Management of infertile men with no sperm


Part One – Introduction

Azoospermia affects 1% of all men and accounts for 10-20% of males who present with infertility. It is defined as the complete absence of sperm in the ejaculate. The largest groups are: abnormally descended testes (17%), Klinefelter’s syndrome (14%), infertility of unknown cause (13%) and previous vasectomy (5%). Essential to the workup of male infertility is the semen analysis. According to WHO specimen collection guidelines, two samples (if the first is abnormal) are required. The goals are to determine the underlying cause and subsequently either treat it if possible; or retrieve sperm for assisted reproductive techniques. All investigations and treatment options are available at the Reproductive Health Group or can be organised by our Urologists at nearby hospitals.

The clinician needs to attempt differentiation between obstructive azoospermia (OA) and non-obstructive azoospermia (NOA).

Obstructive (or post-testicular azoospermia, OA) accounts for 40% of azoospermia and can result from a multitude of causes which may be due to a structural (e.g. vasectomy) or functional problem (e.g. failure to ejaculate). Men with OA classically have normal sex hormones (testosterone and FSH), normal testes on clinical examination and normal ultrasound.

NOA can be classified as pre-testicular (the rarer cause; often due to abnormalities of the hypothalamus or pituitary gland in the brain), or testicular; leading to impaired formation of sperm within the testes. Pre and post-testicular azoospermia are often treatable, whereas testicular causes (apart from azoospermia associated with varicocele), are generally not correctable.

Causes of Obstructive Azoospermia (OA)

Structural

Iatrogenic / traumatic

  • Previous vasectomy (most common cause of OA)
  • Inguinal hernia repair (especially with mesh)
  • Pelvic or scrotal surgery (e.g. hydrocele repair, orchidopexy)

Congenital

  • Congenital bilateral absence of the vas deferens (CBAVD)
  • Young’s syndrome (sinus and chest infections and azoospermia)
  • Mullarian or Wolfian duct cyst/ ejaculatory duct cyst

Infective

  • Chlamydial or gonococcal infection

Functional

  • Drugs, spinal injury, neurological, previous pelvic or abdominal surgery

Causes of Non-obstructive Azoospermia (NOA)

Pre-testicular (hypogonadotrophic hypogonadism)

Congenital

  • Kallmann’s syndrome (inability to smell, delayed puberty)

Acquired

  • Previous surgery of pituitary gland
  • Treatment with testosterone
  • Granulomatous illness
  • Haemochromatosis
  • Autoimmune diseases

Testicular (hypergonadotrophic hypogonadism)

  • Klinefelter’s syndrome
  • Maldescended testes or torsion
  • Varicocele
  • Tumour
  • Drugs – steroid abuse, chemotherapy, gonadotoxins
  • Infection – mumps
  • Idiopathic (i.e. unknown cause)


Part Two – History and Examination

For men referred to the Reproductive Health Group for azoospermia, your Andrologist will carefully explore your medical history and carry out a physical examination as required. Subsequently, various investigation might be required (described in Part 3), before a management plan can be suggested.

History suggestive of Obstructive Azoospermia (OA)

  • Previous surgery (vasectomy, inguinal, scrotal, retroperitoneal)
  • Genitourinary infection
  • Chronic bronchopulmonary infection
  • Family history of cystic fibrosis
  • Normal libido

History suggestive of Non-Obstructive Azoospermia (NOA)

  • Delayed development/ onset of puberty
  • History of undescended testes or testicular torsion
  • Previous gonadotoxic treatments (including chemotherapy and radiation)
  • Environmental exposure to gonadotoxins
  • Treatment with (or abuse of) exogenous testosterone
  • Headaches
  • Visual disturbance
  • Pituitary surgery
  • Low libido

Examination Findings suggestive of OA

  • Normal male characteristics
  • Inguinal or scrotal scars
  • Normal testis size, consistency and position
  • Epididymal fullness or cysts
  • Vasa may be absent
  • Vasal defect from vasectomy
  • (if present assess for position and length of defect and for sperm granuloma)
  • Prostatic or midline cyst on digital rectal examination

Examination Findings suggestive of NOA

  • Lack of male characteristics
  • Small atrophic testes
  • Undescended testes
  • Varicocele
  • Gynaecomastia (breast swelling)
  • Visual field defects


Part 3 – Investigations

Semen analysis

Semen analyses are vital in establishing the quality and quantity of sperm in infertile patients. According to the WHO, at least two evaluations should occur over a two months period.

Men with certain forms of obstructive azoospermia (OA) may have a reduced ejaculate volume (less than 1.5mL). Obstruction in the prostate will result in low semen volume with low pH and fructose levels. Normal volume implies non-obstructive azoospermia (NOA) or obstruction of both vasa or epididymes.

Hormone profiling

Follicle stimulating hormone (FSH), luteinising hormone (LH) and early morning testosterone (T) should be measured. OA results in normal hormonal levels, whilst pre-testicular and some testicular abnormalities may have abnormal levels.

