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      • Case Study: Poor Quality Eggs/Embryos in Young Women With Normal Ovarian Reserve: Case #2 – Male Factor Infertility

      Dr. Geoffrey Sher Recommends

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      Today we continue our series of case studies on unexplained IVF failure with our second case of poor egg/embryo quality in young women. The prior case discussed Polycystic Ovarian Syndrome (PCOS) and the various effects of this condition (along with the prescribed IVF protocols) on egg/embryo quality. Case #2 details a male factor issue that contributed to poor quality embryos.

      Case History #2

      This 28-year-old had conceived in a prior relationship and underwent a therapeutic abortion at 8 weeks without any subsequent complications.She had regular menstrual periods and there were no symptoms or signs of underlying ovulation dysfunction or pelvic disease.Before consulting with me, she and her new partner had been trying to conceive for 3 years, during which time she had undergone 2 attempts at IUI and 2 IVF cycles.Neither had resulted in a pregnancy.Her partner had a sperm count of 60 million, with 35% of sperm being motile.Morphology was also on the low side (around 3% using strict Kruger criteria).In both IVF attempts she had been stimulated with a long pituitary down-regulation protocol using Lupron, and coming off a birth control pill.She produced 15 and 18 eggs respectively, and almost 80% of her eggs were mature (MII’s).Upon fertilization, embryo quality was poor, with the embryos dividing slowly such that by the 3rd day post conventional fertilization, the vast majority were less than 6 cells.In fact, only in her last cycle had there been 2 embryos that were 6-9 cells cleaved.There was also significant fragmentation, and embryo transfers were conducted on day 3.

      Commentary:While it is a fact that in most cases embryo quality is primarily a function of egg quality, this rule does not always apply in cases of significant male factor infertility.In this case, the IVF stimulation protocol seems to have been quite appropriate and the vast majority of eggs retrieved at ER were mature.Yet the embryos were of poor quality.This raises a strong suspicion of an underlying occult sperm dysfunction that was not overtly evident from the semen analyses performed.

      Follow up: When this patient presented to me, I immediately began to suspect that there could be a sperm problem, so I dispatched her husband’s sperm for a Sperm Chromatin Structure Assay (SCSA).The results were grossly abnormal in that the sperm DNA fragmentation index was 57% (normal is under 15%, intermediate is 15-30%).I thus suspected a possible underlying varicocele, which is one of the causes of an abnormal SCSA.First, I tested the man’s FSH/LH and testosterone levels.These were all normal and thus I referred him to a urologist who performed a scrotal ultrasound examination which revealed a sizeable varicocele.I recommended the radiological ablation of the spermatic vein (a benign and very successful cure of this problem).Six months later we repeated the semen analysis and the SCSA.Both had reverted to normal.

      This patient has recently undergone another egg retrieval using a similar protocol for ovarian stimulation. She again yielded a high percentage of mature (MII) eggs, and upon fertilization by ICSI, produced 7 good quality 6-9 cell embryos, all of which were biopsied on day 3 for CGH analysis.Four of the embryos progressed to the expanded blastocyst stage and were vitrified for subsequent selective transfer to her uterus once the results of CGH testing become available a few weeks hence.

      Addendum: It is important to understand that IVF is an ART-Science blend and not all practitioners agree on the same strategies.Thus, in the final analysis, it is important, after discussion with your personal doctor, to follow his/her advice to the letter. Feel free to present your case history in the comments and I will do my best to offer my opinion.

       

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      18 Responses to “Case Study: Poor Quality Eggs/Embryos in Young Women With Normal Ovarian Reserve: Case #2 – Male Factor Infertility”

