Andrology Services

• Semen Analysis
• Intra-Uterine Insemination (IUI)
• Sperm Function Tests
• Sperm DNA Fragmentation
• Semen Freezing
• Sperm Retrieval Techniques
• Semen Freezing & Semen Banking

Skilled andrologists pinpoint the causes of male infertility and prepare sperm for use prior to IVF, IUI and sperm freezing. play an important role in the treatment of male infertility, working closely with fertility specialists to optimize sperm for use in advanced assisted reproductive technology.

A semen sample can be collected by the male at home or at the Andrology collection room. After the semen sample has been collected, the main parameters analyzed include volume of semen, concentration of sperm, motility, and morphology. After the semen sample has been analyzed, the report is reviewed and signed by our Urologist.

Andrology lab performs semen analysis to evaluate samples for:

• Volume of seminal fluid
• Sperm concentration – the amount of sperm present in the ejaculate
• Motility – the sperm’s ability to propel themselves
• Progression – the sperm’s ability to move in a straight direction
• Morphology – the percentage of abnormally shaped sperm
• Anti-sperm antibodies – the presence of which can prevent fertilization or sperm movemen
• Sometimes, agglutination (also known as “clumping”) of sperm cells can be seen when the sample is visualized under the microscope. If the andrologist reports significant agglutination on the semen analysis report, then antisperm antibodies may be present and antisperm antibody testing may be recommended. There are 2 types of Antisperm Antibodies, IgA and IgG, which are from the immune system and may be attached to the head, midpiece, and/or tail of sperm and can potentially impact fertility.

Along with a standard semen analysis all samples examined ,patients undergo an evaluation for leukocytes, or white blood cells. Leukocytes can look very similar to immature sperm cells so it is important to be able to differentiate between the 2 cell types, which is accomplished by using a special stain that allows differentiation between the 2 types. If there are a large number of leukocytes in the semen, this is an indicator of infection or inflammation which will need to be treated by the Reproductive Urologist to improve fertility potential

Post-ejaculatory Urinalysis:

Some men will not have sperm in the semen due to a process known as retrograde ejaculation. This is when sperm go backwards into the bladder rather than out the urethra as they should, and they simply are urinated out with the man’s next voiding of his bladder. This may be seen in men with diabetes, spinal cord injuries, men who have had prostate surgery, are on specific medications, or have other potential risk factors for retrograde ejaculation·Assessment of retrograde ejaculation by obtaining a urine sample immediately after orgasm and can identify sperm in the urine and can process the sperm to be used with assistance to help achieve a pregnancy when applicable.

Viability Testing:

In certain circumstances a semen analysis may show sperm with zero motility, or sperm with no movement. In such cases, it is important to know if the sperm are actually viable to help understand their fertilizing potential with levels of assistance. A specialized viability test is performed in the situations to help elucidate the level of viability of the sperm.

Pentoxyifylline:

When sperm have no or low motility, they can be treated with an agent called Pentoxifylline, which can stimulate sperm motility. This is used to help identify the level of sperm viability as well as helping the andrologist/embryologist to select more viable sperm cells to use with levels of reproductive assistance.

Sperm DNA Fragmentation Index (DFI):

Although the traditional semen analysis parameters of semen volume, sperm concentration, motility, and morphology are certainly important in the assessment of a man’s fertility potential, they may be a relatively crude assessment. They do not tell us about the integrity of sperm’s DNA or its ability to fertilize an egg and maintain a pregnancy.Analysis of sperm DNA is a high level test revealing what percentage of sperm cells in a man’s semen have damaged DNA. When there is a high percentage of DNA damaged sperm, there are associations with lower fertilization and pregnancy rates and higher miscarriage rates. This test is being offered for select patients who have risk factors for having higher levels of DNA fragmentation and the need for this level of testing can be discussed in consultation with a infertility specialist.

Sperm Identification from PESA/TESE:

In men with no sperm in the semen due to an anatomic blockage, such as a vasectomy, percutaneous epididymal sperm extraction (PESA) or testicular sperm extraction (TESE) can be performed to retrieve sperm. This is performed by a Reproductive Urologist in the sperm retrieval suite adjacent to the IVF laboratory with a minimally invasive technique. The andrologist/embryologist assesses the sperm retrieved for use or for cryopreservation for future use.