Low Testosterone with elevated FSH and LH may be found in primary testicular failure (where the testes have stopped working properly, for unknown reasons). Should there be an abnormality of these hormones, an endocrinology referral should be strongly considered. Pre-testicular infertility (with low Testosterone and low FSH and LH) should be further investigated with prolactin levels and imaging of the pituitary gland (such as a brain MRI).

Genetic testing

Genetic testing is an important part of the workup for azoospermia, especially when considering NOA. In these cases, there is an increased frequency of chromosome abnormalities – for example Y-chromosome microdeletions and Klinefelter syndrome.

• Sex chromosome abnormalities

Klinefelter’s syndrome (KS) is the most common chromosomal abnormality (affecting one in 600 males) and accounts for approximately 15% of NOA. The “classical” form (47 XXY) accounts for 80-90% of KS cases. In the remaining 10-20%, so called “mosaics” are found. Clinically, these men have small firm testicles (<5cc) and may demonstrate normal virilisation, but also scant or female hair distribution. Testosterone may be normal or low, whilst FSH is increased.

• Y-chromosome abnormalities

Three microdeletions on the long arm of the Y Chromosome account for about 7% of severe oligospermia/ azoopsermia. AZFc varies between azoospermia and oligospermia. There is a 70% chance of finding sperm with AZFc and thus micro-TESE and ICSI are indicated. If intracytoplasmic sperm injection (ICSI) is utilised, these aberrations will be passed onto male children. In certain countries, pre-implantation sex selection of female embryos may be considered.

With AZFa or AZFb microdeletions, it is highly unlikely that any sperm will be found. Thus, microscopic surgical sperm extraction (micro-TESE) is not indicated and ICSI will fail.

• Autosomal disorders

Cystic fibrosis (CF), an autosomal recessive disorder, is due to a gene mutation. (Children can only develop cystic fibrosis if BOTH parents have the mutation.) It is associated with congenital bilateral absence of the vas deferens (CBAVD), which affects 1% of infertile men. Therefore, in infertile men with no vas on either side, testing for CF in both parents and referral to a genetic counsellor should be offered.

Imaging Options include ultrasound (US), magnetic resonance imaging (MRI) or more invasive methods including vasography.

Scrotal Ultrasound

Scrotal US can verify the size of the testes and look for the absence of structures as well as for evidence of obstruction such as spermatocele or dilatation of vas/ epididymis/ rete testis. It is also useful if the physical examination is suboptimal due to body habitus or testicular pain, or if examination findings are equivocal. In patients with NOA, scrotal US should be strongly considered as there is an increased risk of testicular cancer.

Transrectal Ultrasound

Transrectal US can identify ejaculatory duct obstruction. Aspiration of the seminal vesicles can be performed. Sperm aspirated in such manner can be used for ICSI.

Renal tract Ultrasound

Renal tract US should be performed when unilateral absence of the vas is noted – 20% will have no kidney on the same side.

MRI

MRI can be employed to identify ejaculatory duct or prostatic cysts. It enables evaluation of the vas deferens and seminal vesicles and may indicate the site of obstruction.

Vasography

Vasography is an invasive investigation used to identify the site of obstruction. It is rarely used in purely diagnostic situations and requires microsurgical skills.  It is an open procedure, usually undertaken as part of a therapeutic intervention to reconstruct an abnormality.

Testicular biopsy

Testicular biopsy may be helpful in differentiating OA from NOA in men with at least one palpable vas, normal testis size and normal FSH. It is is possible that performing a diagnostic biopsy may reduce the subsequent success rate of sperm retrieval via micro-TESE for NOA because of bleeding, haematoma and fibrosis. Therefore, should testicular biopsy be performed, having the ability to simultaneously cryopreserve sperm for use in ICSI is desirable.

Key Points for Determining the underlying cause of azoospermia

++ Most azoospermia can be determined via history, examination and first-line investigations

++ CFTR mutation should be tested for and genetic counselling offered for men with bilateral absent vasa. The female partners should also be counselled prior to using the sperm of these men

+++ Men with NOA should have genetic counselling with karyotyping and screening for AZF aberrations

+ Transrectal US +/- aspiration of seminal vesicles is important to exclude ejaculatory duct obstruction (EDO), particularly in men with low ejaculate volume

++ If one or both vasa are absent, renal US should be offered

+ Testicular biopsy may help to differentiate between NOA and OA in equivocal cases but has the potential to decrease the chances of sperm retrieval on subsequent Micro-TESE in cases of NOA: hence should be undertaken in units with facility to simultaneously cryopreserve sperm for use in ICSI.

