Cork woman Maria O’Sullivan (41) is the mother of two children conceived through a sperm donor, Zavier (5) and Aurora (20 months). Her eldest daughter, Freya (all pictured), who was conceived naturally, had just turned nine when she decided to look into sperm donation.

Despite massive changes in Irish society in recent decades, most young women still envisage a future where they will meet Mr Right, get married and have children (not necessarily in that order). However, more and more women who have not met a potential life partner by a certain age and whose biological clocks are ticking louder every year, are now opting to go it alone through donor conception.

Angela O’Mahony, counsellor at Waterstone Clinic, says most of the single heterosexual women she meets who are considering sperm or egg donation have had a long desire to have a child, but have either not met anybody or were in a long-term relationship that did not work out.

“It’s a decision that does raise a lot of ethical and emotional issues for some people, the greatest of which is very much around the implications for the child into the future. Science has made so many amazing advances, but it also throws up challenges on so many levels.

“Counselling is an invitation to explore some of these complexities and challenges, to facilitate the woman making a decision that feels right for her and her potential child,” she says.

Once a woman has made the decision to go ahead and try for a baby through donor conception, the next major challenge facing her is whether to go for an identifiable (known) or anonymous donor. There are no sperm donation facilities in Ireland, so most Irish fertility clinics use sperm banks in Denmark where the law allows for donors to be identifiable, which means a child could contact their donor at the age of 18 if they chose to do so.

Dr John Waterstone, medical director of Waterstone Clinic, says that while the number of single heterosexual women attending the clinic for donor conception is small, it is increasing. Three-quarters of women in this situation who attend his clinic are over the age of 37, and all clients considering donor conception at the clinic must undergo free mandatory counselling in advance of treatment.

“The donation co-ordinator then sits down with the client and goes through the list of available donors. Some donors will provide an extended profile with more information on their background, maybe a baby photo and even a voice clip, which is more expensive than a basic profile.

“Once a client chooses her donor, she needs to decide how much sperm to import. If she is planning to extend her family in the future, she might bring in more sperm so that all siblings come from the same donor,” he explains.

The sperm is deep frozen and imported in straws, one straw containing one unit of sperm. The cost varies depending on the number of straws purchased and whether the donor is anonymous or identifiable. For example, four straws from an open donor will cost about €3,350, and four straws from a closed donor will cost about €1,900.

Clients can opt for intrauterine insemination (IUI), a simple procedure that involves placing the donor sperm inside the uterus to facilitate fertilisation, or in vitro fertilisation (IVF), a more invasive procedure that involves combining the egg and donor sperm in a laboratory dish and transferring the embryo to the uterus. IVF is much more successful, particularly for women in their later 30s, but also about four times more expensive than IUI. The typical cost of one cycle in an Irish clinic is about €750, while the cost of a cycle of IVF is about €4,250.

Maria’s story

Cork woman Maria O’Sullivan (41) is the mother of two children, Zavier (5) and Aurora (20 months), conceived through a sperm donor. Her eldest daughter, Freya, who was conceived naturally, had just turned nine when she decided to look into sperm donation. She had been been in a relationship with a man who already had children, and did not want anymore. With the support of her GP, she decided to go ahead with treatment at Waterstone Clinic Clinic.

“I opted for an open donor as I wanted my child to have the choice of contacting the donor when he or she was 18. I had a choice of five donors and chose somebody I felt I would have sparked with if I was to meet him. It was like a blind date without actually meeting the person.”

After only one cycle of IUI, Maria was fortunate to get pregnant and her son Zavier was born at home in October 2010. She had some sperm from the same donor frozen at the clinic and, four years later, she decided to try for another baby. Aurora was conceived in March 2014, again through IUI and born at home in December that year.

“Freya is now a teenager and Zavier is starting school in September. Aurora is just a dote; she really completes our family. I had been parenting Freya on my own from the start so I knew I would be able to cope. I don’t have a lot of family around, but you make your own family. I have made great friends and have great support, it’s true that it takes a village.”

Maria has always been very open about how Zavier and Aurora were conceived and talked about it with Freya before they came.

A former kindergarten teacher, Maria is now at home with her children full-time. She also finds the time to volunteer as a doula, supporting other women through pregnancy, and with Le Leche League.