      1. Fay says:
        September 25, 2012 at 6:45 pm

        Me: 35 2 prior pregnancies with no problems
        Him 31: Low count and motility, no children
        Doctor#1
        Oct 2011- IVF #1 Mini-ivf 6 follicles, 1 egg retrieved. Fertilized and transferred 3 day. Negative Beta Doctor stated I must have ovulated, that’s the reasoning for low numbers retrieved.
        Doctor #2
        We are going to do ganerelix to prevent ovulation.
        May 2012- IVF #2 16 eggs retrieved, 9 mature. First semen sample shows almost no sperm, second SA shows 50,000. Egg retrieval day we have 2 sperm that are live. They ICSI all eggs, 2 fertilize and are transferred. Negative Beta
        Now doctor 2 wants to do TESA. But I’m leaning towards leaving his practice because he should have sent us to a male infertility urologist when the first SA was so low. I don’t know what to do, I feel both doctors let us down. What’s worse is we have one male factor uro in our state and he’s impossible schedule with. We are going broke and I’d feel better if there weren’t glaring obvious issues with both cycles. I did my part, I took my meds, i rested, and i ate right. Is what happened to us normal?? Is this what we have ahead?? I want to try again but I feel taken advantage of.

        Reply
        • Geoffrey Sher says:
          September 26, 2012 at 3:46 pm

          It all depends on the cause of the MF> Is it testicular failure, or under stimulation of the testes.

          Your husband should have an FSH, testosterone, Prolactin and LH blood tests. Then I think we should talk. You might consider calling 800-780-7437 or 702-699-7437 to arrange a video conference (or Skype) consultation (free of charge to those who reside in the United States or Canada). If need be, someone from SIRM-Patient Relations can contact you in advance of the consultation and assist you in setting this up through your computer. Such audiovisual interaction it is much more personable than a discussion by telephone. However, if you prefer the latter, this too can be arranged.

          Might I recommend that you go to the home page on this site, find a “search bar” in the upper right hand column and type in the following subjects into the bar and it will take you to all the relevant articles I posted there.
           “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
           “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
           “Agonist/Antagonist Conversion Protocol”
           “Male Infertility and hormonal treatment”.
           “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)
           “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
           “A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
           “IVF success: Factors that influence outcome”

          Geoff Sher

          Reply
      2. Fay says:
        September 26, 2012 at 7:17 pm

        Thank you so much for answering. We have had all hormone tests and they are normal. Small varicocele. I will read your articles. I’m especially interested in the traveling for IVF as we live in Indiana. Once again thanks.

        Reply
      3. Lima says:
        January 2, 2013 at 9:01 am

        Hi Dr. Sher,
        We are in the midst of an estrogen priming protocol IVF.
        My husband is 38 with 2 varicocele, 3% morphology, normal motility, and very high sperm count. I am 37 with an FSH of 9.8, AMH of 0.7 and estradiol of 41.2.
        At age 33 I had a first natural pregnancy with my husband end in miscarriage at 14 weeks. After 3 failed IUIs using Clomid and later a low dose of injectibles we had a successful pregnancy on what we thought would be a hail Mary only shot IVF using donor sperm. We luckily got jobs with better insurance and were able to afford more IVFs. Our next IVF using my eggs and my husband’s sperm failed. We’re nervous that though I have been tested, there might be some underlying male issue that could cause embryo problems. What kind of tests can be done? Also, worried that I haven’t been tested for immune issues that could cause implantation issues. When we ask about further male testing we’re told not to worry because he makes over 100 million sperm. What further tests, if any, should we have to ensure we have our best shot and having another baby?

        Reply
        • Geoffrey Sher says:
          January 2, 2013 at 8:48 pm

          When Varicocele affects sperm function it usually presents with what we refer to as a “stress pattern”…i.e., a high count, low motility and a high number of “immature sperm forms” that often presents as poor morphology. In such cases the sperm chromatin structure assay (SCSA) will usually show an abnormal sperm DNA fragmentation index of >30%. I suggest you have this test done on your husband’s sperm.

          Please go to the home page of this blog (www.IVFauthority.com ). When you get to the look for a “search bar” in the upper right hand corner. Type in the following subjects into the bar and it will take you to all the relevant articles I posted there.

           “Sperm Chromatin Structure Assay”
           “Male Factor Infertility”
           “Varicocele”
           “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
           “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
           “Agonist/Antagonist Conversion Protocol”
           “Immunologic Implantation Dysfunction” (posted on May, 10th and on May 16th respectively.
           “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)
           “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
           “A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
           “IVF success: Factors that influence outcome”

          Consider calling 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada) so we can discuss your case in detail.. While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.