Evidence level:

+++ strongly evidence-based
++ less strongly evidence-based
+ not evidence-based but clinically understood / clinical opiniona


Part 4 – Treatment: Reconstruction

Treatment of azoospermia depends on the underlying cause. Essential to determining definitive management is the evaluation of both partners. Female fertility factors (e.g. age, prior fertility, polycystic ovarian syndrome, endometriosis), the number of children desired, success rates of various treatment options, and even financial considerations, may impact the couple’s treatment choice. An understanding that treatments such as vasovasostomy (VV), vasoepididymostomy (VE), and varicocelectomy can take 3-6 months for optimisation of seminal parameters, may also influence a couple’s decision.

Reconstruction for Obstructive Azoospermia (OA)

OA can be overcome by reconstructive surgery, to relieve an obstruction and to restore sperm to the ejaculate. Alternatively, sperm can be harvested from either testis, epididymis or vas, in conjunction with assisted reproductive techniques such as IVF or ICSI.

Reconstruction includes vasovasostomy (VV), vasoepididymostomy (VE), and transurethral resection of the ejaculatory ducts (TURED).

Vasovasostomy (vasectomy reversal)

Despite the numerous factors to be considered, there are no controlled trials investigating whether surgical repair or sperm harvesting with assisted reproduction (AR) provide the better option. However, it appears that unless there are specific dictating female factors, vasovasosotomy provides a more cost-effective option with a higher delivery rate.

This procedure can be achieved by various techniques using an operating microscope or loupes. The principles of repair include a water-tight, end-to-end, tension-free joint with good blood supply.

Although a surgeon may plan for a VV pre-operatively, the decision to undertake VV or VE should be made intra-operatively by analysis of vasal fluid. After prolonged vasal obstruction (longer than 10-15 years), secondary blockage of the epididymis from high pressure can occur, requiring a connection between the vas deferens and the epididymis.

Besides duration since vasectomy, there are several factors that need to be taken into consideration – such as sperm granuloma, length of proximal vas and the microscopic appearance of fluid expressed from the proximal vas (using microscopy).

The following findings will promote VV as the choice of reconstruction:

• Copious clear fluid from the vasal stump on the testicular side

• Motile sperm in this fluid

• Whole sperm or sperm parts in this fluid

• Length greater than 2.7cm

• Sperm granuloma (a small nodule of scar tissue)

If there is absent vasal fluid or the fluid is thick and creamy, VE should be performed regardless of vasal length or presence of sperm granuloma.

An overall VV patency rate has been reported up to 86%, with an average pregnancy rate of 52%. The duration of obstruction and female fertility are important predictive factors in semen return and pregnancy rates.

If the female partner is aged 35 to 39, pregnancy rates are reported as 54%. However, once aged 40 years or older, these rates dramatically reduce to 14%.

Vas reversal outcomes

Obstructive Interval (years)Return of sperm ratePregnancy rate
< 397%76%
3-888%53%
9-1479%44%
>1571%30%

Vasoepididymostomy (VE)

VE is indicated for epididymal obstruction with patency rates of up to 80%, and pregnancy rates of 13-56% being reported. This procedure is technically very challenging and time-consuming. Use of an operating microscope is essential.

Transurethral resection of the ejaculatory duct (TURED)

TURED is a procedure which opens an obstructive midline cyst in the prostate or resects part of the prostate itself, dis-obstructing the ejaculatory ducts. The procedure can be performed at the same time as vasography (cannulation of the vas and injection of a dye).  Once the duct is adequately resected, a tinge of dye can be seen emerging in the prostate.

The procedure improves sperm numbers in 50% of previously azoospermic men, yielding a pregnancy rate of 25%. Complications include re-obstruction, rectal injury, retrograde ejaculation into the bladder and urine reflux, which may affect sperm quality and cause infections.

Part 5 – Treatment: Sperm harvesting, varicocele, hormonal optimisation

Sperm harvesting for obstructive and non-obstructive azoospermia (OA and NOA)

Several targets for sperm retrieval are possible – testis, epididymis or the vas. There are also different methods of harvesting sperm from these areas. It can be undertaken percutaneously (aspiration or biopsy) and with an open technique (with or without the operating microscope). The choice about which area to target and the means by which this is done is based on clinical presentation, available equipment and the skills of the surgeon.

Some options include:

  • Testicular sperm aspiration (TESA)
  • Conventional testicular sperm extraction (C-TESE)
  • Microsurgically assisted TESE (Micro-TESE)
  • Percutaneous epididymal sperm aspiration (PESA)
  • Microsurgical epididymal sperm aspiration (MESA)

Obstructive azoospermia

For men with OA, reconstruction may be possible and this should be considered. Without reconstruction, sperm retrieval is necessary to use with IVF/ICSI to achieve a pregnancy. Most men with OA have normal sperm production capabilities. Thus, any approach to the testis, epididymis or vas should yield sufficient numbers of sperm.

TESA may be all that is necessary. However, although a simple procedure, it yields the lowest sperm numbers which, and may not retrieve enough motile sperm for IVF. In these cases, a PESA or MESA can be utilised.

