Infertility and ICSI
In recent years significant developments have occurred in the field of reproductive technology as one in six couples seek assistance with conception. The increase in demand for infertility services may be related to several different factors. These include the tendency of women to delay childbearing because of career opportunities, so that desired reproduction is condensed into a shorter interval than before, an increased awareness of different treatments for infertility and an increase In the number of physicians with infertility interests (Mikulincer and Nathanson, 1990).

Many of the advances in this field have focused on the treatment of women and deal specifically with the reproductive problems of the female. Infertility services are often associated with gynecology services and infertility clinics may be Linked with gynecology clinics. Despite the improvement in infertility treatment generally, there is still a lack of tangible treatment for the male partner when a so called “male factor” is involved, despite the fact that male infertility is One of the commonest causes of infertility, with a relative incidence of 32% amongst couples presenting with infertility problems (Prosser 1995).

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In the past, when problems such as azoospermia or oligospermia were diagnosed, Donor Insemination (DI) was the only treatment available for couples. Recently Intracytoplasmic Sperm Injection (ICSI) has enabled more couples to have their own genetic child. Both these treatment options, however, circumvent rather than treat the problem of male infertility, as DI avoids the Male partner’s involvement in the reproductive process and ICSI involves the female partner undergoing aggressive drug therapy and a surgical procedure. Due to Infertility Clinics apparent preoccupation with the female partner and the treatment of Women, I feel that the needs of the male partner are not being fully appreciated or considered and I aim to discuss this issue specifically in relation to ICSI treatment.

Whilst many couples will cope effectively with a diagnosis of infertility, its management is experienced by many as an ongoing chronic emotional difficulty which requires major coping skills. Menning (1975) argued that infertility is “a complex Life crisis, psychologically threatening and emotionally stressful”. Clearly the degree of stress and the extent of the threat perceived by the individual will vary as the individual’s response to the situation. Men and women will respond and cope differently with infertility, and their emotional response may be significantly influenced by a gender specific diagnosis. (Nachtigall, Becker and Wozny, 1992).

Assessment of male infertility is based on history, physical examination, semen analysis and other ancillary investigations. A semen analysis involves assessment of the number of sperm present in the ejaculate, the motility of the sperm and their morphological appearance. This test will confirm the presence or absence of sperm, and that ejaculation is occurring normally. Following the semen analysis, normality may be confirmed, or a number of problems may be identified such as azoospermia, oligospermia, asthenozospermia, or teratozoospermia.

As Lee (1996), points out, semen analysis does however give little information regarding actual sperm function, as 5 - 10% of men with normal semen analysis will fail to fertilise ova during IVF treatment, and 25 - 40% with oligospermia or asthenozospermia will demonstrate the ability to fertilise ova during IVF. Opinions regarding male infertility vary enormously, and there appears to be some confusion regarding recent reports of a decline in sperm counts.

Carlsen, Giwercman, Keiding and Shakkebaek (1992) from their review of 61 papers published between 1938 and 1990, have suggested that there has been a progressive decrease in sperm count over this 50 year period. Factors responsible for this Decline includes the effect of oestrogens and environmental factors on testicular function, and an increased prevalence of genito-urinary abnormalities such as testicular cancer. Sexually transmitted diseases may also affect male fertility.

Critics of this review include Forti and Serio (1993) and Bromwich, Cohen, Stewart and Walker (1994) who argue that this decrease in count may not necessarily have been accompanied by a reduction in the fertilising potential of the spermatozoa, and highlight that the introduction of unified procedures by the World Health Organisation may have improved the laboratory methods for conducting semen analysis. They therefore point out, that rather than there being an actual increase in male infertility, laboratories are becoming more efficient at actually performing semen analysis.

Following a diagnosis of “male factor” infertility, several options may exist depending upon the problem identified. DI for example, is the only option if the male is azoospermia. When oligospermia or asthenozospermia exists, in some situations IVF may be appropriate but ICSI would be the treatment of choice. ICSI was developed in Brussels and is more efficient than other micromanipulation techniques, such as zona drilling, partial zona drilling and sub-zonal insemination (Palermo, Joris, Deroey, and Van Steirteghem 1992). The treatment involves a period of down-regulation with GnRH agonists and then the administration of Gonadotrophins to the female partner in order to stimulate multiple follicular development. Oocytes are then collected from the ovaries by transvaginal ultrasound guided follicular aspiration 36 hours after administration of hCG.

