Dear Lord Winston,
My wife and I are considering beginning IVF in the New Year and with this in mind, I would be really grateful if you could answer a couple of questions I have before we decide to go through with IVF. We have being trying to conceive for 3 years now, I am 34 and my wife is 30. We have had 2 rounds of IUI without success. My wife has had hormone tests, ultrasounds and a HSG, all of which have come back normal. I’ve had sperm tests and my results were 146 million/ml with 68% motile and 6% normal morphology, but apparently I have 32% antisperm antibodies. The level antisperm antibodies has always bothered me, because opinion seems to be divided on whether or not the levels I have are significant. In your experience, could you what level of antisperm antibodies is significant? Our Fertility specialist has suggested 50% is a problem but has suggested ICSI – I assume this is to help with fertilisation rates? Also, my wife hasn’t had a Laparoscopy and I know from reading your blog that this is something that you would advocate. I have read that if a HSG is normal, the yield from Laparoscopy is low – is this correct? My wife and I are both really nervous about beginning IVF, which is why I would really appreciate your guidance at this point. We are finding it even harder to start IVF because of the unexplained infertiltiy, but now we have been trying to conceive for 3 years naturally, I assume the chance of natural conception is low? Once again, thank you for your time and your thoughts would be most appreciated. Yours sincerely I.
Looks like quite a good sperm count. I think I would be nervous about going for IVF without clear evidence of the cause of the infertility and I feel, without a laparoscopy, to go for ICSI and IVF on the equivocal results of the sperm antibodies is a bit dubious. But in your case, given the lowish level, I think a consultation with an acknowledged male fertility expert would be highly advisable first.
If you do have IVF at all, I have to say that the value of ICSI is clearly a bit doubtful – indeed in a recent paper (2011) by Dr Zini and colleagues, the authors concluded that more properly randomised studies were needed for a firm opinion to be made. I would add just this. Dr Craig Niederberger from Munster makes this point in his recent editorial in the Journal of Urology (I paraphrase very slightly to make his meaning a bit clearer). “Antisperm antibodies are terrifically sticky and notoriously difficult to knock off sperm. It is not surprising that a number of investigators have observed that, if present, these antibodies interfere with in vitro fertilization. In theory, shoving the sperm directly into the egg with intracytoplasmic sperm injection should improve outcomes in the presence of antisperm antibodies. Dr Zini and colleagues from Canada performed a meta-analysis in reviewing 16 different research studies from around the world to answer the question, is ICSI any better than plain IVF in the presence of antisperm antibodies? They conclude not. My concern with the study is that an odds ratio for pregnancy failure of 1.00 for ICSI is different than that of 1.22 for IVF, with IVF being worse; it is just that the number of included studies did not achieve statistical significance. It is a common problem with meta-analyses that by mixing together differing studies we may be throwing out the baby with the bathwater”.
Even allowing for the somewhat insensitive and unfortunate metaphor at the end of his statement, whatever the truth of the matter, the difference in odds ration seems pretty tiny to me.
I am sorry if this is not very helpful but one of the problems with all this is that there are so many different proteins which may cause this problem and react differently with different stages of fertilisation that I really feel most rather crude results given to patients from routine laboratories leaves them in the dark. This is why I suggest a consultation with a male fertility expert who perhaps does not have a vested interest in IVF.