Sperm Identification from Microdissection Testicular Sperm Extraction:

In cases of nonobstructive azoospermia (NOA), in which a male does not have sperm cells in his seminal fluid due to inadequate sperm production, not due to a blockage, but may have some small pockets of sperm cells within the testicle, a surgery known as Microdissection Testicular Sperm Extraction (microTESE) may be performed by a fellowship-trained Reproductive Urologist. This surgery involves the removal of small biopsies of testicular tissue in the Operating Room; embryologists accompany Reproductive Urologist in the Operating Room and are able to evaluate the testicular tissue under a high-powered microscope at that time in the Operating Room. Sperm obtained through this process can be used in conjunction with invitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) to help couples in this challenging situation conceive.

Sperm processing techniques for ART procedures

IVF: Sperm preparation isolates the best possible population of sperm to either combine with retrieved eggs or inject directly into the eggs using intracytoplasmic sperm injection (ICSI).

IUI: Sperm washing isolates the best-quality sperm and combines them with a nourishing fluid prior to IUI to optimize fertility.

Sperm for freezing and storage. This allows men with male factor infertility to collect enough healthy sperm for use in IVF or IUI procedures, and preserves the fertility of men who wish to delay parenthood due to factors such as cancer treatment or military deployment.

Our embryologist's job starts with an assessment of the male partner’s sperm. We evaluate every specimen for concentration (the number of sperm present in each cc of semen), motility (the percentage of sperm that are alive and swimming), and normal morphology (the percentage of sperm that have a normal shape). We then choose the best sperm preparation technique to use so that we can get the greatest number of normally shaped, motile sperm to add to the eggs.

Once the eggs have been retrieved, they must be identified, removed from their cumulus cells, and placed into culture so that they can continue to mature in the laboratory. Approximately 5-6 hours after retrieval, several thousand moving sperm are either added to a droplet of culture media containing each egg (insemination), or – in cases where the sperm specimen is not of very good quality – a single sperm is actually injected directly into each egg by our embryologists using a tiny needle directed by robotically controlled instruments (ICSI). These eggs are then returned to their incubator for 18 hours of development, during which time fertilization hopefully occurs.

A Week in the Life of an Embryo

Day 1: After documenting fertilization, each embryo is placed in culture media that mimics the environment normally found in the fallopian tube.

Day 2: Embryos are allowed to continue growing without being disturbed.

Day 3: Embryonic development is assessed and a decision is made about next steps. In most cases, we will return the embryos to the incubator where they will continue to grow. In rare cases, we consider embryo transfer, or even embryo biopsy on day 3. If we are going to do your embryo biopsy on day 3, an embryologist will remove a single cell from each viable embryo for preimplantation genetic screening (PGS) or diagnosis (PGD) at this time.

Day 4: Embryos are allowed to continue growing without being disturbed.

Day 5: Aside from Day 1 when we confirm fertilization, Day 5 is perhaps the most important day in an IVF cycle. Day 5 is the first day that embryos reach the critical blastocyst stage. If we are planning on doing a fresh embryo transfer, this is the day that it most often occurs. If, on the other hand, we are planning on freezing all embryos, this is the first day that we start this process. In addition, for those patients who desire genetic testing of their embryos, this is the first day that we start to perform embryo biopsies as well.

Days 6 and 7: Embryos are reassessed for vitrification (freezing) and biopsy (if indicated).

In Vitro Fertilization (IVF)

In Vitro Fertilization (IVF) is one of the Assisted Reproductive Technologies (ARTs) used for couples with infertility that cannot be treated using simpler methods. The four main steps in IVF are:

I. Ovarian stimulation

Ovarian stimulation is the second stage of IVF fertility treatment. The goal is to harvest as many mature eggs as possible from the woman's ovaries. Harvesting many eggs maximizes the chances one of the eggs can be fertilized, implanted back into the uterus, and become a healthy baby

II. Regular Ovulation Cycle

Within a woman’s ovaries are hundreds of thousands of ovarian follicles, each of which contains an oocyte (an immature egg cell). A follicle is a small, fluid-filled cyst.

