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Friday, February 28, 2014

Exploring the stigma of male infertility

The issue of male infertility can leave men floundering and uncommunicative but taking a medical and holistic approach can have astonishing results.
By Catherine Shanahan
THERE are a range of labels and phrases around male infertility designed to kick a man when he’s down. There’s the word ‘jaffa’, slang for an infertile man, inspired by the seedless orange. There’s the reference to ‘shooting blanks’ and ‘bad swimmers’.

The terminology adds insult to injury for men struggling to come to terms with the fact that their ability to father a child is either severely compromised or downright impossible.

Thomas McCluskey, a 32-year-old security worker from Clondalkin, Co Dublin, was beginning to think he was in the latter category after he and wife Karen, (31) had spent five years trying to conceive.

Initially, he kept quiet about his difficulties.

“It’s not like you’d walk into the local and say to the lads ‘I’m shooting blanks’. There’s a stigma attached,” Thomas says.


Perfect result: Baby TJ McCluskey with parents Karen and Thomas McCluskey.

Dr Tim Dineen, laboratory manager at Cork Fertility Centre (CFC), agrees. He conducted a series of interviews to study the male reaction to fertility problems while working on a masters in genetic counselling.

“When I conducted interviews for my thesis 10 years ago, male fertility was a taboo subject and I found men were very slow to discuss it.

“My research suggested that identifying the root cause of subfertility, (a less than normal capacity for reproduction), can help the male psychologically, in that he may not blame himself and/ or think that he contributed to his problem. Men may also be reassured that male factor subfertility can be overcome through various treatment options,” Dineen says.

His research also highlighted the psychological impact of subfertility on the man.

“Many men had feelings of disappointment, failure, anxiety and anger, particularly when it’s something they have little control over such as a genetic condition,” he says.

Then there was the impact of infertility on a relationship. A colleague of Dineen’s did a study which found men can suffer low self-esteem and have high levels of stress when a diagnosis of subfertility is made, and these feelings can be acerbated by a lack of openness to communication. This in turn can decrease the level of overall contentment with the marital relationship.

However, what many men did not realise, says Dineen, is that male factor subfertility problems are not as rare as they might think.

“We see men every week who think they are the only one with this problem, but in fact, in at least one third of all cases, subfertility can be attributed to the male,” he says.

McCluskey was surprised when his sperm count came back on the low side after he had it tested three years into trying for a baby. The doctor advised him to lose weight (he was 19½ stone at the time) and to cut back on smoking (20 a day) and drinking, (24 cans a week).

“There was some sperm there so I though I was not doing anything too wrong. The doctor said, ‘You’re a young lad, try and cut down’, but I didn’t make too much of an effort to change at the time,” he says.

After another year-and-a-half of trying unsuccessfully to conceive, McCluskey went again for semen analysis, the principle investigation used to evaluate male fertility — it measures the number of sperm, the motility, (ability to move), and the morphology, (shape). Costs vary per clinic. At CFC the test ranges between €75 and €125.

Thomas’ sperm count was even lower this time around, but it took a TV show to get him motivated. He heard that TV3 were looking for a couple experiencing difficulties conceiving for a show called How Healthy Are You?.

“I had nothing to lose by doing the show. We didn’t have money to go down the IVF route and the show was looking at alternative therapies, so we went for it,” Thomas says.

The alternatives included analysing diet and lifestyle and making the necessary changes and trying out complementary therapies such as acupuncture and hypnotherapy.

Senior clinical embryologist Declan Keane, founder of the ReproMed clinics in Dublin and Kilkenny, was one of the show’s contributors. He’s a firm believer in exhausting the alternatives before heading down the route of advanced medical treatments.

“At present in Ireland, there’s no true link between those offering medical therapies and those offering complementary or holistic therapies. There should, in my view, be an integrated medical approach incorporating nutrition, dietary advice, psychological advice and other holistic therapies,” he says.

Being identified as subfertile can threaten men’s core identity. Keane believes men take infertility very personally, that it “hits the masculine or macho side”. While Dineen believes men find it difficult to distinguish between virility (sex drive), and fertility.

Many ask, “Am I not a real man if I can’t procreate?” he says.

CFC offers free counselling to help men deal with the psychological side. McCluskey concedes that he was under a lot of stress. “You can get very stressed thinking ‘I’ll never have kids’. From a male point of view you don’t want to think that you can’t father a child,” he says.

The couple seized the opportunities the show offered, changing diet with the help of nutritionist Elsa Jones, moving from heavily processed convenience foods to wholesome, fresh produce. They tried acupuncture with Karen Costin, a therapy Thomas said gave a “huge sense of relief” and hypnotherapist and psychotherapist Aisling Killoran put him in a better mental state. “It might seem like a lot of hocus-pocus to some people, but it’s actually quite practical. It relaxes you and puts you in a fantastic frame of mind,” says McCluskey.

But despite their best efforts, he got more bad news during the show. Another semen analysis showed no sperm present whatsoever.

Was this the end of the road? Not necessarily, Dineen says.

“The good news is that it is possible for him [a man with no sperm in the ejaculate], to still have his own biological child. We can carry out a testicular biopsy, Testicular Sperm Extraction (TESE), to retrieve sperm from testicular tissue; this may either be carried out on the day of ICSI treatment or a sample may equally be frozen and stored for use at a later date.”

