may appear in all other ways to be healthy, as only a small percentage of azoospermic men have genetic causes such as Klinefelter Syndrome.

Azoospermia can either be: i) obstructive; or ii) non obstructive; which requires different treatment strategies in the ART and Chinese medicine clinic. However in both cases, the next step will involve a testicular ultrasound and biopsy.

Before the first testicular biopsy, we recommend an assessment with our team. There are good reasons for this recommendation. For example, we know there are several different types of azoospermia and many different causes, however in all cases (except perhaps obstructive azoospermia) there will be spermatic arrest (when the testes stop making sperm).

Spermatic arrest can occur in varying degrees, and some men may still have small pockets of sperm production continuing in one or both testes, and if this is happening, it is very good news, and Chinese medicine has a long history of supporting sperm count and production (Baocun, 2001; Becker, 2000; Clavey, 2003; Jiasheng, 1987; Liang and May, 1996; Pei et al., 2005; Siterman et al., 1997; Siterman et al., 2000; Xiangyi, 1997; Xinyun, 1998; Yachun, 1990; Chen et al., 2003; Zhang et al., 2002; Zhiyuan, 1996; Zhiyuan, 1997b; Zhiyuan, 1997a; Zongchang, 1997).

On the other hand, all testicular biopsies potentially traumatise the local area, leading to a higher likelihood of irreversible spermatic arrest developing. So while the testicular biopsies are designed to search for small pockets of immature sperm in the testes in order to surgically extract and use in ART cycles, the fewer biopsies needed; the better the long term success.

We like to commence supportive CM treatment to encourage sperm production as soon as possible. Importantly, early intervention may provide optimal results, and this requires a thorough assessment in our clinic to determine all risk factors to spermatic arrest.

There are many risk factors that can compromise biopsy success, for example, research suggests that conception with ART is significantly reduced in cases of azoospermia when FSH (Follicle-stimulating hormone) levels are greater than 20 IU/L. We provide an assessment and tailored treatment program to address all underlying health problems that might reduce the chances of conceiving through ART.

Please note, the acupuncture points selected for treatment tend to be on the legs, hands and abdomen, but never on the testes.

We provide discussion on world's best practice related to ART procedures and biopsies by following systematic reviews and meta-analysis. Our discussion includes biopsies such as TESE (Testicular sperm extraction or testicular sperm incision), MESA (microsurgical epididymal sperm aspiration), PESA (percutaneous epididymal sperm aspiration), PICSI (preselective Intracytoplasmic Sperm Injection), and IMSI (Intra-cytoplasmic Morphologically-selected Sperm Injection).

We provide feedback on local specialists because standards and expertise may vary greatly from one ART clinic to another. Our team independently observes surgical outcomes between one specialist and the next. For example, matching the most appropriate and evidenced based type of biopsy to each man’s condition as well as selecting the most suitable specialist with sufficient expertise in this surgical technique may greatly improve the chance of achieving a healthy pregnancy. New and developing techniques may offer greater success than current procedures being offered at the nearest IVF clinic.

Our familiarity with the most up to date array of relevant systematic reviews and their conclusions and clinical recommendations may assist a patient in asking the right questions in their search for the most progressive medical specialist for their condition.

Some of the men with azoospermia who have attended our clinic already had biopsies with no live sperm found.

This is generally the worse case scenario and devastating news for any couple. Anecdotal evidence at our clinic suggests that 50% of these men go on to have a successful testicular extraction leading to fertilisation and healthy birth with ART after our CM treatment, and we are very excited about these results.

There has also been some promising research using Chinese medicine to support azoospermic men (Baocun, 2001; Bidouee et al., 2011; Gashing, 1987; Liang, 1996; Qiang, 1995; Zhiyuan,1996; Zhiyuan, 1997; Zongchong,1997), and we look forward to further studies.

We offer assessment on the female partner to predict risk to implantation and miscarriage. Significantly, when there is an obvious male factor diagnosed, the main focus of investigation may remain with the man and the female partner may be overlooked. In our experience, lack of thorough screening of the female partner is the single most common reason for a failed ART cycle after successful fertilisation.

Importantly, early identification of a female factor may reduce the number of biopsies a man may require. This is essential because multiple biopsies or dissections may lead to irreversible spermatic arrest and high biopsy failure rate.