The sperm sample is obtained on the day of oocyte recovery, and is usually prepared by high speed centrifusion. The oocytes will be denuded of cumulus in order that those at the correct stage of maturity, i.e. Metaphase II can be identified. The injection of one sperm into the cytoplasm of each oocyte will take place on the day of oocyte collection. Prior to injection the sperm motility may be retarded and the sperm that most closely approximates to normal morphology will be immobilised by crushing its tail. This is undertaken as it is thought to damage the cell membrane and invoke subsequent physiological and biochemical reactions that may promote decondensation of the sperm head and activation of the oocyte.

The oocyte is held flat against a holding pipette using gentle suction and the injection pipette with the immobilised sperm in a position near the pipette opening is pushed steadily against the zona pellucida until it pierces the zona. The sperm is then injected into the cytoplasm of the oocyte. Fertilisation rates will vary, but rates of 60 - 70% and clinical pregnancy rates of 24% may be achieved when the injection technique has been optimised. ICSI treatment has given men who have an epididymal blockage or congenital absence of the vas deferens (often associated with a high incidence of mutation in the cystic fibrosis gene) a hope of having their own genetic child as sperm can be aspirated directly from the Epididymus and used for ICSI. This technique known as Micro Epididymal Sperm Aspiration (MESA) may also be used if the male partner has had a vasectomy previously and wishes to have a child with a new partner.

Edelman, Humphrey and Owens (1994) point out that there are many factors that affect motivation for parenthood. There may be a sociobiological desire to reproduce in order to maximise genetic representation in subsequent generations. In some cultures children may be viewed as an economic necessity as they provide an additional income or member of the workforce, although in our society, in contrast, children may be considered by some to be a drain on a families economic resources. Social and personal identity needs are, however, far more significant motivations for childbearing and the male partner may have motives which I feel are not generally appreciated or understood.

In order to understand how a diagnosis of a specific male factor problem and subsequent progression to ICSI treatment can affect the male and his partner, a clearer understanding of male ideology is necessary. Hite (1991) describes men as being rational, logical, scientific and objective and afraid of their emotions. Further adjectives include responsible, capable, brave, virile and macho. Men seek to have power and control by being emotionally distant, and work, independence and dominance are all important to them. The male ideology described above has developed as a result of socially constructed behaviour and is usually assimilated throughout early childhood. Obviously not all men will exhibit all these characteristics, but a diagnosis of male factor infertility can be devastating for some men as many of their ideals and expectations will be threatened or challenged.

Many of the emotions associated with infertility and discussed below, will be experienced by men undergoing any infertility treatment, but some are specific to men participating in ICSI treatment. Connolly, Edelmann and Cooke (1987) report greater emotional and marital difficulties when the cause of the infertility lay with the man, and these findings are supported by more recent research (Connolly, Edelmann, Cooke and Robson (1992). Some sexual dysfunction may be reported when a diagnosis is made and Link and Darling (1986) discovered 84% of females and 88% of males to be experiencing sexual difficulties. These findings may relate to the fact that for some couples sex may somehow lose its meaning as it does not produce the desired child. The male partner’s feelings of powerlessness and helplessness may lead to feelings of sexual impotence and Berger (1980) reported a 63% incidence of transient impotence following a diagnosis of azoospermia.

Some men will become very absorbed in their work and work long hours as they may feel confident and in control within that environment. This may result in tiredness and avoidance of their partner, which may cause conflict and sexual difficulties. There may, conversely, be an increase in sexual activity and sexual satisfaction as both partners express an increased need to be loved and valued. The process of investigation itself has been reported to be beneficial in certain situations in helping reduce marital and sexual problems, as it may be perceived that some positive steps are being taken to deal with the ongoing infertility (Raval, Slade, Buck and Lieberman 1987).

The loss of self esteem together with feelings of guilt reported by many men, may relate to their perceived inability to fulfil their expected role in society, i.e. to procreate. They may experience feelings of failure as they are unable to provide their partner with the role of parent. Fertility is often associated with virility, and the man who is unable to father a child may feel others will doubt his masculinity (Mahlastedt 1985). In order therefore to retain a brave/macho image, many men may turn difficult issues into a joke, or appear outwardly light-hearted about the issue of infertility. Alternatively men may ensure that no-one knows about their problems and this can result in the only means of support being their partner. This may lead to feelings of isolation and frustration as the female partner copes with her own feelings and those of her partner.

To admit to feelings of distress and to needing help and support goes against the male needs for displaying power and control, and whilst women will often seek help and support, men may try and avoid the issue and often do not attend with their partners for counselling (Lee 1996).

The longer the tests on the male partner continue the more likely they are to report feelings of anger, guilt and diminished success (Connelly et. al. 1987). This fact is particularly relevant when dealing with men participating in ICSI treatment, as following an initial semen analysis it is likely that they will be required to provide further samples in order to confirm certain findings. These repeated investigations will be stressful for both partners.