“I do worry about the financial side of things. I’m renting and the rental sector is a bit crazy at the moment, but I tell people not to let finances stop you from having a baby. There’s not much you need in the first couple of years, apart from your arms and boobs. I would definitely recommend sperm donation to other women. You can have a relationship any time in your life, but you can’t have babies any time. I’m so glad I had my babies, they’re amazing.”

Alison’s story

Alison (40) had been in a long-term relationship on and off with a man who had been married before and had two teenage boys. He had always been honest about the fact that he did not want any children, but she was convinced she would change his mind.

“I was 36 heading for 37 and the pressure was building. I went to the US for work, and was involved in a very serious head-on collision. That was a wake-up call for me. I loved the guy, but he was not prepared to have more children so we split up. It was a difficult decision but the right one.”

Six months after the breakup, Alison made the big decision to try for a baby alone through sperm donation. Two close female friends encouraged her on her journey, while her mother and sister attended appointments and supported her along the way.

“I was 37 heading for 38 when I made the decision. I had a voice constantly in the back of my mind saying you can’t not be a mum and that voice got louder every year. My friends and brother were on their way down the traditional life path of marriage and children that I had always thought I would follow. My family were not staunch supporters of my decision at the beginning but, to be fair to my parents, their concern was coming from the right place. They knew how hard it was raising kids with two parents, let alone one.”

Alison was referred by her GP to the Clane Fertility Clinic (since acquired by Instituto Marques). It took two rounds of IUI and one round of IVF before she became pregnant with her daughter Katy, now two years and 10 months old.

She is open about how she had Katy and intends to be open with her daughter in the future. For now, she explains to Katy how every family is different and while she doesn’t have a daddy, she has a mummy who loves her very much.

“Katy is not three yet but she says “Mammy, I have no Daddy” She sees the dads collecting other children from her childminder’s house. She has my dad and brother as male role models and if the right person comes into our lives, I would like him to adopt Katy, but I would need to be 150 per cent sure about him.”

A communications manager, Alison has a busy career and, as the sole provider for her little family, bears all the responsibilities for her daughter’s care. There is nobody to help her in the middle of the night when Katy is sick, nobody to help her with drop-offs and collections and it’s simply not an option for her to be sick herself.

Despite all of the challenges though, she says the decision to have Katy was the best she ever made and she will never forget the day her daughter was put into her arms for the first time and describes motherhood as “incredibly rewarding”.

As an administrator for the Single Mums by Choice and Single Mums By Choice in Waiting private Facebook groups, Alison explains that the groups are strictly for women either trying to or who have conceived through sperm donation. Anybody who wants to join can send a request via email to [email protected] which will be reviewed by the administrators. Members of the group come from all over Ireland, but are mainly concentrated in the Dublin area and they meet up for regular coffee mornings and days out.

Counsellor Angela O’Mahony says one of the biggest challenges for women considering donor conception tends to be about how to deal sensitively with questions from their child about the identity and whereabouts of the donor.

She encourages women to look for as much non-identifiable information as possible to help give their child a better sense of who the donor is, such as what kind of music they like or whether they are into football. This may also help the child to identify where his /her particular interest or talent originated.

“Women who opt for sperm donation on their own often have made a safe and conscious choice about how to have their baby. The sharing of the genetic narrative with a child is part of that decision-making process. While this can be daunting for some, keeping it age appropriate and honest tends to work well for most mothers,” O’Mahony.

Michelle McDonagh

http://www.irishtimes.com/life-and-style/health-family/parenting/what-s-the-reality-of-going-it-alone-through-sperm-donation-1.2768318

When the time comes to choose a clinic, there are a number of factors to consider, with one of the most important being success rates.

Pregnancy rates will often be quoted on a website, but you also need to look at the live birth rate – the number of babies born per completed cycle of treatment. Pregnancy rates are usually higher than live birth rates, but it’s the chance of having a baby from treatment that you are actually interested in. A call to the clinic should give you an indication, for your age of how likely it is that you would have a baby from one treatment cycle.

It is really important that you trust the clinic and get a good feel for the team. If you have an opportunity to visit a clinic or attend an information evening, you should get a good sense of the clinic and its ethos.