Further, we have observed that many of the blood tests and ultrasounds conducted on women fail to identify simple reasons for a female factor, leading to increased risk for miscarriage and poor implantation rates during ART cycles. We monitor these commonly overlooked risk factors in our assessment of the female partner through Chinese medicine ‘patterns of disharmony’ (see Female Intertility - Unexplained Infertility).

We offer Chinese medicine treatment support for the female partner. Support includes acupuncture and Chinese herbal medicine (see Female Intertility - Unexplained Infertility). Importantly, there have been some very good clinical trials showing higher implantation and pregnancy rates after acupuncture treatment during ART cycles compared to ART alone.

(Balk J et al., 2009; Benson et al., 2006; Cheong et al., 2008; Dalton-Brewer et al., 2010; Dieterle et al., 2006; Horn et al., 2007; Magarelli et al., 2004; Meagrely et al., 2009; Manheimer et al., 2008; Paulus et al., 2002; Quintero et al, 2004; Siterman et al., 1997; Siterman et al., 2000; Smith et al., 2008; Smith al., 2006; Song et al., 2008; Teshima et al., 2007; Udoff et al., 2007; Westergaard et al., 2006; Yang et al., 2005; Youran D et al., 2008; Zhang et al., 2003). Conversely, one study suggested placebo acupuncture produced higher pregnancy rates (So et al., 2009).

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VASECTOMY REVERSALS

Our team has significant experience in treating men with poor results following vasectomy reversal, as it is a common surgery. Around 15,000 - 16,000 vasectomies are performed in Australia anually.

A man is able to reverse his vasectomy through microsurgery, and studies suggest that success is relatively high if the reversal is done within 3 years of the vasectomy (Schouer and Thomas, 2000). However, optimal sperm count and quality will continue to decline the greater the lapse of time after reversal. Around 70% of men will develop sperm antibodies post vasectomy reversal (see Sperm Antibodies). Our team often sees high levels of sperm antibodies and abnormalities, poor motility and low sperm count, post reversal.

Importantly, spermatic arrest (when the testes stop producing sperm) may also occur after a vasectomy reversal due to the side effects of both procedures. It is not known if this arrest is reversible.

Due to the range of potential outcomes that we have seen in our clinic post surgery, we have developed the following treatment strategies:

1. Chinese medicine assessment is recommended before surgery for vasectomy reversal. This provides an opportunity for risk assessment for poor outcomes post surgery based on ‘CM patterns of disharmony’. For example, one pattern called 'turbid phlegm damp obstruction in the lower heater', may indicate a low grade (medically overlooked) testicular infection, indicating increased risk of spermatic arrest and higher levels of sperm antibodies, abnormalities, and poor sperm count post surgery.

2. When low grade testicular infection is indicated, Chinese medicine treatment should commence before vasectomy reversal surgery, in order to optimise testicular health prior to surgery when there is any indication of low grade testicular infection. We wish to avoid the occurrence of spermatic arrest.

3. Acupuncture treatment post vasectomy reversal should recommence between 3 - 5 days post surgery. Our anecdotal evidence suggests optimal outcomes when acupuncture is given post surgery. Further, we prefer to avoid any risk of testicular infection developing, because as early as the 1980’s, scientists named this infection, ‘super bugs’ (Franken and Kruger, 2004b), because they are so very difficult to clear and their impact on sperm quality is indisputable.

Please note, the acupuncture points selected for treatment tend to be found on the legs, hands and abdomen, but never on the testes.

4. Chinese herbal medicine early intervention is recommended post surgery to support sperm count and reduce the incidence of sperm antibodies and abnormalities (Siterman et al., 2000).

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SPERM ANTIBODIES

The diagnosis and treatment of sperm antibodies is encouraged in our clinic, because high levels will make it hard to conceive. We often see this parameter overlooked on fertility assessment, and yet our anecdotal evidence suggests good pregnancy rates naturally after Chinese medicine treatment.

There are two types of sperm antibodies that can be measured in semen samples: IgA and IgG. An indication of positive for sperm antibodies is found when the total of either type is greater than 50%.

What are sperm antibodies?

Sperm coated with antibodies become very restricted and may die or adhere to other sperm leading to compromised motility and fertilisation potential. Therefore a couple trying to conceive naturally will have difficulty when antibodies are above 50%.

