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Dr. Eric Daiter

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Dr Eric Daiter has served Monmouth and Middlesex Counties of New Jersey as an infertility expert for the past 20 years. Dr. Daiter is happy to offer second opinions (at the office or over the telephone) or new patient appointments. It is easy, just call us at 908 226 0250 to set up an appointment (leave a message with your name and number if we are unable to get to the phone and someone will call you back).


"I always try to be available for my patients since I do understand the pain and frustration associated with fertility problems or endometriosis."


"I understand that the economy is very tough and insurance companies do not cover a lot of the services that might help you. I always try to minimize your out of pocket cost while encouraging the most successful and effective treatments available."

NJ Center for Fertility and Reproductive Medicine - Infertility Tutorials

Treating Abnormal Sperm
In general, it should be remembered that the predictive value (in terms of fertility) of the semen analysis is low. A man with an abnormal semen analysis with a history of proven fertility (prior pregnancy) without an intervening event associated with infertility has a better prognosis than a similar man without proven fertility.

When the cause for the semen abnormality can be identified, treatment directed specifically at this cause is the most direct and effective plan. In many cases, the cause for the semen abnormality will not be discovered. In this situation, treatment is directed at improving the sperm's ability to fertilize an egg. Even in extreme cases of male factor infertility, if any live sperm can be retrieved either by ejaculation, from the postejaculatory voided urine, or through surgical retrieval from the scrotal sac there are fertility options which have reasonable success. This section reviews these options.

* (1) excessive exposure to heat

Limit such exposure and recheck the semen analysis 3-5 months later to allow for a nonoverlapping cycle of spermatogenesis

* (2) substance abuse, toxin exposure, and medications

Discontinue these substances (only change medications in conjunction with the prescribing physician) and recheck the semen analysis 3-5 months later to allow for a nonoverlapping cycle of spermatogenesis.

* (3) radiation

The effects can be transient, but are often permanent when greater than 60 rads has been administered to the pelvic region.

* (4) surgery

Postoperative changes are rarely treatable with further surgery. One possible exception is an obstruction in the outflow tract from the testicle involving the epididymis, vas deferens or ejaculatory duct.

* (5) testicular failure

These causes for azoospermia and severe oligospermia are rarely correctable. If any live sperm can be retrieved assisted fertilization (such as ICSI) at the time of IVF has a good pregnancy success rate. Use of very poor quality semen for COH/IUI or standard microdroplet IVF rarely results in pregnancy.

* (6) antisperm antibodies

Usually treated with intrauterine inseminations (to avoid the cervical mucus) or In Vitro Fertilization, regardless of antibody type. Since this treatment does not change according to the site on the sperm that is attached to the antibodies simply determining whether the patient has an abnormal postcoital test appears to be the most direct, simple and cost effective test for these antibodies.

Antisperm antibody titers may be suppressed with steroids. These medications have potentially serious complications, appear to have an effect on antisperm antibody titers only after several months of administration, and the dosages of the medications for this indication have not been clearly established. Therefore, I have not tried to suppress the production of antibodies with steroids.

* (7) varicocele

Repair is not always recommended. Specific findings on semen analysis and/or exam suggest the utility of repair. The semen analysis of subfertile men with a varicocele may show increased numbers of abnormally shaped sperm, a decrease in sperm motility and/or a decrease in sperm concentration.

Repair of a clinically detectable varicocele appears to be indicated if a persistent abnormal semen analysis is detected, especially if characterized by the so called "stress pattern" that is associated with a varicocele (a decreased sperm count or an increased number of tapered forms with an increased number of amorphous or immature sperm)

Repair of subclinical varicoceles (varicoceles that can only be detected by special tests like ultrasonography, doppler studies or invasive venograms) have not been shown to result in improved fertility. Therefore, the repair of these subclinical varicoceles is highly controversial.