Consider the opening times and the location of the clinic. It is important that the clinic is within reasonable distance of your home or work. It’s best to avoid long journeys as they will result in added stress, time off work, expense etc.

The cost of treatment is a very important factor to consider. Enquire if there will be additional costs involved or added extras, as you do not want to be faced with an unexpected bill at the end of your treatment.

You also need to be sure that the clinic offers the full range of treatment options. In addition to offering IVF, the clinic should also provide the less invasive treatments. If you are aware of a specific problem that is causing your fertility issues or contributing to it, it is always best to make a phone-call and ensure they are the best clinic to treat your concern.

http://www.her.ie/health/start-seeking-fertility-help/309081

Dr John Waterstone, Medical Director of the Waterstone Clinic, tells Catherine Reilly about the challenges facing fertility services and the urgent need for regulation

The area of fertility is rapidly changing. Science is delivering new possibilities, but the efficacy and affordability of some treatments have created cause for concern.

Questions marks have recently surrounded pre-implantation genetic screening (PGS) or aneuploidy screening, for example, which is used by some clinics in Ireland and internationally to seek to identify chromosomally normal and abnormal embryos.

In an interview with the Medical Independent (MI), Waterstone Clinic’s Medical Director Dr John Waterstone said routine PGS is “not warranted”. He said PGS is often marketed in the US as a ‘standard’ element of IVF treatment, which he found disquieting.

Dr Waterstone, who is President of the Irish Fertility Society (IFS) but spoke in a personal capacity, said the Waterstone Clinic would only recommend PGS for a small cohort in particular clinical circumstances.

“Personally, I am worried about the role of PGS full-stop,” Dr Waterstone told MI. “I don’t know just how promising it is, I don’t know how beneficial it is.”

Confusion

Mosaicism has recently emerged as a particular uncertainty in respect of PGS. Dr Waterstone noted that cases are being reported internationally of ‘mosaic embryos’ developing into healthy euploid newborns.

“When you do PGS on an embryo, you take out two-three-four-five cells from the embryo, usually from the part of the embryo that is going to form the placenta, and you do that at the blastocyst stage where there are maybe 150 cells present,” outlined Dr Waterstone.

“But some embryos contain a mixture of different cells; some of the cells are genetically normal and then other cells have an extra chromosome, or a chromosome too few.”

The growing evidence around mosaicism has thrown the area of PGS into confusion, he indicated.

“So for me, as Medical Director of Waterstone Clinic, we are proud that this is a technique we can do successfully but I am not at all certain right now, in 2016, about how the whole thing is going to pan-out with regard to PGS.”

PGD

Dr Waterstone said the centre was very happy with its pre-implantation genetic diagnosis (PGD) programme, which he said offers clear benefits.

“The couples are coming to you with a very real risk, usually a 25 per cent risk or a 50 per cent risk, that any baby they have would be affected by a very serious genetic condition. PGD is a good thing in my mind; there is no debate there.”

Dr Waterstone said the centre is doing a small number of PGD procedures. Waterstone Clinic is planning a relocation to a larger site that will facilitate a greater volume of work in this realm, he said.

“We are going to move to a new unit on the outskirts of Cork. We are opening there in January and our laboratory space is going to go from 300 square feet to about 1,400 square feet, so we will have a whole lot more space and a dedicated area for PGD.”

The centre has adopted the list of conditions approved for PGD by the UK fertility services regulator, the Human Fertilisation and Embryology Authority (HFEA). Dr Waterstone said there was a pressing need for long-awaited legislation and regulation around assisted human reproduction (AHR). The emergence of expensive ‘add-ons’ in IVF treatment is a particular concern.

In the UK, he noted, the HFEA has expressed alarm that certain IVF units are recommending extra treatments with the aim of “extracting more money from patients but without measurable benefits”.

Dr Waterstone said examples included intracytoplasmic morphologically-selected sperm injection (IMSI), which is not supported by data. He was also of the view that no additional cost should be associated with time-lapse incubators.

Commercialisation

“What I have been saying to the Department of Health is we certainly need regulation of IVF, but the most pressing concern is the commercialisation of IVF. The regulations that are introduced must address that issue, because that is one of the most pressing concerns — that couples coming through are maybe being exploited commercially by clinics that just want to maximise profit, rather than just maximise the outcomes for their patients.