During each menstrual cycle, several follicles begin to develop, each capable of releasing a mature egg during ovulation. Normally, a single one of these—called the dominant follicle—will grow faster than the others. A dominant follicle that is ready to ovulate is about 18-28mm in diameter.

The dominant follicle releases an egg during ovulation, at the mid-point of the menstrual cycle. If a woman isn’t pregnant, she will normally have her period around 14 days after ovulation.

Some female factor fertility issues can affect the development of follicles. The most notable is Polycystic Ovarian Syndrome, a very common and highly treatable condition.

III. Stimulation procedure

In an IVF cycle, you maximize your chances of success by generating as many mature eggs as possible. The stimulation phase involves the injection of medications for 8-14 days, to induce the ovaries to produce many eggs. The stimulation phase takes longer if your follicles are slower to mature.

The medications stimulate (and are derived from) two key hormones, Follicle Stimulating Hormone (FSH) and Lutenizing Hormone (LH). These hormones have the following effects:

As the name suggests, FSH stimulates follicles to develop during the menstrual cycle. Normally, non-dominant follicles die off before ovulation as FSH levels fall. FSH injections maintain higher levels of FSH in the body, allowing the ovaries to produce more mature eggs.

Just before ovulation, higher levels of estrogen trigger a spike in LH, which causes ovulation. A ‘trigger shot’ of a large dose of human chorionic gonadotropin(hCG), which stimulates ovulation, starts the process.

After ovarian stimulation, but before ovulation, comes the egg retrieval phase of IVF.

IV. Egg Retrieval

Before the time of oocyte retrieval, patients have already undergone ovarian stimulation with regular monitoring from their IVF specialist. In the lab, before any oocyte retrieval can begin, the embryologist must perform identity verification. Multiple times throughout every procedure performed in the lab, the embryologists confirm first-hand that the patient’s paperwork matches up with their oocyte, embryo, or sperm sample. In addition, a second embryologist confirms that the patient information matches.Once the team confirms identification for the retrieval, the physician surgically aspirates each follicle and the attending nurse will bring several tubes from the operating room to the embryologist. The tubes are—hopefully—filled with follicular fluid containing eggs. At the time of the retrieval though, the physician does not know exactly how many eggs he/she will obtain. . The egg count is dependent upon factors like the woman’s age or the individual diagnosis.An embryologist must examine the contents of each vial in a culture dish with an inverted microscope. Using a sterilized pipette, the embryologist hunts through the follicular fluid and blood, looking for the retrieved oocytes. Once he/she finds the eggs, the count is marked down and told to the nurse. Then the oocytes are put into media, specially designed and formulated to replicate in vivo conditions, and placed into an incubator

IN VITRO FERTILISATION

Conventional fertilization occurs when the embryologist places the male partner’s washed sperm directly on top of the egg and leaves it overnight. The embryologist brings together the highest quality egg and sperm and then lets them come together on their own. This doesn’t always work out though, particularly if male factor infertility is present.

Vitrification

Vitrification is an advanced cell-freezing technique, which allows a higher survival rate after thawing due to the fact that high concentrations of cryoproctectants are used along with reduced volumes and timings. Thus, the formation of intracellular ice crystals is prevented, which are responsible, in most cases, for provoking irreparable cell damage.

The vitrification process is used to freeze oocytes or embryos and it guarantees a survival rate of more than 80%. This technique enables the vitrified oocytes which have survived the thawing process to have similar attributes to fresh ones. They are then able to be fertilized by the sperms. The generated embryos can then be implanted and develop into healthy children. Although the implantation rate is lower than with fresh embryos, frozen embryos, once thawed, achieve a normal pregnancy.

Blastocyst culture

Whenever IVF or ICSI is performed, embryos may be cultured for either one day, two days, or even five days, before transferring them back into the woman. In order to culture the embryos for five days, i.e. to the “blastocyst” stage, extended culture has to be done.