PESA involves percutaneous passage of a fine needle through the epididymis whilst applying negative pressure through a syringe. It is simpler and more accessible than MESA, as it does not require microsurgical training. However, it is not as precise, resulting in lower retrieval rates. Complications are usually minor, but can include haematoma, spermatocele and fibrosis and scarring at the injection site. PESA may therefore potentially compromise future reconstruction attempts.

MESA can procure sperm in OA in 90% of cases and pregnancy rates range from 40% to 60%. MESA has the advantage of being able to accurately target the epididymal tubules which, under the operating microscope appear favourable for containing motile sperm. Reconstruction might be possible at the same setting.

There is conflicting evidence as to the best choice for sperm retrieval techniques for OA. The American Urological Association (AUS) Best Practise Statement suggests there is no difference in outcome for IVF or ICSI in relation to the method of sperm harvest and therefore the choice of method is dependent on local facility and surgeon factors. The American Society for Reproductive Medicine guidelines suggest that MESA yields the best pregnancy rates in OA, but requires microsurgical expertise so cannot be recommended for all cases.

Non-obstructive azoospermia (NOA)

Depending on the underlying pathology, up to 70% of men with NOA, will harbour sperm within the testes and, if found on harvesting, live births can result in 30% to 50% of such couples. In men with NOA, the AUA Best Practice Statement recommends open surgical testicular sperm retrieval with or without microscopic magnification for patients with NOA. Cryopreservation of sperm should be offered at the time for use with ICSI.

Micro-TESE involves the use of a surgical microscope at 15x to 20x magnification, targeting larger and more opaque testicular tubules. This improves sperm retrieval rate. The majority of studies show statistically better retrieval rates ranging from 45% to 57% for micro-TESE compared with conventional TESE. Micro-TESE appears to claim a lower complication rate compared with conventional TESE, and there is a smaller volume of testicular tissue removed.

Conventional-TESE involves opening of the testois and excision of several tubules, often from several regions of the testis. The specimen is then sent for processing and immediate microscopic evaluation. Complications include haematoma whilst large volume TESE can result in permanent reduction in testosterone levels.

TESA involves percutaneous aspiration of sperm from the testis with a needle and syringe. Multiple passes are made. The benefits include no need for microsurgical training, rapidity and non-invasiveness. Retrieval rates range from 10-30%. It appears likely that TESA have sperm retrieval rates that are inferior to that obtained with TESE.

Hormonal optimisation

(For hypergonadotropic hypogonadism and subsequent sperm retrieval)

There have been several publications suggesting that optimisation of the hormonal environment improves sperm retrieval rates in patients with NOA.  These studies are particularly applicable to patients with Klinefelter’s Syndrome but may also be applied to non-Klinefelter’s patients.  Different protocols have been suggested and may include consideration of testosterone to oestradiol ratios, or improvement of FSH levels. The most common drugs used are Clomiphene Citrate, Anastrazole, Tamoxifen and/or hCG for 3-6 months prior to attempted sperm retrieval.

Risks of AR techniques

Whilst IVF and ICSI are available, there appear to be slight additional risks to both mother and child. The risks of pre-term labour (10% versus 8%), low birth weight (7% versus 4.7%) and birth defects (5% versus 4%) is higher in babies born following IVF compared with naturally conceived babies.

Key points for sperm harvesting

  • The type of azoospermia and surgeon preferences determines the method choice ++
  • OA should be treated if possible; simple sperm retrieval techniques can be employed +
  • NOA usually requires open surgical sperm retrieval with micro-TESE having the highest sperm retrieval rates ++
  • Repeated biopsies may reduce subsequent sperm retrieval rates ++
  • AR may incur slight absolute increases in major birth defects ++

Evidence level:

  • heavily evidence-based +++
  • less substantively evidence-based ++
  • not evidence-based but are clinically understood +

Varicocele

Recent data suggests a benefit for treating varicoceles in patients with abnormal semen parameters and a clinical varicocele. In patients with a clinical varicocele and NOA, the main potential benefit is for motile sperm to be detected in the ejaculate which may obviate the need for a (micro) TESE. Return of sperm into the ejaculate has been reported in 12 studies and range from 21-56% of azoospermic men post varicocele repair. However, these studies are retrospective and uncontrolled. Furthermore, most men still require a micro-TESE to retrieve adequate sperm for ICSI despite a varicocele repair. The absence of a varicocele may enhance spermatogenesis and improve the success rate at micro-TESE.

The choice of treatment of a varicocele is based on the skill set of the treating doctor, but based on two meta-analyses, microsurgical varicocelectomy has demonstrated the highest success rates with the lowest recurrence and complication. This has led some authors to suggest that a microsurgical varicocelectomy is currently the gold standard for varicocele repair.