“That to me is something that urgently needs to be addressed but which hasn’t really been addressed by legislation and regulation in other countries… It is a very practical issue for couples who are cash-strapped and finding it hard to afford IVF anyway and meanwhile they are confused as they go through and are being offered these add-ons.”

Currently, it is unclear when the Department will publish its draft legislation on AHR. MI understands drafting of the bill’s General Scheme is ongoing and there will be consultation after its publication.

“I hope they are making progress but from a pragmatic point of view, I cannot see that the Government are going to be eagerly trying to legislate on a contentious area, seeing as they are not in a strong position anyway,” Dr Waterstone commented.

IVF stakeholders were invited to a meeting in Hawkins House in July 2015. At that point, recalled Dr Waterstone, the Department already had a “framework for legislation”. “We in the IVF community were slightly upset and surprised that the plans had advanced so far without them seeking advice from us,” said Dr Waterstone of this meeting.

Many felt there was also insufficient consultation on legislative AHR provisions in the Children and Family Relationships Act 2015, developed by the Department of Justice. The Act provides for a National Donor-Conceived Person Register and bans use of anonymous donor gametes in Ireland. These parts of the legislation have not yet commenced.

“I personally think it was bad legislation; I think it was a missed opportunity for good legislation. I think it is far too restrictive, it actually infringes people’s constitutional right to privacy and autonomy,” said Dr Waterstone.

Currently, many fertility clinics in Ireland use sperm from Denmark and the majority of donors choose to be anonymous.

“The initiative from the Department of Justice, which is in law but not actually introduced, tries to ban anonymous donation. In other words, every donor in the future has to be someone who could be identified. I personally think it is over-intrusive, it is too dogmatic. I think people should be allowed a choice.”

The majority of heterosexual couples using donor sperm have opted for anonymous donors. This option is also taken by a “significant minority” of single women and same-sex female couples, he outlined.

Dr Waterstone added that around 1,000 couples per year go abroad for egg donation, usually to Spain or the Czech Republic, where it is anonymous by law.  The Department of Health, which will oversee implementation of this part of the legislation, has said the provisions relating to donor-assisted human reproduction, including those pertaining to non-anonymity and the National Donor-Conceived Person Register, will only apply where the donor-assisted human reproduction procedure takes place in Ireland.

The Department contends that the provisions reflect international best practice.

However, Dr Waterstone said the need to go abroad to access anonymous donor sperm or eggs would mitigate against less well-off people.  There is also a possibility that people will not involve clinics in the process at all, he said.

“We are also concerned in the Irish Fertility Society about ‘do-it-yourself’ donor sperm treatment for women. Say, a single woman who wants to use donor sperm finds some man on the Internet who is saying ‘I am a sperm donor’ — it is completely uncontrolled and so they just deal with an individual and not with a sperm bank.

“Then you don’t have these safeguards of viral testing and there is a possibility of sexually transmitted disease… we have expressed concern that if donor sperm is restricted it will encourage unofficial, do-it-yourself sperm donors which, if you go on the Internet, apparently it is quite frightening; there are lots of men out there advertising their services as personal sperm donors. We think that is frightening… we have expressed that concern in communications to the Department of Health already.”

Contentious

He acknowledged that donor anonymity is a contentious area and even people working within assisted reproduction hold different views. Nevertheless, the position of the IFS is that a ban is not warranted.

“There will always be debates about anonymity for gamete donation, is it good or is it bad… but while it is uncertain, people should have the freedom to choose anonymity or identifiability, and that is the situation that has obtained for a couple of decades and I think it has worked out very well.”

Catherine Reilly

http://www.medicalindependent.ie/94291/the_ethics_of_fertility

Nearly three out of four couples that begin fertility treatment will eventually become parents, long-term studies suggest.

The analysis of nearly 20,000 Danish couples found 65% had children within three years and 71% within five years.

Doctors, presenting their data at a fertility conference, said the odds were heavily influenced by age.

But experts said the findings were very encouraging for couples struggling to have babies.

There is strong evidence that about one in three cycles of IVF is successful in women under the age of 35.

But what happens in the long run, when some couples try over and over again, others give up and some have problems that cannot be treated, has been uncertain.