When the embryos develop to the blastocyst stage, they use a 3-character grading system which focuses mainly on the Inner Cell Mass (ICM), the Trophectoderm (the outermost layer of cells) and the degree of expansion and size of the embryo. Under IVF culture conditions only about 60 to 70% of human embryos progress to the blastocyst stage after 5 days. Several eggs (oocytes) may have initially fertilised, but not all of them will progress to the four-cell stage on day two and to the eight-cell stage on day three in culture, and even fewer will develop into blastocysts. Around day 5 it starts embedding itself below the surface of the endometrium and this is the reason why we cannot keep the blastocyst in the laboratory at this stage – it cannot delay starting the process of embedding in the uterus.

The problem with extended culture to day 5 is that there may be a loss of some embryos that might have “made it” if they had been transferred earlier.The major advantage (despite the already mentioned disadvantage) of day 5 transfer is embryo selection. The implantation rate per day 5 blastocyst transfer is greater than for transfer of day 2 or 3 embryos. But only 20 percent to 50 percent of day 2 embryos can develop in vitro to day five no matter how perfect the in vitro culture system. There is a potential loss therefore of what could have been viable embryos. So selection is the only advantage of blastocyst culture, and this selection has nothing to do with the “quality” of the baby, but rather just whether the embryo “makes it” or not to becoming a baby.

Either way, because our system of embryo freezing is so good, we do not lose anything if we transfer less embryos to reduce risk of triplets or quadruplets, and just save the extra embryos for a later pregnancy. We can even transfer just one embryo at a time without at all reducing your chance of pregnancy.

Embryo transfer

Our team performs a two-step identification confirmation before an embryo transfer can occur. An additional identification confirmation is done with the patient for this procedure. Early in the morning, the embryologists do an assessment of each transfer patients’ embryos, selecting the best possible one(s) for transfer.If a frozen embryo transfer is planned appropriate embryos are thawed with identification checks and cultured in the incubator.Once the embryologist selects the best embryo, he/she will go into the transfer room to identify the patient directly. All parties involved—the patient, embryologist, physician, and a witness—will verbally confirmed and sign off on the number of embryos the physician will transfer. Via ultrasound, the physician places the embryo(s) into the uterus. The embryologist then checks the catheter in the lab to make sure that there are no embryos remaining, thus confirming that there was a successful transfer. After the transfer, the patient will receive a picture of their embryo.

INVITRO MATURATION (IVM)

Ovaries are minimally stimulated with less fertility medication to get ovaries to produce eggs in IVM treatment. IVM is an assisted reproductive technology which involves collecting eggs from a woman before they are matured. The eggs are then matured in a laboratory using a culture medium comprising small amounts of hormones. The matured eggs are manually fertilized using intracytoplasmic sperm injection- a tiny needle containing one sperm injected into an egg. Once the development of the embryos begin, they are transferred to a woman’s womb, and the wait begins to see if she gets pregnant.

Who Can undergo IVM

The women who will typically benefit most include:

• Women at a higher risk of Ovarian Hyperstimulation Syndrome (OHSS) including women with Polycystic Ovarian Syndrome (PCOS)
• Women who are younger, not obese and have normal menstrual cycles
• IVM can also be tried with regular IVF cycles when the stimulation protocol allows many immature eggs to be retrieved.
• In an IVF procedure, a woman goes through multiple hormonal injections to retrieve mature eggs while the eggs are in the ovaries. The IVM procedure retrieves the eggs when immature, and the woman is spared from the injections.
• IVF patients undergo three ultrasounds, five blood tests and hormone injections within a month. The new IVM procedure requires a few blood tests and transvaginal ultrasounds that are completed in less than a week.
• Hormonal intakes in IVM are administered in the form of pills or suppository and about 90% scaled down in comparison to IVF.
• With little hormonal boosters, fewer tests in the lab the cost of IVM is definitely much lower than IVF

Post egg retrieval and maturation the eggs and sperm are mixed in a dish or manually fertilized using intracytoplasmic sperm injection both in IVF and IVM.

Laser assisted hatching (LAH)

Assisted hatching is a technology which helps embryos to attach to the womb of the woman. Pregnancy cannot occur unless the human embryo hatches.