Treatment of pre-testicular infertility

For these conditions, referral to an endocrinologist is recommended. In hypogonadotrophic hypogonadism, there are some effective medical treatments including androgen replacement and human chorionic gonadotrophin (hCG) combined with follicle-stimulating hormone (FSH). Pulsatile gonadotrophin releasing hormone may be used if there is a pituitary cause. Whilst testosterone replacement is justified for other symptoms (such as low energy levels and libido), there is no role for this to improve fertility. Exogenous testosterone can reduce gonadotrophin levels and hence impair spermatogenesis; and should be ceased during fertility treatment. Prolactin producing pituitary adenomas can be treated medically (microadenomas) or surgically (larger adenomas).
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Part One – Introduction
Part Two – History and Examination
Part 3 – Investigations
Part 4 – Treatment: Reconstruction
Part 5 – Treatment: Sperm harvesting, varicocele, hormonal optimisation
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Fertility Friendly Recipe - Banana and Egg Pancake

Here is the latest in our series of fertility friendly recipes from RHG Partner, Rosie Tadman. In case you missed it, you can view her frittata recipe here.

When you are following a fertility friendly diet, that doesn’t mean what you are eating needs to be dull or boring – this recipe is a great one for all the senses and true soul food too. These naturally gluten free pancakes are full of protein, vitamin, minerals and taste amazing – why not give them a go?

Prep time: 1 minute

Cook time: 5 minutes

Serves: 1

Ingredients:

  • 1 banana (ripe)
  • 1 egg
  • 1/4 tsp of xanthan gum (to help them hold)

Method: 

  1. Put the ingredients in a blender and pulse until smooth
  2. Warm cast iron pan to medium heat, wipe with coconut oil. Cook 8-10cm pancakes for 45 seconds on each side.
  3. I chose to serve mine with Hemsley’s mango cashew cream. However, you could also top them with yoghurt, nut and fruit of your choice.
Fertility Recipe - Frittata - aka Baked eggs

Here is our first fertility friendly recipe from RHG partner Rosie Tadman. Rosie is a registered Nutritional Therapist (CNHC and BANT registered) and specialises in fertility, pregnancy and postpartum Nutrition. Over the coming weeks we will post a series of recipes, all designed to provide the right vitamins and minerals that are essential when you’re trying to fall pregnant.

Good quality, organic eggs are a great and reasonably priced fertility food. They are full of b-vitamins, choline and a protein which will balance your blood sugar levels. What is not to love? You can enjoy these baked eggs packed full of phytonutrients (aka plant nutrients) with veggies of your choice. ​

Prep Time: 15 minutes

Cooking Time: 30 minutes

Serves: 6 (or keep in the fridge if you are not one for sharing)

Ingredients:

  • 8 eggs (whisked) with a pinch of salt and pepper added
  • 1 large onions (diced)
  • 3 cloves of garlic (finely chopped)
  • 1 tbsp. butter/ coconut oil

Broccoli, pea and feta

  • Full head of broccoli (finely chopped)
  • 200g of peas
  • 100g feta, mashed

Mushroom, spinach and chorizo 

  • 400g mushrooms, finely diced
  • 400g spinach
  • 120g chorizo, finely diced

Mixed veggies (peppers, courgette, red onion)

  • 1 large green, red and yellow pepper – deseeded and cut in half
  • 1 courgette
  • 1 large red onion

Method:

  1. In a frying pan, add the butter/ coconut oil and melt on a low-medium heat and sauté the onions until clear. Then add the garlic for 1 minute.
  2. Add your veggies of choice to the pan and cook for 5 minutes, you want your veggies to have started to soften.
  3. Add the whisked eggs and mix
  4. Add the mixture to a 15inch baking tray and bake on 180 degrees for 30 minutes, until there is no runny egg remaining
  5. Remove from the oven and leave to cool.
  6. Cut into slices – I store mine in an airtight container for up to 4 days.

I’ve given some frittata suggestions, but the options are endless…why not make sure the veg you add are seasonal? Seasonal vegetables are going to have the most nutrients.

Fertility Nutrition (preconception advice)

When we spend so much of our early life trying not to get pregnant, it is natural to assume that getting pregnant will be a piece of cake – but that is not always the case. Around 1 in 6 couples struggle to conceive – ‘struggling to conceive’ is defined as 12 month of unprotected sex with no pregnancy.

Advice you often hear when trying to conceive is ‘relax and it’ll happen’ and although there may be an element of truth to that statement, it is not the whole picture.

Fertility can depend on many factors –  physical, environmental and emotional. Couples often spend years planning weddings, buying houses, building careers and relationships and yet we often expect pregnancy to just happen.

It is ideal to do some preconception preparation before conceiving and I will generally recommend at least 3 months of preparation prior to conceive as 3-months is the amount of time it takes for new sperm to form and for eggs to mature.