Researchers at the Copenhagen University Hospital used rigorous registry records in Denmark to follow 19,884 women from the moment they started fertility treatment.

The results, presented at the European Society of Human Reproduction and Embryology, showed that more than half had given birth within two years, rising to 71% after five years.

For women under 35, 80% had children within five years. But the figure fell to 61% in those between 35 and 40 years old; and fell again to 26% in women over 40.

Dr Sara Malchau, one of the researchers, told the BBC News website: “There is a very good chance of having a child, even if you have difficulties conceiving on your own.

“Most causes of infertility can be overcome, but age is the most important factor to predict if treatments are going to be successful or not.

“Also women with a body mass index under 30 had better outcomes as well as women who didn’t smoke.”

The study also found that nearly a fifth of the women under 35 ended up conceiving as a result of sex – despite having sought fertility treatment.

However, Dr Malchau cautioned Denmark prioritised fertility treatments that made it easier for women to keep trying. Many other countries are less generous.

Common causes of infertility

Women:

• damage to the fallopian tubes
• ovulatory problems
• endometriosis
• age
• polycystic ovary syndrome
• diabetes
• being overweight or underweight
• smoking

Men:

• low sperm count
• problems with the tubes carrying sperm
• problems getting an erection or ejaculating
• diabetes
• being overweight

Prof Nick Macklon, from the University of Southampton, said: “It really does provide some encouraging news for those who are about to embark on the journey of fertility treatment – the chance of having a baby is good.

“There will always be individual factors that affect an individual’s prognosis, but overall it shows us fertility treatments are working.

“There’s been a lot of debate about whether women should be having their children earlier, most of the people in my field would be of the view that if you can start earlier then your chances of completing the family you desire is going to be much higher.”

By James GallagherHealth editor, BBC News website

http://www.bbc.com/news/health-36662600

A pioneering new treatment for men with fertility problems has led to its first reported pregnancy in Ireland.

The new technique increases the likelihood of men becoming fathers without needing to use donor semen.

Microsurgical Testicular Sperm Extraction (Micro-TESE) is used to extract viable sperm cells from men suffering from azoospermia, which means they have no or practically no sperm cells in their semen.

The now father-to-be had previously undergone testicular surgery which had affected his sperm production. However, he had Micro-TESE at Waterstone Clinic and then his partner underwent IVF successfully.

In Micro-Tese, an incision is made in the scrotum through which one or both testicles can be seen.

Tubes within the testicle tissue are then inspected with a special high-powered microscope and dissected to see if they contain a trace of sperm. The use of the microscope means that the sperm retrieval rates are much higher than they are using traditional Tese and less issue is removed from the testicle.

Men can have a low sperm count due to low testosterone levels, an injury, following surgery or because of medical problems.

Up to 30% of fertility problems in couples are believed to originate with the male, another 30% with the female, a further 30% are a combination of both the man and woman, while 10% are non-identifiable.

The successful Micro-Tese was performed by CFC’s consultant urologist and andrologist Dr Ivor Cullen at University Hospital Waterford.

Dr Cullen said: “This is a landmark pregnancy and positive news regarding the treatment of male infertility and in particular azoospermia. It offers renewed hope to these men, and to men who have been diagnosed with defective sperm production, or had previous unsuccessful conventional sperm retrieval procedures.”

Micro-Tese allows the urologist to better distinguish between healthy and unhealthy testicular tissue. The healthy tissue samples are later examined in the laboratory. If viable sperm is found, it is prepared and frozen for use in a subsequent IVF cycle.

CFC head of laboratory services, Dr Tim Dineen said azoospermia is either caused by a duct obstruction or else by other hormonal or medical factors.

Obstructions are normally dealt with by a traditional biopsy while cases, where no obstruction is evident, can be helped by Micro-Tese as it is “much more targeted than traditional Tese”.

CFC has offered in-house testicular biopsy — traditional Tese — for men with azoospermia for over a decade. Micro-Tese is the more advanced procedure.

Micro-Tese is a day procedure — the patient can walk out the same day. It costs approximately €5,000 while IVF costs over €4,200.

Dr Dineen added that Irish men are handling fertility problems better than they would have 10-15 years ago.