Laser assisted hatching is one out of several methods to help the fertilised egg to hatch and attach to the uterus. Other methods are acid or mechanical hatching of one part of zona pellucida.After treating the fertilised egg with laser assisted hatching, we transfer the embryo into the woman’s womb.

Who can undergo LAH ?

Especially women older than 37 years of age, have a tendency to produce eggs with a harder zona pellucida than younger women.

The same applies for women treated with higher doses of follicle stimulating hormone (FSH).

• Poor Embryos’ Quality
• Cases with embryos harder and/or thicker zona pellucida
• Cases using frozen eggs or embryos

The problem of a harder zona pellucida is that the eggs may not hatch or use excessive energy for getting out, thus not being able to attach to the woman’s uterus. Hatching of the egg is necessary to become pregnant.

Preimplantation Genetic Diagnosis and Screening (PGD/PGS with IVF)

Advances in human genetic studies have enabled us to identify several genes that not only are responsible for our physical traits but also for inherited diseases. New technologies are now available to screen embryos at their earliest stages of development, allowing us to select embryos that are free of genetic disease and that contain the normal number of chromosomes. These embryos, when transferred to the uterus, will have the highest rate of implantation and the highest possibility for a successful, normal pregnancy.

Two different procedures are available for patients at risk of having children affected by an inherited disease or abnormal chromosome numbers. Patients wishing to diagnose their embryos for an inherited genetic disease may use a procedure called preimplantation genetic diagnosis (PGD). Patients with a history of recurrent pregnancy loss and/or of advanced age may use a procedure called preimplantation genetic screening (PGS), which evaluates the number of chromosomes

Preimplantation Genetic Testing (PGT) helps identify embryos that have recognizable chromosomal abnormalities prior to transfer to the uterus. PGT can be used for patients of all ages who have unexplained fertility, severe male factor, advanced maternal age and several failed IVF cycles with poor quality embryos. This procedure benefits families who have a known history of certain genetic abnormalities.

On the fifth day of embryo development, a single cell is taken from an embryo through an opening made in the shell of the embryo through assisted hatching. The DNA from that single cell is then analyzed for any chromosomal abnormalities. The analysis usually takes 48-72 hours to complete. The embryologist will determine which embryos are to be transferred based upon the results of the analysis.

How Does PGD Work?

PGD is an invaluable technology for patients who are carriers for genetic diseases. The technology can diagnose embryos with no inherited mutated genes to promote a higher likelihood of healthy offspring who are free from genetic disease. Patients who choose to have their embryos diagnosed with PGD must undergo in vitro fertilization (IVF) with ICSI to produce a sufficient number of embryos for diagnostic testing.

In IVF, the female partner receives fertility medication to stimulate her ovaries to produce multiple eggs. Eggs are then removed from the ovaries and fertilized in the laboratory with the male partner’s sperm. Resulting embryos are then cultured for five days to the blastocyst stage. A small cellular sample is then removed from growing blastocysts on day five and sent to a highly specialized molecular genetics diagnostic laboratory. This process does not harm the embryos, and they continue to grow as they otherwise would in the laboratory while awaiting test results.

Embryos determined to be free of genetic disease may be transferred on day six of embryo growth. Sometimes, due to testing protocol limitations, which can take several hours to days, embryos might be frozen while awaiting test results. In these cases, a frozen embryo transfer will be arranged after all genetic testing results have been received.

When is PGD Recommended?

PGD is indicated for individuals or couples who know they have or carry a specific gene defect and are thus at risk of passing the condition on to their child. There are many ways to determine if a female or male partner carries a genetic abnormality due to his or her previous history of child birth with a genetic birth defect or serious medical condition. Family members may carry gene mutations, or a condition may be found during a routine pretreatment genetic screening.

Accuracy of PGD testing

The accuracy of PGD is generally 95 to 99 percent. Patients wishing to confirm a PGD diagnosis are advised to undergo additional genetic testing such as amniocentesis and chorionic villus sampling (CVS) during early pregnancy. Additional testing will confirm the preimplantation genetic diagnosis to near 100 percent accuracy.