Sperm antibodies are not always tested on the semen analysis, because they do not impact IVF cycles. However, sperm antibodies will impact natural fertility, therefore a semen analysis should always test for their presence.

How do we work with sperm antibodies?

The Fertility Health team predicts sperm antibody risk by the observation of certain classical Chinese medicine patterns of disharmony. If there is a risk, another more rigorous semen analysis is recommended to confirm sperm antibody levels.

Chinese medicine treatment for sperm antibody is provided at our centre. The treatment strategy is greatly influenced by the type of elevated antibody found (IgA or IgG). Our anecdotal evidence suggests good outcomes and pregnancy rates by treating both types of sperm antibodies with acupuncture and Chinese herbal medicine.

Treatment includes a complex array of classical CM formulas that addresses a pattern of disharmony including ‘damp heat in the lower heater’. Multiple variations are often made to the formulas we mix in our clinic, depending on the constitution of the man and the observation of other CM patterns.

Common CM patterns of disharmony observed in men seen with sperm antibodies may also include: spleen qi vacuity, gall bladder damp heat, hot stomach, kidney yang vacuity, kidney yin vacuity, liver qi stagnation and heat, blood vacuity or blood stagnation, wei qi vacuity, and turbid phlegm damp obstruction in the lower heater.

There are a few CM studies that cite evidence for the use of Chinese herbal medicine and acupuncture to reduce sperm antibodies (Li et al., 1995; Yu et al., 2004). Our anecdotal evidence suggests CM intervention lowers antibody levels, leading to a natural pregnancy.

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VARICOCELE

The diagnosis of varicocele is rarely pursued when there are high levels of abnormal forms found in a semen sample, despite a 50% chance of the man having a varicocele. We see good results in our clinic when varicocele is treated with Chinese medicine after embolisation.

What is varicocele?

A varicocele is a varicose vein of the testes. If present it is generally located on the left testis, and occasionally found on both. A varicocele is thought to impact natural conception by reducing sperm count and increasing abnormalities. Around 37% of sub fertile men have a varicocele (McLachlan, 2004), and it is thought that all men over 50 are likely to develop a varicocele at some stage of their lives.

We have found that 50% of men with abnormal sperm morphology higher than 96% in semen samples are likely to have varicocele.

Varicocele can often be seen by visual observation and palpation of the testes; however a visual examination is not conclusive. To confirm a diagnosis, best evidence suggests an ultrasound of the testes to screen for an internal or ‘sub clinical’ varicocele (Evers and Collins, 2003; Jarow et al., 1996).

If a varicocele is found we recommend consultation with a urologist specialising in male infertility. A urologist experienced in this field, can determine not only if the varicocele is small, moderate or large, but importantly the clinical significance.

At Fertility Health we have observed a pattern of commonly seen factors that predict varicocele. Certain patterns of change in the semen analysis report over a couple of years also suggest risk. We recommend an ultrasound of the testes if normal forms are below 4%.

What is the TREATMENT FOR VARICOCELE?

A systematic review on the benefits of ligation or surgery to remove varicocele (Evers and Collins, 2003), concluded that the majority of robust randomised clinical trials (RCTs) showed no evidence or significant improvements in semen parameters after surgery. For example, such as ligation provided by several Sydney uroligists.

We have observed similar poor outcomes, as well as long term side-effects, such as numbness and pain of the testes lasting more than six months.

For this reason the Fertility Health team has, over many years, investigated other cost effective, minimally invasive interventions such as embolisation, and found consistently good improvements in semen parameters and pregnancy rates when complemented with a thorough Chinese medicine assessment and treatment.

We recommend acupuncture continue within one week post embolisation to support recovery and sperm count and quality. While several Chinese medicine (CM) studies have outlined good outcomes after intervention with CM (Cakmak Y et al., 2008; Ishikawa et al.,1996), in our experience this is more likely to be seen when acupuncture is complemented with embolisation.

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SPERM MUCUS HOSTILITY

(see Female Infertility - Sperm Mucus Hostility).

SPERM COUNT

From one man to the next, sperm count can vary greatly, and our study showed excellent improvement in sperm count after eight weeks of Chinese medicine treatment.

What is a poor sperm count?