“Certainly there is more talk about male infertility and the taboo that was once there isn’t there as much, but compared to women’s ability to talk openly about it, they still aren’t quite there yet,” he added.

http://www.irishexaminer.com/ireland/men-with-fertility-issues-can-now-be-biological-dads-402749.html

Waterstone Clinic has announced the first reported pregnancy as a result of an advanced sperm retrieval technique, Microsurgical Testicular Sperm Extraction (Micro-TESE) in Ireland. This development offers new hope to men struggling with sperm-related fertility issues. It means there is a greater possibility for affected couples to have children, without having to use donor semen.

The Micro-TESE procedure was carried out on a patient from Cork in conjunction with the centre’s scientific team, before the man and his partner underwent IVF treatment. The patient previously had testicular surgery which affected his sperm production, and as a result required Micro-TESE.

The procedure was performed by Waterstone Clinic’s Consultant Urologist and Andrologist, Dr Ivor Cullen at his practice in University Hospital Waterford. Dr Cullen is one of only a few urologists in Ireland qualified to carry out this highly specialised surgery.

Commenting on the success with Micro-TESE, Dr Cullen said “This is a landmark pregnancy and very positive news regarding the treatment of male infertility and in particular azoospermia. Azoospermia is a condition where no sperm cells are found in a semen sample, perhaps as a result of a hormone imbalance or other medical problem. It offers renewed hope to these men, and to men who have been diagnosed with defective sperm production, or had previous unsuccessful conventional sperm retrieval procedures.”

Micro-TESE is a welcome development in the treatment of men who cannot produce sperm. The procedure involves carrying out targeted dissection of tiny tubes within the testicle, which are more likely to contain sperm. A high powered microscope is used during the procedure to distinguish between healthy and unhealthy tissue. The healthy tissue samples are then examined in the laboratory. If viable sperm is found, it is prepared and frozen for use in a subsequent IVF cycle.

Head of Laboratory Services at Waterstone Clinic, Dr Tim Dineen, also commented “The team at Waterstone Clinic is delighted for this couple and would like to extend our congratulations. This procedure involved precise surgery and robust laboratory techniques; we will continue to pioneer innovative and evidence-based procedures and techniques, such as Micro-TESE, that help and benefit our patients overcoming their fertility struggles.”

Waterstone Clinic has carried out in-house testicular biopsy – known as TESE – for men with azoospermia for over a decade, and achieved their first birth through this technique in 2004. TESE is beneficial for azoospermic men whose basic problem is duct blockage. Micro-TESE is a more advanced procedure for men whose basic problem is failure to produce sperm cells. Both treatments are available at Waterstone Clinic.

Under the covers with men’s sexual health issues

Do a quick Google search for womens health. You will receive approximately 152 million results. Do the same for mens health and you will get 22.3 million. Is this sexism in another guise, or is it purely indicative of male reluctance to discuss their health issues, even with Dr Google?

Consultant urologist and andrologist at University Hospital Waterford (UHW) Ivor Cullen says men should be aware that there is a wide range of solutions to many problems they may perceive as being embarrassing or distressing.

Cullen trained in several ground-breaking techniques during his time working in the leading urology centre at University College London Hospital. Many of these have not been available in Ireland until now.

Breakthroughs in fertility medicine have not just been confined to female fertility issues; the area of male infertility has seen a revolution in recent times, says Cullen.

Sexual dysfunction has also moved on from the “little blue pill”. When Viagra doesn’t work, there are many other options for men struggling with erectile dysfunction.

The important thing to remember is that no worrying or “embarrassing” health problem can be addressed if a man doesn’t approach his GP or health professional about it, Cullen says.

Erectile dysfunction

Erectile dysfunction affects about half of all men at some point in their lives. For some it may just be temporary, but for others it can be a persistent problem. For some this can be treated with physiotherapy and muscle re-education exercises. It can also be treated with medications – the phosphodiesterase type 5 inhibitors (such as Viagra). However, for those men who do not respond to these treatments, there is now the surgical option of an inflatable penile prosthesis.