If you are feeling anxious about your fertility, the below 6 steps might help you:

  1. Get a basic fertility MOT. That means gents go for a sperm test and ladies track your period and ovulation to ensure they are regular and get some of your basic hormones tested on day 3 of your cycle (FSH, LH, oestradiol, prolactin and testosterone). Then find a practitioner who can support you with the interpretation of these results.

    Then regardless of the above results, the below nutritional and lifestyle advice can support everyone:

  2. Ensure you have complex carbs (wild rice, oats, root vegetables, quinoa, buckwheat, legumes, lentils, spelt pasta and bread), protein (meat, fish, eggs, nuts, seeds and nuts), healthy fats (avocado, olive oil, olives, nuts, seeds) with each meal.
  3. Eat 5 portions of vegetables and 2 portions of fruit a day – preferably organic.
  4. Get rid of hormone disrupting plastics in your life. Replace plastic water bottles with glass. Replace plastic Tupperware with glass.
  5. Stop smoking, reduce sugar and refine (beige) carbs, stop drinking alcohol and reduce caffeine as much as possible.
  6. Make sure you ladies are taking a good quality pre-natal that includes folate (much better than folic acid). Brands for different budgets, include; Together Prenatal, Cytoplan prenatal and Optimal prenatal.

Rosie Tadman is a registered Nutritional Therapist (CNHC and BANT registered) and specialises in fertility, pregnancy and postpartum Nutrition.

She is also one of our RHG Patient Support Partners.

To view Rosie’s profile and contact details please see here.

Introducing Sue Faulkner

We’re proud to introduce Sue, one of our Front of House Executives, working alongside her colleague Liz as one of the first people you’ll meet when you arrive at our clinic.  Sue joined RHG in 2017 with over 13 years experience in reception work. Away from work she enjoys spending time walking with her dog and relaxing with friends and family.

Sue, what are your main day to day responsibilities at the clinic?

I work mornings so arrive before the day’s activities begin to prepare the reception and waiting areas, making sure that everything is clean and tidy and that the drinks dispensers are filled. Once patients and visitors begin to arrive, I am responsible for greeting everyone in a friendly, professional and courteous manner. I also take incoming telephone calls and transfer these through to the correct colleague or department and deal with enquiries. All non-patient visitors to the clinic need to be logged and issued with passes or fobs.  As patients come back down to Reception following their appointments they may need further visits or appointments arranging.

What aspect of your role is the most rewarding?

Sometimes patients can understandably be nervous or anxious when they arrive for their appointment, particularly if they are fertility patients attending for something like a viability scan to see if their fertility treatment has been successful. To meet them again afterwards and see the difference when they have been given good news is very rewarding.

 What has been your proudest moment at RHG?

It’s nice when patients leave the clinic with a smile and thank me for my help especially during what may be a difficult time for them.

Introducing Claire Caldow, Fertility Coach

Meet Claire Caldow, one of our Patient Support Partners. Claire’s background is in psychology and person centred counselling and she trained as a Freedom Fertility Coach following her own IVF fertility journey.

She is passionate about supporting the emotional wellbeing of those experiencing fertility challenges, supporting and empowering individuals and couples to understand and regain emotional control transforming how fertility issues are impacting upon their lives.

Here one of Claire’s current clients explains how she and her partner have found fertility coaching to be beneficial:

“After 2 years trying tirelessly to conceive a baby and suffering a heartbreaking miscarriage in 2017, we were referred to the NHS for investigations. Unfortunately, we had a 6 month wait for our appointment and therefore made the choice to go to a private clinic. Within a month we were about to start IVF treatment and that was when the panic set in.

The desire for a baby had consumed our lives for 2 years; it was a constant weight on our minds. We would leave children’s birthday parties feeling rock bottom as we wondered if we would ever have a child of our own. We would cry to each other and share a feeling of grief each and every month that we had not succeeded in becoming pregnant. We knew we had to try IVF as my AMH level was low. However, the week before starting treatment we felt very vulnerable, we had been through such an emotional roller coaster already and we felt mentally drained. We knew that we had to somehow be positive and stay focused to survive the next month and give ourselves the best chance but we felt that we were drowning in our own fears, doubt and “what if?” questions.

It was then then that we found Claire. As soon as I spoke to her on the phone, I felt that a weight had been lifted. It was such a relief to find someone who knew exactly what we were going through and was willing to be by our side on every step of our IVF journey. During our sessions with Claire, we opened up about our fears and thoughts about IVF. She was fantastic at helping us face each step of our IVF treatment at a time and gave us strategies to stop our minds wandering out of control with the “what if?” questions. I called her “my security blanket” as she helped us completely change our mindsets and outlook in order to imagine what we wanted to happen but she was there for us to run back to whenever we needed her during our treatment.