Sperm numbers are usually measured in sperm density and count. Sperm density refers to the sperm count per ml collected and a healthy density is when there is over 20 million sperm per ml seen, while lower numbers may suggest poor conception potential. Sperm density is an indication of the ability of the testes to produce spermatozoa (Pacey, 2006).

A total sperm count of more than 40 million sperm is ideal and anything less may suggest a male factor. Total sperm count is calculated by the total seminal volume collected (normally 2-5 ml), multiplied by the sperm density (count per ml collected). If a man has no sperm in his ejaculate he is diagnosed with azoospermia.

While total sperm count is considered an important parameter, some research suggests that count is likely to vary extensively from one day to the next. For this reason count may be an unreliable predictor of a male factor due to potentially huge variations during any given month. This is why the collection of data across a wide group of semen parameters may assist to more accurately predict a male factor.

What is the evidence for Chinese medicine treatment?

Several studies and papers claim good pregnancy outcomes and statistically significant improvements on sperm density after Chinese medicine treatment. (Baocun, 2001; Becker, 2000; Chen et al 1996; Chen et al., 2003; Clavey, 2003; Dieterle et al., 2009; Jiasheng 1987; Liang and May, 1996; Mehmet et al., 2006; Minghua 1993; Pei et al., 2005; Siterman et al., 1997; Siterman et al., 2000; Xiangyi, 1997; Xinyun, 1998; Yachun, 1990; Zhang et al., 2002; Zhiyuan, 1996; Zhiyuan, 1997b; Zhiyuan, 1997a; Zongchang, 1997).

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MORPHOLOGY

Morphology is considered the most important parameter in predicting a man’s fertility potential. However, predicting risk to a man’s long term health can also be made through morphology assessment, and we have collated data on this subject for many years, while achieving good results using Chinese medicine treatment.

What is morphology?

Sperm or spermatozoa are a single cell, and this cell has a head, neck, mid piece, and tail. Morphology refers to the shape and design of this single cell and whether it is normal or abnormal.

Under magnification it is possible to find deformities on any one or more of these areas of the cell (sperm). Morphology documents the percentage of ‘normal forms’ or normal sperm found in the semen sample once all these abnormalities have been taken into consideration. A robust semen analysis will also break down the percentage of normal forms found on all areas of the cell, including head, mid piece, and tail.

Why is morphology important?

Misshapen forms of the sperm are important to assess because they influence the sperm's ability to swim, fertilise an egg, and support embryo development. Importantly, head defects reduce the sperm's capacity to fertilise an egg both naturally and in vitro (in a test tube) because, when there is a misshapen head, the sperm cannot penetrate the outer wall of the egg. Therefore, the higher the number of head defects the higher the difficulty conceiving naturally and in a test tube.

High levels of head defects also make it more likely to have elevated levels of sperm DNA fragmentation because the cell nucleus and genetic material are found in the head of the sperm. Therefore, when there is a high level of abnormal forms sperm DNA testing should be considered.

Further, there are several different types of head defects and, depending on the defect, a different disease may be indicated. For example, if the head of the sperm has a ‘tapered’ shape this may indicate some form of exposure to environmental poisoning. So there is more to semen assessment than predicting fertilisation potential. Many scientists believe that the sperm quality (which is just another cell in the body), is a ‘blueprint’ for the health of the man.

For example, endocrinology, toxicology, and risk for certain diseases and cancers may also be predicted through semen analysis (Franken and Kruger, 2004a;). In particular, the tapered head abnormality specifically suggests environmental factors (Franken and Kruger, 2004a; Hofman and Haider, 1985; Menkveld et al., 1991). Mild, moderate, or severe tapering may indicate mild to severe environmental damage, reflecting the treatment time necessary to improve semen parameters and general health. Severe tapering is thought to be irreversible (Hofman and Haider, 1985).

Therefore, certain risk factors may be monitored through a good semen analysis. This includes risk for testicular, prostrate, and bowel cancers, as well as low grade testicular infection, compromised immune system, auto immune disease, chronic fatigue, and depression. Consequently, our team believes a thorough semen assessment is essential.

Why is morphology assessment not that straightforward?

Monitoring sperm quality and predicting fertilisation potential based on the current assessment procedures is not straightforward. This is because semen assessment was designed to assist the ART industry to select the optimal procedure and lab fertilisation technique based on a man’s semen assessment. Assessment was not developed to predict natural fertilisation potential and, as a result, several important parameters are not assessed because they do not impact ART fertilisation procedures.