As part of this procedure, hydraulic pumps are inserted so that men with erectile dysfunction can have functioning erections and have sex normally. Although this procedure has been offered in Ireland before, in Cullen’s opinion, the uptake has been quite poor, mainly owing to a lack of knowledge in the area among both patients and the health profession at large. “Penis implant surgery is just not requested or desired by patients as they are unaware of the option,” says Cullen, contrasting this with his experience in London where a significant proportion of men with ED are aware of and will choose the implant surgery as an option when the medications fail. “It has been offered to a limited number of patients in one or two centres. There is very little knowledge about penis implant surgery. No one talks about it here, but in other parts of the world that’s not the case, it’s quite commonplace.”

According to Cullen, common candidates for this procedure are younger men with type 1 diabetes who often ultimately get erectile dysfunction early in life, often starting after the age of 40 and medication eventually does not work. In addition, men who have had their prostates removed or had radiation or hormonal treatment, usually as a result of prostate cancer, would also benefit from this surgery, as the majority of these will lose the ability to have an erection and often will not respond to the usual medications.

The procedure can be carried out by Cullen and his team at UHW. A three-piece hydraulic inflatable implant is inserted, which isn’t visible externally. A small pump sits in the scrotum, much like a third testicle, explains Cullen. The two-piece prosthesis is implanted in the penis, while a reservoir is laced in the lower abdomen. When the pump is squeezed, the fluid goes from the reservoir into the prosthesis and makes it erect. This ensures a rigid erection every time, satisfactory for penetrative intercourse and dispensing with the need for expensive medications or injections. “Obviously that’s not for everyone but it is a fantastic addition to our options. Satisfaction rates with penile implant surgery are always remarkably high – 90-95 per cent. In a well-chosen patient who is properly counselled, it can be a wonderful option for erectile dysfunction,” Cullen says.

Curved penis

A curved penis, also known as Peyronie’s disease, affects 4-8 per cent of men, and can make normal intercourse impossible. “Peyronie’s disease does not refer to a mild curve,” explains Cullen. “Every man’s penis has a minor degree of curvature, but problems arise when there is over a 30-45 degrees of curvature, making penetrative sex impossible.

“The curve develops because of abnormal deposition of scar tissue – “plaque” in the erectile bodies within the penis – which shortens the affected side and results in curve development. “Men cannot have a satisfactory sex life due to the shape of their penis, which can resemble a boomerang.”

Several surgical options exist for patients, whereby the penis can be straightened. One possible option to correct the curvature is the Nesbit procedure, which involves plication (suturing) of a section of the penis opposite the problematic plaque or scar. This operation will usually ensure a straight penis albeit with a minor loss of length.

Other potential approaches range from injections of a digesting enzyme (collagenase) into the scar tissue to break it down, grafting procedures and potentially implant surgery, if the co-existing erectile dysfunction is significant. Again Cullen says that in most cases men are not forthcoming about what they might see as an embarrassing problem. “Men are often very bashful and shy and don’t talk about these problems with their partners or friends, much less see their doctors about them,” says Cullen.

“It can often be slowly destroying their relationship or marriage, and they need to understand that this is a recognised and correctable phenomenon, and easily fixable surgically.”

Male factor infertility

Male factor infertility contributes to approximately 50 per cent of cases of infertility and for men whose semen analysis is suboptimal, there are more treatment options than ever before. There is a plethora of reasons as to why someone might have what is deemed an “abnormal” semen analysis, says Cullen.

“They may have a low count, poor motility, or a low number of normal sperm forms. We evaluate them and investigate them and, in many cases, we have medical, surgical options or lifestyle interventions that can improve the quality of their sperm. It could be something as simple as stopping them from using daily saunas and Jacuzzis, to putting them on zinc and folic acid supplements.”

One of the more common reasons for a subnormal semen analysis is a varicose vein of the spermatic cord, known as a varicocoele. This condition can raise the temperature of the testicle and impair sperm production. “Lots of men have a minor degree varicocele, which is of no clinical significance, but when we find a significant varicocoele in a gentleman with an abnormal semen analysis, simply tying off the extra varicose veins will typically improve that man’s sperm analysis.” Unfortunately, there are also men with no sperm at all in their semen, a condition known as azoospermia. Cullen says these are the most challenging patients he will treat with respect to male infertility. “It is a devastating diagnosis for a man; they will usually have been trying for a family for 12-18 months before someone says, let’s get checked. To find out there is no sperm at all is just a disaster for them.”

