Self therapy does not exist.
Chemotherapy (chemo, CTX, CTx or CT) is the standard treatment for nonseminoma (a type of testicular cancer that arises in specialized sex cells called germ cells that give rise to sperm). With the advance in chemo-therapies, cure rate of germ cell tumor with combination chemotherapy is high even disseminated (spreaded to the body) testicular cancer.
Chemotherapy is a category of cancer treatment that uses one or more anti-cancer drugs (chemotherapeutic agents). Traditional chemotherapeutic agents are cytotoxic by means of interfering with cell division (mitosis) but cancer cells vary widely in their susceptibility to these agents.
Chemotherapy can be swallowed in pill form, but more frequently it is injected by needle into a vein or muscle. The drug than circulates through the bloodstream of whole body- this is called systemic therapy. This helps to destroy the cancer not only in the origin, but also the metastases anywhere in the body except lymph node and distant organs.
The chemotherapy is given in cycles, each period of treatment is followed by a rest period, because the body must recover. Generally, the chemo treatments last about 3 to 4 weeks.
The standard chemotherapy protocol of nonseminoma includes three, or sometimes four, rounds of Bleomycin-Etoposide Cisplatin (BEP). Bleomycin acts by creating DNA double strand breaks, mimicking the effects of ionizing radiation, but the underlying exact mechanisms of action remain incompletely understood.
An alternative, equally effective treatment involves the use of four cycles of Etoposide-Cisplatin (EP). The increase in survival and cure rate in the last decades has been due mainly to effective chemotherapy.
As an adjuvant treatment, use of chemotherapy as an alternative to radiation therapy in the treatment of seminoma (a different type of germ cells tumor, with different subgroups, which spread more quickly) is increasing, because radiation therapy appears to have more significant long-term side effects (for example, internal scarring, increased risks of secondary malignancies, etc.).
Estrogen and other hormones are given to postmenopausal women in order to prevent osteoporosis as well as treat the symptoms of menopause such as hot flushes, vaginal dryness, urinary stress incontinence, chilly sensations, dizziness, fatigue, irritability, and sweating. Fractures of the spine, wrist, and hips decrease by 50–70% and spinal bone density increases by ~5% in those women treated with estrogen within 3 years of the onset of menopause and for 5–10 years thereafter.
Before the specific dangers of conjugated equine estrogens were well understood, standard therapy was 0.625 mg/day of conjugated equine estrogens (such as Premarin). There are, however, risks associated with conjugated equine estrogen therapy. Among the older postmenopausal women studied as part of the Women's Health Initiative (WHI), an orally administered conjugated equine estrogen supplement was found to be associated with an increased risk of dangerous blood clotting. The WHI studies used one type of estrogen supplement, a high oral dose of conjugated equine estrogens (Premarin alone and with medroxyprogesterone acetate as PremPro).
In a study by the NIH, esterified estrogens were not proven to pose the same risks to health as conjugated equine estrogens. Hormone replacement therapy has favorable effects on serum cholesterol levels, and when initiated immediately upon menopause may reduce the incidence of cardiovascular disease, although this hypothesis has yet to be tested in randomized trials. Estrogen appears to have a protector effect on atherosclerosis: it lowers LDL and triglycerides, it raises HDL levels and has endothelial vasodilatation properties plus an anti-inflammatory component.
Research is underway to determine if risks of estrogen supplement use are the same for all methods of delivery. In particular, estrogen applied topically may have a different spectrum of side-effects than when administered orally, and transdermal estrogens do not affect clotting as they are absorbed directly into the systemic circulation, avoiding first-pass metabolism in the liver. This route of administration is thus preferred in women with a history of thrombo-embolic disease.
Estrogen is also used in the therapy of vaginal atrophy, hypoestrogenism (as a result of hypogonadism, castration, or primary ovarian failure), amenorrhea, dysmenorrhea, and oligomenorrhea. Estrogens can also be used to suppress lactation after child birth.