Repair of a varicocele detected in the presence of a normal semen analysis, normal testicular exam and "unexplained infertility" is also controversial, with no clear basis for the surgery. That is, the mere presence of a varicocele in the context of a couple suffering from infertility is not independently an indication for surgery.

Following varicocele repair there usually is little improvement in the shape of the sperm (morphology) yet there is improvement in the sperm counts and motility in up to 70% of patients. The improvement in fertility, the desired goal, is unpredictable and different reports suggest a wide range of outcomes.

Some urologists have suggested hormonal treatment of varicoceles with either Clomiphene citrate or hCG (which acts like LH on the Leydig cells of the testes, improving parameters like testosterone production) alone or following surgery. In general, the research in this area is lacking. Limiting hormonal management to patients with a solid basis for treatment (such as a documented serum FSH, LH or testosterone concentration deficiency) seems prudent at this time.

* (8) disorders of emission or ejaculation

Treatment with pharmacological agents attempt to optimize emission and bladder neck closure. Ephedrine sulfate, pseudoephedrine hydrochloride, phenylpropanolamine hydrochloride, and imipramine hydrochloride have been used to stimulate contraction of the bladder neck. These agents seem to work best with minor nonsurgical causes of bladder neck flacidity. Following such operations as childhood YV plasty the pharmocologic agents are rarely effective.If no specific cause for the abnormal sperm is identified, treatment options include intrauterine inseminations, controlled ovarian hyperstimulation, and IVF with ICSI. I typically recommend a progression through the available treatment options from less aggressive to more aggressive.

* (9) intrauterine insemination (IUI)

Intrauterine insemination (IUI) of sperm has been a widely accepted technique for improving fertility when there is a mild male factor.

The basis for placement of sperm within the uterine cavity or within cervical mucus is the rapid dropoff of the number of sperm as they "naturally" progress from the vaginal vault to the cervical mucus to the uterine cavity to the fallopian tubes (where fertilization normally occurs). Reportedly, when about 50-500 million sperm are placed within the vaginal vault during intercourse (where they normally live for less than 1-2 hours), only about 1 million sperm find their way to the "friendlier" cervical mucus (where they normally can live for days), only a few thousand sperm may eventually find their way to the top of the uterine cavity where the tubal openings are located, and only hundreds to thousands of sperm may enter the tube in search of a mature egg. The mechanism for this tremendous dropoff of sperm along the way to the tube is not fully understood. The theory supporting intrauterine insemination is that placing more than 1 million sperm (many men with decreased sperm counts will have greater than 1 million motile sperm per ejaculate) at the top of the uterine cavity near the opening of the tubes improves the ability of those sperm to enter the fallopian tubes in search of fertilizable eggs.

The success of procedures that attempt to optimize the sperm's natural fertilizing ability is limited by the inherent sperm quality. When equal numbers of motile sperm are separated from sperm initially with a normal semen analysis versus sperm initially with a poor semen analysis, there appears to be better function of the sperm from the normal sample.

Insemination of sperm can be into the cervix or into the uterus. Intracervical insemination is ideal if the couple's only apparent problem with fertility is the inability to complete intercourse. Otherwise, this is a technique with limited proven utility. The primary indication for intrauterine insemination without the addition of controlled ovarian hyperstimulation is an abnormal postcoital test. Intrauterine insemination requires that the sperm is "washed" free of the semen since semen

*contains molecules (called prostaglandins) that cause painful contractions of the uterus if placed into the uterine cavity,

*may contain bacteria, and

* may have oxygen reactive species of molecules that could interfere with fertilization.

Techniques to separate sperm from semen can partially determine the amount and quality of sperm inseminated. Many infertility specialists have suggested that 1 million motile sperm following the sperm separation procedure is the minimum amount of sperm associated with a reasonable chance of pregnancy success at intrauterine insemination. The basis of this suggestion is not clear from a review of the literature, however, my own personal experience is in general agreement.

In sperm with decreased motility, chemical agents similar to caffeine have been used to enhance motility. These agents include pentoxyfylline which when applied to sperm will often improve motility considerably. Many sophisticated sperm labs apply these agents to sperm.