          Geoff Sher

          Reply
      4. Sara says:
        January 9, 2013 at 3:31 pm

        Weve had two failed IVFs.. My husband has low sperm count<12 million/ml motility <15%. (no varicocele or hormonal problem) Im 27 and ive had 12 egg retrieved in first IVF and only 5 were mature. In my second IVF 12 eggs retrieved and 6 mature. Only 2 made it to day 5 (early blasts) and were both transferred. Eggs were described as grainy and dark centered. Antagonist protocol (ganirelix) was used both times. Is there any hope in getting pregnant without donor eggs and sperm? Does protocol affect egg quality? Is there a way to get more mature eggs?

        Reply
        • Geoffrey Sher says:
          January 9, 2013 at 9:09 pm

          Indeed the most likely explanation lies in the protocol used for stimulation. At age 27, there is no way that you will have inherent egg problems warranting a donor. I would be happy to discuss this with you if you wish. Call 800-780-7437 and if you live in the U.S.A or Canada, you would be entitled to a free consultation by Skype or by phone.

          Geoff Sher

          Reply
      5. Wahida says:
        January 10, 2013 at 9:59 pm

        me-26,hx of ovarian cyst 2009,first icsi-2012 long protocol, retrieved 3 eggs only, transfer 2 embryo.failed pregnant
        Second icsi-2013 jan,short protocol, 4 eggs retrieved. transfer 3 blastocyst day5.failed pregnant
        Husband-low sperm count.

        Married-3.5 years
        If we repeat icsi,what we need to do?
        Please help me. My doc said that next cycle is my last chance.

        Reply
        • Geoffrey Sher says:
          January 11, 2013 at 6:28 am

          At 26Y, it is highly unlikely that you have an intrinsic egg issue. However, your response to stimulation needs to be explained. Do you have premature diminished ovarian reserve (DOR) (I would be interested in your FSH/E2 on day 3 and your AMH) or was it a case of low or “suboptimal choice of protocol for controlled Ovarian Stimulation (COS). (i.e. 1)What dosage and type of gonadotropins did you use; 2) for what duration of time did you receive gonadotropins before the Trigger shot of hCG and, 3)what type of hCG and dosage (i.e. was it Ovidrel (250mcg or 500mcg),or Novarel/ Profasi/Pregnyl…5000U or 10,0000U).

          It also concerns me that with 3 blastocysts you did not conceive. At your age, that begs the question as to whether you have an implantation issue (i.e. a thin lining, uterine cavity surface lesions or an immunologic implantation dysfunction).

          Please go to http://www.IVFauthority.com . When you get to home page, look for a “search bar” in the upper right hand corner. Type the following subjects into the bar, click on it and it will take you to all the relevant articles I posted there.

          1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)

          2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”

          3. “Agonist/Antagonist Conversion Protocol”

          4. “Immunologic Implantation Dysfunction” (posted on May, 10th and on May 16th respectively.

          5. “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)

          6. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)

          7.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)

          8. “IVF success

          Consider calling 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail.. While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.

          Geoff Sher

          Reply
          • Wahida says:
            January 11, 2013 at 7:22 pm

            My doctor didnt take AMN & fsh..he only want the quality of eggs.rather than produce more eggs.about my uterus,never do any imunologic test.maybe next icsi,will focus to my uterus…..i want to skype with u.i will made appointment.thanks doc.i realy appreciate ur suggstion.

            Reply
      6. Kiwi says:
        May 12, 2013 at 11:46 pm

        Hi, I am 29 and my husband 31. I have no known issues. my partner had an undescended teste that wasnt treated until he was 11 and he has a low count (11mil), low motilty/morphology.
        We have been trying to get pregnant 2.5 years. In January we did our first ivf/icsi cycle, got 11 eggs, 8 mature, all 8 fertilised and we went on to have 5 blastocysts.
        We have transferred 1 fresh and 1 frozen embryo (natural cycle) both embryos high grade, both times negative.
        Our embryologist mentioned that not many of the sperm were binding so there could be a dna fragmentation issue but we have not had a scsa test yet.
        I understand our next FET will be a medicated cycle.
        So, do you think if we have a dna frag issue we would still be able to create such high quality blastocysts? Do you think that could be the reason for no implantation? Have you got any ideas or suggestions on how we should proceed? We still have 3 blasts to try.
        Otherwise I have read about icsi with imsi, do you think that could help us?
        Really appreciate your time
        Thanks

        Reply
        • Geoffrey Sher says:
          May 13, 2013 at 10:07 am

          I do not think with your embryo generation that it is a sperm issue. Also you must consider having your embryos karyotyped (CGH) in any future fresh attempts.