Radiation therapy of testicular cancer is a therapy, which uses ionizing radiation, especially on seminoma (a germ cell tumor of the testicle; Pic. 1).
Pure seminoma is a rare pathology of the young adult, often discovered in the early stages. Its prognosis is generally excellent and many therapeutic options are available, especially in stage I (cancer that is limited to the testes) tumors. High cure rates can be achieved in several ways. One of the therapeutic options is radiation therapy.
Radiation therapy is used on tumors because of its ability to control cell growth. Ionizing radiation works by damaging the DNA of exposed tissue thus killing it. To spare normal tissues (such as skin or organs which radiation must pass through in order to treat the tumor), doctors aim weaker radiation beams from several angles of exposure to intersect at the tumor, providing a much larger absorbed dose there than in the surrounding, healthy tissue.
Besides the tumor itself, the target for the radiation may also include the lymph nodes that drain the area. Doctors include the lymph nodes if they are clinically or radiologically involved with tumor, or if there is thought to be a risk of that individual cancer cells will spread. It is impossible to aim the radiation beam exactly because the tumor moves as the patient breathes. So, doctors also expect to include some healthy tissue around the tumor to make sure that the entire tumor is hit by radiation.
Radiation therapy works with a machine, which directs high-energy beams of radiation into body. Patient lie on a table and this machine is moving around to deliver radiation from several angles (Pic. 2). Patients may be positioned to access better direction.
Typically, radiation is received five days a week over a certain period of time. In most cases treatments are spread out over several weeks to allow healthy cells recover between sessions. Each treatment last approximately 10-30 minutes. Every patient and situation is individual, so these protocols can be changed.
Radiation therapy also works together with chemotherapy. Radiation therapy has been used before, during, and after chemotherapy in cancers known to be affected by radiation.
Radiatiotherapy or radiation therapy is therapy using ionizing radiation, generally as part of cancer treatment to control or kill malignant cells by linear accelerator (Pic. 1). Radiation therapy may be curative in a number of types of cancer if they are localized to one area of the body (Pic. 2). It may also be used as part of adjuvant therapy, to prevent tumor recurrence after surgery to remove a primary malignant tumor (for example, early stages of breast cancer; Pic. 3). Variations in the indication for treatment, as adjuvant, radical or palliative radiotherapy, also define different variables in the influence.
Radiation therapy is commonly applied to the cancerous tumor because of its ability to control cell growth. Ionizing radiation works by damaging the DNA of cancerous tissue leading to cellular death. This DNA damage is caused by one of two types of energy, photon or charged particle. This damage is either direct or indirect ionization of the atoms which make up the DNA chain. Indirect ionization happens as a result of the ionization of water, forming free radicals (hydroxyl radicals), which then damage the DNA.
Before treatment, a CT (computered tomography) scan is often performed to identify the tumor and surrounding normal structures. The patient receives small skin marks to guide the placement of treatment fields. Patient positioning is crucial at this stage as the patient will have to be set-up in the identical position during treatment. Many patient positioning devices have been developed for this purpose, including masks and cushions which can be molded to the patient.
Most of times, conventional treatments with radiotherapy are delivered in five weekly fractions (Pic. 4) throughout an uninterrupted variable period of two-eight weeks, depending on the disease to be treated; however, alterations in the therapeutic scheme may occur.
Radiotherapy, especially when administered in limited fractions of high dose, positively influences tumorspecific immunity. Current fertility preserving strategies before chemotherapy/radiotherapy such as cryoconservation (using freeze) of oocytes or ovarian tissue and limitation of the dose applied to the ovaries, ultimately were depending on the use a surrogate mother, as uterine dysfunction after pelvic radiation therapy was assumed to preclude to carry a pregnancy to term.