The criteria for the timing of inseminations should be clearly established. The goal is to perform the insemination at about the time of ovulation. Ovulation occurs about 36 hours after the onset of the LH surge (signal from the brain to the ovaries to ovulate) in a natural cycle. Ovulation predictor kits detect LH in the urine after metabolism and excretion into the urine. The LH in the urine reacts with the test kit material which then changes color (pink or blue). The detection of high levels of LH in the urine correlates with the occurrence (not the onset) of the LH surge in the blood. Generally, ovulation occurs the day of or the day following the positive LH ovulation predictor kit result, but exact timing of ovulation with these kits is not possible. On occasion, ovulation may occur 2 days after the kit's detection of the LH surge.

I have normally recommended that the patient have an IUI the day of or the day following the positive kit result. If the patient cannot return to the office for an insemination until 2 days following the positive result, I will allow an IUI if the patient understands that there may be a somewhat decreased chance of success. The mature egg is most likely fertilizable for 24 hours following release from the ovary. If intercourse rather than IUI is planned, then the couple should have relations each day for 3-4 days starting the day of the positive kit result. I have not found there to be an improved success in pregnancy outcome when 2 rather than 1 IUI is performed per natural cycle. However, there are some reports in the literature claiming improvement of pregnancy rates with 2 rather than 1 IUI.

If ovulation is triggered using hCG then injection of this medication simulates the LH surge. If hCG is given when there is a mature egg present in an ovarian follicle then ovulation should occur about 36 hours later. With hCG triggered ovulation, some research suggests a higher pregnancy outcome when 2 IUIs are performed with the initial procedure at 18 hours and the second procedure at 42 hours. These findings have not been widely accepted.

Controlled ovarian hyperstimulation (COH) uses fertility medication to mature greater than one egg per month and may be useful in the treatment of male factor infertility. By maturing multiple eggs in a given month you increase the number of "targets" for available sperm. The use of menotropins with intrauterine insemination is a widely accepted approach of moderate level aggressiveness for mild to moderate male factor infertility. COH/IUI is also used for unexplained infertility and ovulatory dysfunctions resistant to or intolerant to clomiphene citrate.

The literature regarding the use of these techniques is not abundant, but does suggest

* for male factor infertility or couples with an abnormal postcoital test, menotropins with IUI increase the pregnancy rate up to 4 fold over no treatment, to a success rate of 10-15% per cycle for male factor and slightly higher for those with only an abnormal postcoital test;

* for unexplained infertility the per cycle success rates in one study are about 3% for IUI alone, 6% for menotropins alone, and 26% for menotropins with IUI;

* clomid, menotropins and IUI alone are relatively ineffective in the treatment of male factor or unexplained infertility

When the sperm quality is not adequate to recommend COH/IUI, or if this management has not resulted in pregnancy within a reasonable trial period (3-6 cycles with good apparent multiple egg development) then alternative treatment plans should be considered.

* (10) donor sperm:

The use of donor sperm is a major decision and absolutely must be discussed by both members of a couple and agreed upon prior to initiating treatment. Indeed, both members of the couple will sign the consent for the donor insemination.

* (11) ICSI:

The use of assisted fertilization techniques have evolved over the past decades from (a) making small nicks or incisions in the shell of the egg (zona pellucida) called zona drilling or partial zona dissection (PZD), to (b) inserting a small number of sperm under the shell of the egg but not within the plasma membrane (oolemma) of the egg called subzonal insertion (SUZI), to (c) inserting individual sperm under the plasma membrane of the egg directly into the contents (cytoplasm) of the egg called intracytoplasmic sperm injection (ICSI). ICSI has far greater success than the earlier techniques in terms of pregnancy. The only sperm requirement of ICSI is having as many alive (generally motile) sperm as there are eggs for injection.


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Eric Daiter, M.D. - Edison, NJ - E-Mail: - Phone: (908)226-0250

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