The Fertility Health team believes it is important to assess all semen parameters that impact natural conception, and frequently recommends further testing be conducted and offers a second opinion on semen assessment and reporting.

Significantly, before DNA testing was available, researchers believed ‘morphology’ or sperm abnormalities were the most important parameter to predict fertilisation potential (Carlson, 1999; Coetze, 1998; Windt and Kruger, 2004) in vitro (the laboratory). Importantly, due to a lack of standardisation in semen analysis laboratories, an assessment may not be reliable. For this reason, if the Fertility Health team suspects a male factor during our initial consultation, we routinely recommend another test be taken with a reliable laboratory. If there are high levels of abnormal forms found, we also recommend DNA fragmentation be tested.

What does Chinese medicine say about sperm morphology?

Chinese medicine pioneered the theory that there are many different reasons why a man may develop high levels of abnormal forms.

Further, both Chinese medicine and modern science agree that sperm quality is a ‘blueprint’ of a man’s general health. Factors considered are testicular health, the man’s general health, his lifestyle, and his environment. These are some of the issues that are investigated and addressed at our centre (see Male Infertility: Diagnosis and Assessment).

There have been several clinical studies showing good outcomes in the treatment of sperm morphology with Chinese medicine treatment (Baocun et al 2001; Garfinkel et al., 2003; Jiasheng 1987; Mehmet et al., 2006; Pei et al., 2005; Yachun et al.,1990; Zhiyuan, 1997).

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MOTILITY

Sperm motility gives a measure of the integrity of the sperm axoneme and tail structures as well as the health of the mitochondria (the energy supply of the sperm) (Pacey, 2006).

Abnormalities of the tail may reduce a sperm’s ability to swim. Other factors that might influence a sperm's motility include the incidence of sperm antibodies, clumping; elevated pH, and increased viscosity and agglutination.

Each of these parameters may impact the seminal fluid or the environment in which the sperm needs to function, and as such are important for sperm health and natural conception. Motility is often divided into rapid, progressive, and immotile and given a motility index. When sperm motility is compromised, one may also expect morphology to be compromised.

What are the implications for tail defects?

It is said that the energy required for a sperm to swim and meet an egg is equivalent to a person walking from Sydney to Canberra.

Fertility is compromised when the sperm is unable to swim the distance, however there are several different types of abnormalities that can be found on the tail, and it is important to have these described by the scientist making the assessment because different shapes can give insight into different health implications.

For example, coiled tails are associated with damage to sperm as a result of a man’s exposure to organic solvents such as those found in glues, paints, and cleaning fluids (Alexander, 1992; Franken and Kruger, 2004b). Similarly, it is also considered important to identify men who have acquired sperm DNA damage as a result of contaminants because this damage may be passed on to offspring through assisted reproduction technology procedures (Braude and Rowell, 2003b).

What is the evidence in Chinese medicine?

In some small studies good outcomes have been measured after Chinese medicine intervention on motility rates. (Baocun et al., 2001; Chen et al.,1996; Chen et al., 2003; Jiasheng, 1987; Minghua, 1993; Mehmet et al., 2006; Pei et al., 2005; Siterman et al., 2000). A thorough Chinese medicine assessment is recommended when motility is compromised, and the team is interested in improving motility scores, as well as determining all causative factors and consequent health ramifications (see Diagnosis and Assessment).

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SPERM DNA FRAGMENTATION

Research suggests sperm DNA fragmentation over 25.5% predicts increased risk of poor fertilisation, compromised embryo development, low implantation rates, and high miscarriage rates during IVF (Lopez et al., 2013). If you are a couple trying to fall pregnant naturally or considering assisted reproductive treatment, the following information may assist you in making a more informed fertility choice.

Research suggests that environmental and lifestyle factors may be associated with DNA fragmentation. (Sinclair, S., 2002). Other scientists emphasise the importance of specifically determining environmental factors in semen abnormalities in order to identify men at risk of developing further disease related to this exposure (Branigan, 2003; De Jager and Borman, 1999; Sinclair 2002; Townsend, 2004). Similarly to tail defects above, it is also considered important to identify men who have acquired such sperm DNA damage because this damage may be passed on to offspring through assisted reproduction technology (ART) procedures.