During the first two weeks after fertilization, radiation therapy is lethal (causing death) but not teratogenic (causing developmental malformations). High doses of radiation during pregnancy induce anomalies, impaired growth and intellectual disability, and there may be an increased risk of childhood leukemia and other tumours in the offspring.
In males previously having undergone radiotherapy, there appears to be no increase in genetic defects or congenital malformations in their children conceived after therapy. However, the use of assisted reproductive technologies (ART) and micromanipulation techniques might increase this risk.
Assisted reproductive technology (ART) is the technology used to achieve pregnancy in procedures such as fertility medication, artificial insemination, in vitro fertilization and surrogacy. It is reproductive technology used primarily for infertility treatments, and is also known as fertility treatment. It mainly belongs to the field of reproductive endocrinology and infertility, and may also include intracytoplasmic sperm injection (ICSI) and cryopreservation. Some forms of ART are also used with regard to fertile couples for genetic reasons (preimplantation genetic diagnosis). ART is also used for couples who are discordant for certain communicable diseases; for example, HIV to reduce the risk of infection when a pregnancy is desired.
If conservative medical treatments fail to achieve a full term pregnancy, the physician may suggest the patient undergo in vitro fertilization (IVF). IVF and ART generally start with stimulating the ovaries to increase egg production. Most fertility medications are agents that stimulate the development of follicles in the ovary. Examples are gonadotropins and gonadotropin releasing hormone. After stimulation, the physician surgically extracts one or more eggs from the ovary, and unites them with sperm in a laboratory setting, with the intent of producing one or more embryos. Fertilization takes place outside the body, and the fertilized egg is reinserted into the woman's reproductive tract, in a procedure called embryo transfer.
Intracytoplasmic sperm injection (ICSI) is beneficial in the case of male factor infertility where sperm counts are very low or failed fertilization occurred with previous IVF attempt(s). The ICSI procedure involves a single sperm carefully injected into the center of an egg using a microneedle. With ICSI, only one sperm per egg is needed. Without ICSI, you need between 50,000 and 100,000.
Two techniques that enable to some extent the selection of physiologically normal spermatozoa have recently been developed. One of these is termed intracytoplasmic morphology-selected sperm injection (IMSI). Here, spermatozoa are selected for ICSI and analysed digitally prior to the microinjection procedure in order to deselect morphologically abnormal spermatozoa. With this technique, abnormalities not visible in standard ICSI procedures have been observed. IMSI increases the pregnancy rate during ICSI cycles, and some data suggests that the level of pregnancy termination is also decreased. A second technique recently introduced to assisted reproduction is that of sperm selection with hyaluronic acid (HA), e.g. PICSI. In this technique, mature sperm with HA receptors are distinguished from immature and abnormal sperm since these do not express such receptors.
Men who ejaculate no sperm, because of blocked tubes in their testes, or because of a genetic condition that prevents their sperm being released, require some form of surgical sperm retrieval to enable ICSI to take place. Epididymal sperm obtained by microsurgical aspiration (MESA) or percutaneous sperm aspiration (PESA) and testicular sperm obtained by surgical excision (TESE) or percutaneous aspiration (TESA) are used in ICSI treatment. Alternatively, the retrieved sperm can be cryopreserved for use in future sperm injection attempts. If all efforts to extract vital sperm cells fails, then donated ones may be recommended.
Infertile couples may also resort to egg donation or embryo donation when the female partner cannot have genetic children because her own eggs cannot generate a viable pregnancy. Surrogacy via a gestational carrier is also an option when a patient's medical condition prevents a safe pregnancy, when a patient has ovaries but no uterus due to congenital absence or previous surgical removal, and where a patient has no ovaries and is also unable to carry a pregnancy to full term.
Among women with older reproductive age, with history of repetitive abortions or genetic disorders, genetic analysis is highly recommended. The PGS/PGD allows studying the DNA of eggs or embryos to select those that carry certain damaging characteristics. It is useful when there are previous chromosomal or genetic disorders in the family, within the context of in vitro fertilization programs.