The 2 week wait was the most difficult time as the stomach pains from the medication I was taking reminded me of our miscarriage. If it hadn’t been for the strategies and resources that Claire had given us, I honestly believe I would’ve lost all hope during those weeks. Instead, I stayed in control of my mindset, visualised what we wanted and after 2 weeks we found out that we were pregnant! It was the most incredible feeling in the world but of course the day after, the fears set in. Claire’s strategies and techniques to stay positive and in control are helping us through the pregnancy and I’ll be eternally grateful for the skills she has given us, not just for the pregnancy but for life.”

You can view Claire’s profile here.

Sperm Freezing

In men with azoospermia (complete absence of sperm in the semen), surgical sperm extraction from the testis or epididymis might be their only option. Recent research has also shown that in men with sperm present in their semen, but of very low concentration and quality, surgically extracted sperm directly from the testicle is often completely normal.

The handling of surgically retrieved sperm then becomes a major logistical challenge. If a couple wanted to use fresh eggs and fresh sperm on the same day for IVF or ICSI, both partners would need to undergo surgery simultaneously. If this single cycle fails, there would be no back-up.

Sperm Freezing” addresses this dilemma and retains precious sperm in storage. If a cycle of IVF or ICSI fails to create embryos, or embryo transfer fails to result in a pregnancy, further cycles of assisted fertility treatment can be attempted later.

Cryopreservation technology aims to preserve the normal function of cells at very low temperatures, where normal cellular function does not take place.

Cryopreservation of surgically retrieved sperm (in comparison to healthy ejaculated semen) is more cumbersome and difficult because of

  1. low number of retrieved sperm
  2. lack of sperm motility
  3. contaminated with high proportion of cellular debris and red blood cells.

However, it is perfectly feasible in the hands of trained embryologists. Cryopreservation of testicular spermatozoa on the day of biopsy is an upcoming strategy, since many studies have shown that there are no significant differences in terms of fertilization and embryo developmental rates compared with those of fresh testicular sperm.

At the Reproductive Health Group, this technology is part of our standard services. If you would like to talk to us about sperm freezing, please call us on 01925 202180 or contact us here.

The 7 things I have learnt since becoming a solo mum

If you’re single and looking to start a family, we can help. Our supportive and experienced staff will guide you through choosing the best process for you, using donated sperm with either intrauterine insemination or IVF treatment. Through our Patient Support Partners network, we also offer support that goes beyond clinical advice with access to counselling and fertility coaching services which may be of benefit when considering the wider emotional aspects that go with considering starting a family as a solo parent.

Fertility coach and RHG Partner Mel Johnson created The Stork and I to empower single women to understand their options for starting a family following her own experience of IVF with donor sperm which resulted in the birth of her daughter Daisy.

‘Going Solo’ is an online group coaching course which Mel runs remotely for women considering the journey to solo motherhood, for up to eight participants at a time, covering topics such as making the decision to start the journey to solo motherhood, grieving for letting go of the traditional route to motherhood, getting your friends and family on board, reviewing your finances and your options, choosing a clinic or alternative path, choosing a suitable treatment or method of conception, choosing a donor, preparing yourself and your body for your fertility journey, managing treatment solo, your support network and planning for the future.

Find out more about ‘Going Solo’ courses here: https://thestorkandi.com/groupcoaching/

Read Mel’s blog on ‘7 things I have learned since becoming a solo mum’ here:

At 37 I found myself ‘socially infertile’. I was more than ready for motherhood, but had been single for most of the previous 10 years. With no partner to try to conceive with naturally, I decided to become a solo mum using IVF with donor sperm. I certainly did not make this decision lightly, it took almost 3 years of consideration to be sure I wanted to take this path. I had to allow myself to grieve for the loss of my dream of following a more traditional route to motherhood.

I chose solo motherhood based on the fact that I was approaching forty and was worried that due to my age, there was a strong possibility that my fertility would be in decline. I felt that I may lose out on the opportunity to become a mum altogether if I waited any longer to meet a suitable partner.

After disappointment following the first embryo transfer, the second frozen embryo transfer resulted in a positive pregnancy test. 9 months later saw the arrival of my beautiful daughter Daisy.

Since having my daughter I have been contacted by numerous women in the same situation looking for advice. I run an online course called Going Solo, that specifically helps to support women considering this option. I have also collated 7 things that I have learnt that will hopefully help others who find themselves single but ready for motherhood.

1. Your support network is key

You can do it alone. I’ve known people who have. But it will be significantly easier with a support network around you. Identify who your ‘tribe’ is and ensure that you share with them how they can best help you.

 2. Don’t worry about what other people will think

One of my biggest concerns was what other people would think of me. What I’ve come to realise is that everyone will always have an opinion about your situation whatever you do. I’ve been lucky that everyone so far has been positive, but if I encountered negative opinions I would try to ignore them and focus on what I am doing, not what others think.

3. Adult company is important

Most women who are in a partnership get to spend the evenings and weekends with their partner or at least have them at the end of the phone for support. As a solo mum, you might find that many evenings are spent alone, once your little one has gone to bed. The more people you can find who are happy to come and hang out with you at your house the better, so you can still have adult company in the evenings. You might need to plan ahead more often to ensure this happens.