One of the first signs of risk for high DNA fragmentation is a high level of head defects seen in the semen analysis because the cell nucleus and genetic material are found in the head of the sperm. The higher the number of head defects, the greater the likelihood of DNA fragmentation and abnormalities in the cell nucleus.

Defects of the head may compromise a sperm’s ability to fertilise an egg because a sperm with an abnormal head cannot penetrate the outer layer of the egg. This is a good example of a natural selection process that reduces the chance of birth defects as a result of potential genetic abnormalities. However, this process is no consolation when a couple is not able to conceive.

Of significance, as mentioned above, is that problems may occur when this natural selection process is by-passed.

For example, natural selection is not possible during ART procedures, such as ICSI (intra cytoplasmic sperm injection), because the scientist makes selection based on a motile, moving, or active sperm, and the sperm with high DNA fragmentation may still have normal tails and motility.

If a damaged sperm is motile and active it may appear healthy and therefore meet selection criteria during ICSI procedures. As a result, we often observe higher fertilisation rates during ICSI but disappointing implantation rates.

Therefore, ICSI is extremely good at by-passing male fertilisation problems (Liu and Baker, 2003). However, it attracts criticism because of the potential negative health ramifications to offspring as a result of injecting sperm with DNA or chromosomal damage into an egg (Newby, 2003; Hansen et al., 2002; Bartoov et al., 1999).

We also see higher rates of miscarriage during ART cycles compared to natural conception and world wide we observe increased levels of babies born with birth defects after ICSI. Therefore, DNA fragmentation tests are recommended if a couple decide to go through ART, especially if there are high levels of abnormal sperm in the ejaculate. This will assist the doctor in choosing the most appropriate sperm selection procedure against the sperm quality. For example, PICSI (Preselective Intra-cytoplasmic Sperm Injection) or IMSI (intra-cytoplasmic morphologically selected sperm injection) may be more appropriate than ICSI.

We also advise that all men have their sperm DNA tested before the commencement of an ART cycle because sperm morphology testing is not always reliable. For example, sperm may potentially have ten different forms of head defects, however the IVF clinic may only screen for four. For this reason we also recommend sperm DNA screening be conditional for donor sperm.

How do we improve DNA fragmentation in Chinese medicine?

Chinese medicine diagnosis and assessment incorporates the observation of patterns of disharmony that is well suited to monitoring general health, lifestyle, and environmental factors that may contribute to sperm DNA fragmentation and high morphology. Our team also has extensive experience in assessing and treating heavy metal contamination.

We have observed, on numerous occasions, men who are unaware of their exposure to significant levels of heavy metals because they are not at risk in their current work environment. Other men, at obvious risk due to their work or hobbies, are unaware of the implications to their health and fertility.

During our assessment certain questions must be asked for the line of investigation to exclude heavy metals or other environmental factors in order to develop a comprehensive treatment strategy. All known contributing factors, including testicular infections, environmental, lifestyle, and general or chronic health conditions, must be systematically assessed for treatment outcomes to be ideal.

Sometimes there appears to be no obvious reason for DNA fragmentation and the man may appear to be healthy in every other way. This is where the CM assessment incorporating ‘patterns of disharmony’ may be useful in the diagnostic process.

Chinese medicine treatment is recommended to support improvement in all chronic and acute health problems, as well as determining and treating associated endocrine, testicular, and environmental factors. CM ‘root’ and ‘branch’ diagnosis and treatment strategy endeavours to identify and treat cause and symptom.

There are several Chinese medicine studies that give support to CM treatment of sperm abnormalities, suggesting increased pregnancy rates both naturally and in support of ART. (Jiasheng, 1987; Siterman et al., 1997; Yachun, 1990; Zhiyuan, 1996; Zongchang, 1997).

If DNA fragmentation is diagnosed, a Chinese medicine assessment and treatment at our clinic is recommended whether you are intending to use ART, or to fall pregnant naturally.

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REFERENCES

  1. Lopez et al., Diagnostic value of sperm DNA fragmentation and sperm high magnification for prediction outcome of assisted reproduction treatment. Asian J Androl. 2013 Nov; 15(6): 790–794. Published online 2013 Aug 5.
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