ICSI was developed to help men with severe male factor infertility, or when the fertilising ability of the sperm is in doubt i.e. when previously failed fertilisation has occurred during IVF treatment. Lee (1996) points out that men have more difficulty coming to terms with their infertility when their are some sperm in the ejaculate. This may be because they have limited understanding regarding the process of reproduction and fertilisation, and the nurse specialist may help men appreciate how their specific problems are contributing to their infertility by discussing in detail this process with them. When severe oligospermia is present, the male partner participating in ICSI treatment may have further anxieties about whether their sperm sample will be adequate on the day of oocyte collection. Counselling regarding the use of donor sperm as “back up”, if indeed insufficient sperm were isolated, may cause conflicting emotions as the male partner may, despite this new treatment, have to come to terms with the fact that he may after all not have his own genetic child. In such a situation an acceptance of the need to use donor sperm may be reached too readily, and this may lead to problems in the future in terms of acceptance of a child. Owens and Edelmann (1993) highlight that both men and women have anxieties about future rejection of the child when the use of donor sperm is being considered, and the nurse specialist must ensure that couples reach their decisions having received sufficient counselling.

ICSI and IVF is concerned with women despite the infertility being on the part of the male, and in order to increase his feelings of involvement, and control the male partner should be involved as much as possible in the planning and Organisation of the treatment if appropriate. The male may be distressed at seeing his partner undergoing the surgical procedure, and some women may even resent having to take drugs and experience oocyte recovery when they may consider themselves blameless. It is possible that men who have previously undergone vasectomy, and therefore require ICSI to enable them to have further children, may experience heightened feelings of guilt and distress at the time of oocyte recovery, as they witness their partner’s discomfort.

In my experience some couples report that as ICSI is still a relatively new treatment, their families have very limited understanding and acceptance regarding the treatment and this can be perceived by some as a lack of support and encouragement from family members. Parents of the male partner may have feelings of guilt and blame, and may be trying to identify how or when their son’s problem may have developed. Men may also search their past for some explanation, and any unresolved guilt about past behaviour should be identified and dealt with if necessary.

Any feelings of low self esteem and failure that a man undergoing fertility treatment may be experiencing could be further compounded if the couples are unable to afford ICSI treatment, as there is often no NHS funding available for this treatment. The male partner may feel that he has failed in his role as financial provider and conflict may occur if DI is then the only option for the couple. Schover, Thomas, Miller, Falcone, Attaran and Goldberg (1996) make the point that the development of ICSI has created a two tiered system of care for men with severely limited fertility: a genetic child if you can afford to pay for one, and otherwise the options of a child who is not biologically related or living without technology have not been accompanied by an increase in awareness of the relationship between infertility and psychological factors particularly when male factor infertility is involved. This may be a reflection on medical training, in that there may be generally more emphasis on diagnosis than on the social and sychologicaldimension of infertility. Further research is required to assess the impact male infertility has on a couple but it may be that the development of ICSI has redirected funds that may have been used for research in this area.

Doctors within the field of reproductive medicine predominantly males who could have problems relating to the infertile male due to their own beliefs and experience of male ideology. There is often a rapid turnover of staff within Assisted Conception Units, and there are few specialists in male infertility. HFEA, within their Code of Practice (1993), identify and emphasise the need for counselling, and this is an area where improvements could be made in the field of male infertility. Counselling should be readily available, promoted in a positive manner and should be encouraged for all couples undergoing ICSI.

The infertility nurse specialist has an important role in ensuring that the emotional needs of the male partner are clearly identified from the outset. A non-threatening environment is essential in order that men do not feel powerless and out of control when attending clinics. Continuity of care may enable both partners to express their anxieties more readily, and if the male partner feels that a named nurse specialist has a clear understanding of his feelings relating to the infertility, he may be more willing to seek help and advice. Within an ACU it is extremely beneficial to have a nurse specialist who has a good understanding regarding all the aspects of ICSI treatment, as this will ensure that couples will always know who to liaise with about their treatment.

The acceptance of infertility is difficult regardless of diagnosis, but Lee (1996) that some men may never come to terms with their infertility. ICSI, despite being seen as a revolutionary treatment is still not very successful and may not even be perceived as an option for many couples due to financial constraints. This technology may therefore be giving some men unrealistic hope that a solution for their infertility may be found, and the nurse specialist should ensure that all couples should have the relevant facts relating to their chances of success. Discussion regarding coping strategies for the couple will be useful in the event that the treatment will fail, and more long-term follow up and counselling should be available to ensure that all specific emotions are being dealt with, and other treatment options such as DI are being considered in a rational and logical manner.

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