How Does PGS Work?

Preimplantation genetic screening of embryos is highly recommended for patients who have experienced multiple (recurrent) miscarriages or repeated unexplained IVF embryo implantation failures. We also highly recommend PGS for patients of advanced maternal age. With this genetic testing, embryos are biopsied and analyzed for all chromosomes. Too few or too many chromosomes may indicate a number of conditions that could cause implantation failure, early miscarriage or a baby with Down syndrome, a genetic condition marked by significant physical and cognitive difficulties

Fertility preservation

Fertility preservation is a concept of “safeguarding” current reproductive abilities into the future by storing reproductive cells or tissues “out of harm’s way.”Different methods of fertility preservation may be appropriate, depending on medical conditions and/or gonado-toxic treatments needed, as well as the patient’s personal circumstances. In some cases of gynecological cancers, use of specific surgical and medical treatment techniques can be used to avoid damage to vital reproductive organs.

Comprehensive array of fertility preservation options are there for both medical and social reasons, for men, women and pre-pubescent children among. fertility centers:

• Embryo banking (freezing)
• Egg banking (freezing)
• Ovarian tissue banking (freezing)
• Sperm banking (freezing)
• Fertility preservation for children

Female fertility preservation

Ovarian tissue cryopreservation is another fertility preservation option, and may be most appropriate for women and girls who are not candidates for either embryo or oocyte banking.Cryopreservation technology is necessary to support experimental fertility preservation options such as ovarian tissue transplantation and investigational in vitro follicle maturation.

Ovarian tissue cryopreservation (freezing) is an experimental method of fertility preservation in which the outer layer of an ovary, which contains a large number of immature eggs, is taken out of the body and frozen for future use. In ovarian tissue freezing process, a part of an ovary or a whole ovary is surgically removed, usually by laparoscopy. In the laboratory, the ovary’s outer layer (called ovarian cortex) is cut into small strips and frozen. An experimental procedure, ovarian tissue freezing is for the most part performed for medically indicated fertility preservation in cancer patients.

A major advantage of ovarian tissue freezing is the number of eggs that can be frozen in “one shot.” Embryo freezing and egg freezing typically result in approximately 10 eggs or embryos per freezing attempt. In contrast, ovarian tissue freezing lets women freeze a vastly larger number of immature eggs—hundreds to thousands—for future use. When frozen ovarian tissue is re-implanted into the body and regains its functions, immature eggs that were frozen within the tissue start developing normally, and become retrievable in an IVF procedure.

Unlike egg and embryo freezing, where just one cycle can take a few weeks to complete, ovarian tissue freezing can be performed on very short notice. Even women who must undergo chemotherapy or radiation almost immediately after diagnosis may be able to preserve their fertility using this method.

Since ovarian tissue freezing is typically performed for patients facing life-threatening illnesses and ovary-toxic therapies, close communication and coordination among patients, physicians treating the primary disease (oncologists, oncologic surgeons, etc.), fertility specialists performing the fertility preservation procedure and family members is essential

Male fertility preservation

Sperm cryopreservation (sperm freezing) is the most established method of fertility preservation for men.

Pre-pubertal males were highlighted as perhaps the most challenging group of male patients in terms of providing fertility preservation care. Testicular tissue cryopreservation may also provide an opportunity for fertility preservation for prepubertal boys.

For adult men and boys with ongoing spermatogenesis, sperm banking must always be offered as a first line treatment.. In men, this is a validated and non-invasive procedure to preserve fertility. Assisted reproduction techniques with semen cryopreserved before the onset of gonadotoxic treatment has shown good fertility outcome.

Fertility Preservation for Childhood Cancer Patients

For pre-pubertal children, adult fertility preservation methods like egg freezing and sperm freezing are not feasible. For boys, testicular tissue can be frozen. For girls, tissues from the ovaries can be frozen. These tissues can be thawed and re-transplanted into the body in the future when the patients are free of cancer. Both ovarian tissue freezing for girls and testicular tissue freezing for boys can be performed quickly upon diagnosis when cancer treatments have to start almost immediately.