Tests are carried out to determine if the condition is due to an obstruction in the transport of sperm cells from the testicle to the ejaculate, or if there is a fundamental problem with sperm production within the testis. The obstructive type could be due to scarring of the vas deferens or epididymis, sometimes as a result of chlamydia or gonorrhoea.

A hernia repair or undescended testicle repair may also be the culprit. This can often be treated with a procedure that is much like a vasectomy reversal. “With this scenario, it really isn’t the end of the world, because even if you can’t fix it, their testes are still full of sperm,” explains Cullen. If this is the case, an option is a intracytoplasmic sperm injection (ICSI), where the sperm is injected directly into the egg. This treatment is offered in a number of clinics in Ireland. “That works so well now that all we need is sperm.”

In cases of non-obstructive azoospermia, a man will have no sperm at all in his semen. Recent advances in treatment have meant that at last these men have therapeutic options.

In the past, these couples had no choice other than using donor sperm or going down the route of adoption. In particular, a technique known as microdissection testicular sperm extraction (micro-TESE), has revolutionised the approach to finding small numbers of hidden sperm for use in the ICSI procedure.

The technique is another Cullen learned during his time in London; he now offers the procedure in conjunction with the Waterstone Clinic. He warns, however, that there is only a 50/50 chance of “success”; small numbers of sperm will be located in approximately half of the men he treats, while no sperm will be found in the other 50 per cent. “What I am trying to do is find their sperm for use in ICSI or as part of an IVF regime. But before I carry out the procedure I like to make sure that couples have had a chance to discuss and develop a back-up plan and perhaps speak to the sperm donor service if they so wish. “When there is no success, it can be devastating for a couple, and anticipating and discussing the implications of not finding sperm in advance of the operation often helps tremendously.”

Andrology

Andrology (from Ancient Greek, Andros, meaning man) is the medical specialty that deals exclusively with male genital, reproductive and sexual health. It is the counterpart to gynaecology, which deals with medical issues specific to the female reproductive system. It is a recognised subspecialty of urological surgery. Although andrology is a well-established subspecialty in mainland Europe and also the UK, thus far Ireland has had low numbers of specialists trained in this field.

Cullen suspects this is because of the well-recognised need for prostate, bladder and kidney specialists in Ireland, with the majority of his contemporaries instead choosing these routes for subspecialisation. The area remains under-served in Ireland.

“Andrology is a fascinating subspecialty, which offers tremendous medical and surgical options to gentlemen with a variety of male specific ailments,” says Cullen, who has spent 13 years training in this area.

With men living longer and our increasingly elderly demographic, he says there is a need for particular focus to be paid to late onset hypogonadism – often termed the “male menopause” – in older men. Symptoms range from sexual, such as erectile dysfunction, physical, with a loss of vigour and frailty, as well as having significant psychological impact. This can be successfully treated with testosterone replacement therapy, although lifestyle modification, weight reduction and appropriate treatment of comorbid diseases is the first step, Cullen is keen to emphasise. “Symptoms of low testosterone are well recognised and correctable in the hands of a specialist, which can lead to tremendous improvement in cardiovascular, sexual, mental and metabolic health.”

http://www.irishtimes.com/life-and-style/health-family/under-the-covers-with-men-s-sexual-health-issues-1.2660563

Waterstone Clinic takes pride in providing the highest standard of fertility treatment with evidence-based medicine the cornerstone of our good clinical practice.

We at Waterstone Clinic welcome the recent British Fertility Society practice guidelines published in Human Fertility, which confirms our long-standing belief that insufficient evidence exists to recommend adjuvants such as intravenous immunoglobulin (IVIG), anti –TNF α agents (e.g. Humira), intralipid infusions, corticosteroids, aspirin, sildenafil, DHEA or low molecular weight heparin in routine IVF practice.

Indeed, apart from the lack of evidence to support the use of these adjuvant therapies, the practice guideline emphasises the potential risks associated with these therapies, such as the risk of anaphylaxis and infection with IVIG and the increased risk of lymphoma, skin cancers and granulomatous infections with prolonged use of anti –TNF α agents. It is of paramount importance that patients prescribed unproven therapeutic agents have the available evidence for clinical benefit and the potential adverse effects discussed with them.

Waterstone Clinic continues to produce excellent success rates that are not reliant on the provision of therapies of unproven benefit.