Op-Med is a collection of original articles contributed by Doximity members.
Like numerous other medical societies, The American Society for Reproductive Medicine (ASRM), in response to the ongoing crisis of the COVID-19 pandemic, responsibly elected to conduct its annual conference virtually. For decades, I had been fortunate to attend this meeting, learning from international experts and renewing longtime meaningful friendships. As this year’s president of the ASRM affiliate — the Society of Male Reproduction and Urology — I sorely missed the social and professional interactions with so many of my colleagues and hope that next year we can resume a more normal lifestyle.
The ASRM congress began with the virtual Mask-R-Aid gala, which has historically been a truly spectacular event. As in the recent past, this year was focused on raising needed funds for the ASRM Research Institute. There continues to be areas of important infertility research that are not supported by traditional sources and thus rely on ASRM for funding and advancing the field of reproductive medicine.
Male factor infertility accounts for 40% of all infertility cases and the 2020 ASRM virtual congress presented a robust program that highlighted significant advances in science and clinical practice for this medical specialty.
Access to Care
Evaluation of the male factor by a trained urologist remains a gap in the model of optimal fertility care. The opportunity to optimize male fertility, improve sperm quality, and enhance the chances of conception without utilizing the most advanced technologies is best achieved by the upfront engagement with such trained specialists. Persily et al., from the NYU Grossman School of Medicine, highlighted that access to care for male factor infertility is an ongoing concern whereby only half the men seeking help to have a child undergo infertility testing. Access to care remains an issue and this group emphasized that the men who ultimately receive an infertility evaluation had a higher income. Fantus et al., from Northwestern University Chicago, Illinois highlighted that more than a third of office visits for male infertility were performed by non-urologists, suggesting that many of these men are receiving suboptimal care. Dr. Danis from University of Southern California demonstrated that men undergoing a reproductive urologist consultation reported this was helpful for understanding fertility, and 95% said it was helpful to have a “sperm doctor” as an adjunct to their partners’ “egg doctor.”
The emergence of telemedicine as a beneficial mainstay of health care delivery is here to stay. Numerous presentations highlighted the capability, utility, and time and cost benefit for the initial and follow-up evaluation of male infertility utilizing telemedicine. While not replacing the need for a physical examination, blood work, and (when needed) imaging studies, the incorporation of telemedicine continues to demonstrate value. Zhu et al., from Ann Arbor Michigan, analyzed 70 male infertility video visits and reported the total median savings per patient ranged from $149 (half day off) to $252 (full day off). They concluded that video visits are a feasible option for follow-up infertility care and are a patient-centric modality that reduces travel and financial burdens.
Advanced Paternal Age
The impact of advanced paternal age on fertility outcomes continues to be studied. Marsidi et al., from Emory University in Atlanta, Georgia, looked at more than 77,000 IVF cycles and showed that, compared to paternal age of younger than 45 years, paternal age of older than 46 years is associated with lower likelihood of pregnancy and live birth among couples undergoing IVF. A trend toward increased miscarriage risk was noted as paternal age increased, even for couples where female age was younger than 35. This report contributes to the ongoing body of science that suggests that overall, advanced paternal age negatively impacts reproductive outcomes. A symposium titled "Advanced Paternal Age and ART" thoroughly reviewed this topic and highlighted that advanced paternal age is associated with decreased sperm concentration, motility, and sperm quality, including DNA fragmentation and oxidative stress. The presentation emphasized that more than 75% of human germline mutations are paternal in origin and are worsened with advanced paternal age. There continues to be an emphasis on specific genomic regions of DNA methylation that are commonly altered with age and importantly, a significant portion of these alterations occur at genes known to be associated with schizophrenia and bipolar disorder.
The role and efficacy of nutritional support for male infertility is an ongoing controversial topic. An interactive session was dedicated to the topic highlighting that while several recent studies have not demonstrated clear benefit additional better designed randomized studies are encouraged. Of note, Masterson et al., from Cedars Sinai Medical Center in Los Angeles, California, shared data from a randomized perspective-controlled trial of 75 infertile men demonstrating that consumption of walnuts improved sperm motility and morphology.
Advanced Sperm Testing and Techniques to Optimize Sperm Quality
An emphasis on the importance and necessity to better evaluate and obtain quality sperm was a central theme in many presentations. Advanced sperm testing such as sperm DNA fragmentation assays was often discussed. Abnormal sperm DNA fragmentation can occur in the setting of correctable conditions such as infections, obesity, toxin exposure, smoking, and varicoceles and thus should be evaluated for, recognized, and addressed in the work up of male infertility. High DNA fragmentation nay negatively impact embryo development during IVF cycles and techniques to improve outcomes by obtaining better quality sperm was explored. Several of the presentations demonstrated that surgical techniques, whereby going to ‘the source” and obtaining testicular sperm, yielded better quality sperm and improved ART outcomes. Another less invasive nonsurgical protocol using microfluidic sperm filtering technology in the embryology laboratory was also presented as a viable option to acquire more optimal sperm for ART.
Special Lectures and Symposia
Dr. Kyle Orwig presented the AUA Bruce Stewart Memorial Lecture and provided a glimpse of what the future of spermatogonia stem cell (SSC) (precursor cells for sperm) transplantation may look like. Most impressively, it appears that in theory, this is currently technically feasible in higher primates. He introduced us via video to a monkey named Grady who is the world’s first primate baby born from autologously grafted, frozen, and thawed prepubertal testicular tissue. This miraculous advancement provides scientific merit to those ongoing research protocols, whereby SSC are harvested from prepubertal males with the hope of preserving their future fertility. This presentation was nothing short of inspirational.
Dr. David Shin et al., from the Hackensack Medical Center, chaired a session on lifestyle issues in male and female reproduction. Paternal obesity is associated with reduced reproductive potential decreased fertility potential, sperm DNA damage, and may have an impact on live birth rates, ART outcomes, and miscarriage rates. Data was presented indicating that through intervention and weight loss, improvement in semen parameters can be achieved. Regarding marijuana usage, he noted that with increased usage, one noted a decrease in sperm concentration morphology and motility. The impact of marijuana usage on time to conceive either naturally or with IVF was less definitive and better-quality studies are needed. Caffeine usage was noted to be associated with levels of testosterone and sex hormone binding globulin. High cola — as defined as an intake more than 980 mg caffeine/week — was associated with a decrease in sperm concentration. Additionally, more than 308 mg caffeine — an equivalent of three cups of coffee daily — had a negative impact on sperm DNA quality. Contrasting studies were presented regarding fecundity and caffeine consumption. Of note, ART live birth rates decreased for 55% to 19% as caffeine consumption increased. In conclusion, it appears that moderate caffeine consumption may have a limited negative impact, but excessive intake may be detrimental.
An interactive session titled Optimization of the Embryo and Couple in Male Factor Infertility with me, Dr. Paul Shin of Georgetown University, and Dr. McCulloh of NYU Grossman School of Medicine, highlighted that infertility is a couple’s problem. Infertility is best managed with good communication and collaboration between male fertility specialists, reproductive endocrinologists, and the embryologists who provide the remarkable technologies available within the ART laboratory. Individualizing care and harnessing emerging new advancements to optimize sperm quality requires a multidiscipline team effort that brings to bear the latest in clinical and laboratory science.
Dr. Bar-Chama has no conflicts of interest to disclose.
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