ICSI (Intracytoplasmic Sperm Injection), one of the most popular techniques used to overcome the problems of low sperm count and poor motility, involves injecting a single moving sperm into the female partner’s egg, (collected for fertilisation outside the womb and transferred back after fertilisation has occurred).

At CFC, TESE is carried out under local anaesthetic and takes approximately 20 minutes; the clinic carries out approximately 40 procedures a year. Dineen says this method of sperm retrieval is very successful, and sperm is retrieved from tissue in about 80% of cases, resulting in a live birth rate of 42% per transfer.

However for men who undergo biopsy and no sperm are recovered, they do unfortunately hit a genetic cul de sac. “And you are then looking at options such as use of donor sperm,” he says. Donor sperm was not an option McCluskey had ever considered. It was suggested to him after the test where no semen was found.

“That was stunning news. That was life-changing. When it only takes one sperm to get pregnant, that news was devastating. I felt I had nothing to work with.”

In a panic, the couple sought more intense help from the therapists and doctors involved in the TV3 show. Declan Keane was encouraging. “He told me it takes three months to make sperm. I think that’s why my lifestyle changes didn’t take immediate effect. But I didn’t now that until he told me,” says McCluskey.

In the end, he did have something to work with. On January 5, he and Karen, an office administrator, had their first child, Thomas Jack (TJ).

Against what seemed like overwhelming odds, it was a spontaneous pregnancy. And amid all the stress and disappointment, the manner in which McCluskey learned he would finally become a father had its humorous side.

Karen was a week late menstruating and decided to do a pregnancy test.

McCluskey didn’t encourage her. “I said ‘Karen, we’ve been here so many times before’.” Karen did a test anyway but didn’t hang about for the result. “She was annoyed with me about something. She went off to work and left the pregnancy test on top of the cistern,” he says.

Later in the bathroom, he spotted the test. A casual glance gave way to an incredulous stare. “I’ll never forget it as long as I live. It was a massive surprise. There were two blue lines,” he says.

McCluskey rang his wife with the news. She didn’t believe him. In the end he had to send a photograph via his iphone. So now that he’s achieved what seemed the impossible, (in his words “a true miracle”), what advice does he have for other men dealing with infertility issues?

“Do your research. Don’t give up. You don’t necessarily have to go down the IVF or ICSI route. Examine your diet and lifestyle”.

And ultimately he says ‘Get yourselves checked out’.

“When you are coming to an age where having children is on the agenda, get the test done to see where you are on the scale.”

Sunday, February 2, 2014

Low folate in male diet linked to risk of offspring birth defects

Previous research has shown that what mothers eat during pregnancy affects the health of their offspring. But now, a new study suggests that a father's diet prior to conception could also play an important role in their child's health, particularly when it comes to consumption of folate.

Folate , also known as vitamin B9, is found naturally in a broad variety of foods, including dark green leafy vegetables, nuts, beans, peas, fruit and fruit juices, dairy products, poultry and meat, eggs, seafood and grains.
In 1998, the US Food and Drug Administration (FDA) required manufacturers to add folate to enriched breads, flours, cereals, cornmeals, pastas, rice and many other grain products, since these products are highly consumed in the US.

The researchers, led by Sarah Kimmins of McGill University in Canada, say that in order for mothers to help prevent miscarriages and birth defects, it is well known that they must consume sufficient levels of folate.

According to the Office of Dietary Supplements, a part of the National Institutes of Health, women of childbearing age should have 400 mcg (micrograms) of folate each day from dietary supplements and/or fortified foods, and this increases to 600 mcg a day for pregnant women.

But the investigators note that whether a father's folate levels play an important role in the development of their offspring has been under-studied.

Folate deficiency linked to increased risk of birth defects

New research has revealed that a man's diet could impact the health of his child, and low levels of folate could significantly increase the risk of their infant having birth defects.

To investigate this further, the research team conducted a mouse study in which they compared offspring of fathers who had sufficient folate levels to the offspring of fathers who had low folate levels.

Their findings, published in the journal Nature Communications, revealed that offspring of mice fathers who had insufficient folate levels had a 30% increase in birth defects, such as cranio-facial and spinal deformities, compared with offspring of fathers who had adequate levels of the vitamin.

Explaining the reasons behind their findings, the researchers note that there are areas of the sperm epigenome that are sensitive to lifestyle choices, particularly diet. The epigenome can influence the way in which genes are activated and how certain information is passed on to offspring.

They say that the sperm can carry a "memory" of a father's lifestyle choices and diet, and the information from a father's diet is transferred to an "epigenomic map," which can influence a child's development.

Fathers 'need to think about diet just as much as mothers'

Sarah Kimmins says their findings suggest that fathers need to think about what they eat, smoke and drink just as much as mothers do, as their lifestyle choices could impact future generations.

And she notes that although folate is added to many foods, fathers who have diets that are high in fat or who are obese may be unable to metabolize folate in the same way as those who have sufficient levels of the vitamin.

She adds:

"People who live in the Canadian North or in other parts of the world where there is food insecurity may also be particularly at risk for folate deficiency. And we now know that this information will be passed on from the father to the embryo with consequences that may be quite serious."

The researchers say that the next steps from this research will be to collaborate with professionals at a fertility clinic in order to further investigate how a man's diet and weight could impact their child's health.

Written by Honor Whiteman