          Finally do not discount an implantation problem as another possibility.

          Please go to the home page of this blog, http://www.IVFauthority.com. When you get there, look for a “search bar” in the upper right hand corner. Type the following subjects into the bar, click on it and it will take you to all the relevant articles posted there.

          1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)

          2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”

          3. “Agonist/Antagonist Conversion Protocol”

          4. “Immunologic Implantation Dysfunction” (posted on May, 10th and on May 16th respectively.

          5. “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)

          6. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)

          7.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)

          8. “IVF success: Factors that influence outcome”

          9. “Staggered IVF”

          Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail

          Geoff Sher

          Reply
      7. Kiwi says:
        May 13, 2013 at 2:08 pm

        Thank you for your time, I will read those articles. Much appreciated!

        Reply

      Leave a Reply

       
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      My IVF Cycle Failed – What Went Wrong? Question #19: Why Do I Keep Having Chemical Pregnancies and Miscarrying?
      This is the 19th in a series of answers to common questions about failed IVF. Early pregnancy loss – whether due to miscarriage or chemical pregnancy – is due to two major factors. In more than 70-80% of cases the cause is attributable to... more
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      My IVF Cycle Failed – What Went Wrong? Question #18: My Fertility Clinic Reports a High Success Rate – How Could I Have 2 Failed Cycles In A Row?
      This is no. 18 in a series of answers to common questions about failed IVF. While it is true that IVF failure can be due to preventable factors, it is as important to understand that optimal medical care does not always equate with an optimal outcome... more
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      My IVF Cycle Failed – What Went Wrong? Question #17: Why Didn’t I Get Pregnant When I Used a Young Egg Donor and Had Good Quality Embryos?
      This is #17 in a series of answers to common questions about failed IVF. For women whose advancing age and/or ovarian resistance make having a baby with their own eggs unfeasible or unlikely, IVF using donated eggs from a young donor (under 35 years)... more
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      My IVF Cycle Failed – What Went Wrong? Question #16: Why did my hCG levels stop rising properly?
      This is the 16th in a series of answers to common questions about failed IVF. Immediately following implantation, the root system (trophoblast) of the embryo begins to release the pregnancyhormone, human chorionic gonadotropin (hCG) into the surround... more
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      My IVF Cycle Failed – What Went Wrong? Question #15: Might My Mental State Have Played a Role?
      This is the 15th in a series of responses to common questions about failed IVF There is little doubt that stress and emotional lability plays a role in the normal physiological/hormonal regulation of the menstrual cycle.After all, Eskimos often stopp... more
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      My IVF Cycle Failed – What Went Wrong? Question #14: Could it Have Been Due to Inadequate Hormonal Support After the Egg Retrieval & Embryo Transfer?
      This is the 14th in a series of answers to common questions about failed IVF. In vitro fertilization establishes an abnormal hormonal environment in the uterus.In some cases (especially older women and those with a diminished ovarian reserve), high o... more
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      My IVF Cycle Failed – What Went Wrong? Question #13: Did the Number of Embryos I Had Transferred Play a Role?
      This is the 13th in a series of answers to common questions about failed IVF. Virtually everyone recognizes that pregnancy with multiples (especially triplets or greater) is associated with a high incidence of premature delivery that has serious cons... more
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      My IVF Cycle Failed – What Went Wrong? Question #12: Might the Timing of Embryo Transfer – Day 2-3 (Cleaved) vs. Day 5-6 (Blastocyst) Play a Role?
      This is the 12th in a series of answers to common questions about failed IVF. (Note: I’ll be hosting a live video chat on Aug. 2 on the topic of Failed IVF where I’ll discuss the issues addressed in this series of posts and take your ques... more
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