Going Solo4. Don’t write off meeting a partner

It is still possible to meet someone after becoming a solo mum. You can just look at having done things in a different order.

I went back to online dating when my daughter was 4 months old and found it much easier than previously as all time pressure has disappeared.

My profile clearly says I have a young baby that I chose to have on my own and many men say it is easier with there being no ex involved and are happy to date someone with a baby. I’m hopeful I will meet someone to settle down with now the pressure of having a baby has been lifted.

5. Learning to ask for help will make your life significantly easier

If you have always been fiercely independent, now is probably a good time to learn how to ask for help. If you accept you don’t need to be super woman and do everything yourself, life will become a lot easier.

6. Don’t be fooled by other peoples ‘perfect’ situations

It might seem like everyone around you has the perfect family life, but that is very rarely the case. Everyone has their own circumstances to deal with. It’s best to focus on making the most of your own situation rather than comparing yourself to others.

7. It’s not as difficult as you might worry about

Once you are responsible for a baby, the likelihood is you’ll step up to the mark and nail it. You will never have known any other way, so it will just be the norm for you. There are also some advantages that come with doing things on your own that you will discover. If you need support Thriving Solo is a course to support how to best manage on your own.

 

Mel Johnson is the founder of The Stork and I, a support group for single women considering solo motherhood. She run’s Group Coaching Courses and a solo mum support group as well as offering 1:2:1 coaching.

Photo Credit: N C Hope Photography

Introducing Katrina Green

We are delighted to introduce Katrina Green, our Healthcare Assistant here at our Daresbury clinic. Katrina joined our friendly nursing and care services team earlier in the year and has fast become an integral part of our team. Here is a little bit about Katrina in her own words.

Katrina, what are your day to day responsibilities in the clinic?

My role is quite a varied one and includes phlebotomy (taking bloods), supporting the consultants and nurses and acting as chaperone for the nurses when they are in clinic with the patients.

What aspect of your role is the most rewarding?

Seeing the patients fertility journey from beginning to end is very rewarding. Every patient’s journey is an individual one, I see different things every day with different patients, but to be part of it all is just such a privilege. I also like to learn new things, which I have the opportunity to do in this role.

What has been your proudest moment at RHG?

Just being involved in the patient journey and playing a part in it makes me very proud.

When trying to conceive, NHS and healthcare professionals often recommend that both men and women stop drinking alcohol. But is one glass of wine too much? Here’s what research has shown so far:

Alcohol affects both male and female fertility, but the level of consumption associated with risk is unclear. High levels of maternal alcohol consumption are known to be dangerous to the unborn child, but the effects at lower levels are less certain.

Drinking between one and five drinks a week can reduce a women’s chances of conceiving, and 10 drinks or more decreases the likelihood of conception even further.

In women, drinking more than one to two units a day during pregnancy, there is increased risk of low birth weight, preterm birth, and being small for gestational age.

Men’s fertility can be affected by alcohol as it lowers testosterone levels, it can cause impotence, reduce libido and affect sperm quality.

The effects of alcohol on fertility are:

  • Lowers testosterone
  • Impotence
  • Reduce libido
  • Affect sperm quality
  • Reduce chance of live birth
  • Increase risk of miscarriage
  • Increased risk of pre-term birth
  • Increased risk of low birth weigh

Image source: BBC

How much is too much?

Current general advice for people not trying to conceive is for both men and women is not to exceed 14 units per week.

Even though there is uncertainty about the effects of low levels of alcohol on fertility and pregnancy, for the reasons mentioned above, it is recommended that women trying to have a baby should not drink alcohol at all to keep health risks to the baby as low as possible.

Where can you get help?

If you’re pregnant or trying to conceive, the advice is not to drink alcohol at all

If you want to reduce or stop alcohol consumption, you can speak to your GP.

A fertility counsellor or coach trained on managing addictions can also help you.

You can also find more information at:

If you are worried about the amount of alcohol you are drinking and would like to reduce and find a healthy alternative or learn more about leading a healthy lifestyle for fertility, book a Free Fertility Coaching consultation with our awarded Nurse Consultant and NLP Coach Andreia Trigo.  Book your appointment here.

About Andreia Trigo

Andreia Trigo (RN, BSc, and MSc) is the founder of inFertile Life, multi-awarded nurse consultant, fertility coach, author and TEDx speaker.  Combining her fourteen-year medical experience, CBT, NLP and her own eighteen-year infertility journey, she has developed unique strategies to help people undergoing similar challenges achieve their reproductive goals. The Enhanced Fertility Programme is helping people worldwide and has been awarded Best Innovation in Business 2018 and E-Business of 2018. Check her out at www.infertile-life.com

Andreia Trigo
Nurse Specialist | NLP Coach of 2017 | TEDx Speaker
www.infertile-life.com