The fertilized eggs (embryos) are cultivated under very stringent conditions and examined every day by the embryologist to evaluate their progress. The embryos are usually cultured for 3 to 5 days, before the best one(s) are selected to be put (transferred) in to the womb.
Morphological assessment of embryo appearance at the proper, distinct time points during development is a routine procedure in embryo selection. Moreover, time-lapse technology improvements has been evaluated as an aid to identify the embryo(s) with the highest implantation potential that enable to objectively select the embryo(s) for transfer. Time-lapse embryo monitoring allows continuous, non-invasive embryo observation without the need to remove the embryo from optimal culturing conditions.
The technique of selecting only one embryo to transfer to the woman is called elective-Single Embryo Transfer (e-SET) or, when embryos are at the blastocyst stage, it can also be called elective single blastocyst transfer (eSBT). It significantly lowers the risk of multiple pregnancies, compared with e.g. Double Embryo Transfer (DET) or double blastocyst transfer (2BT).
In a natural cycle the embryo transfer takes place in the luteal phase at a time where the lining is appropriately undeveloped in relation to the status of the present Luteinizing Hormone. In a stimulated or a cycle where a "frozen" embryo is transferred, the recipient woman could be given first estrogen preparations (about 2 weeks), then a combination of oestrogen and progesterone so that the lining becomes receptive for the embryo.
Prior to the implantation, the embryo has to escape from the ZP (Zona pellucida), a process known as hatching at the blastocyst. Some embryo implantation problems in patients with recurrent implantation failure may be explained by the inability of the embryo to hatch out of its zona pellucida. In such cases, zona pellucida can be thinned in one part using the laser technique (LAZT - laser-assisted zona thinning) to improve the pregnancy and implantation rate. Media supporting implantation may also improve implantation process. The environment created for the embryos by the cytokine contained in the medium culture "in vitro" very closely resembles the “in vivo” environment (in natural conditions) and thereby improvements their ability to implant and keep itself in mucous membrane, and grow further.
Approximately 14 days after the embryo transfer the woman should have a quantitative beta hCG (Human chorionic gonadotropin). This is the first measurable indication of embryo implantation.
The rate of success for IVF is correlated with a woman’s age. More than 40 percent of women under 35 succeed in giving birth following IVF, but the rate drops to a little over 10 percent in women over 40.See full description of Assisted reproductive technology
Egg donation is the process by which a woman donates eggs for purposes of assisted reproduction or biomedical research. For assisted reproduction purposes, egg donation typically involves IVF technology, with the eggs being fertilized in the laboratory; more rarely, unfertilized eggs may be frozen and stored for later use. Egg donation is a third party reproduction as part of ART.
Egg donor may have several reasons for donate her eggs:
First step is choosing the egg donor by a recipient from the profiles on or clinic databases (or, in countries where donors are required to remain anonymous, they are chosen by the recipient's doctor based on recipient woman’s desired trait). This is due to the fact that all of the mentioned examinations are expensive and the agencies/clinics must first confirm that a match is possible or guaranteed before investing in the process.
Each egg donor is first referred to a psychologist who will evaluate if she is mentally prepared to undertake and complete the donation process. These evaluations are necessary to ensure that the donor is fully prepared and capable of completing the donation cycle in safe and success manner. The donor is then required to undergo a thorough medical examination, including a pelvic exam, blood tests to check hormone levels and to test for infectious diseases, Rh factor, blood type, and drugs and an ultrasound to examine her ovaries, uterus and other pelvic organs. A family history of approximately the past three generations is also required, meaning that adoptees are usually not accepted because of the lack of past health knowledge. Genetic testing is also usually done on donors to ensure that they do not carry mutations (e.g., cystic fibrosis) that could harm the resulting children; however, not all clinics automatically perform such testing and thus recipients must clarify with their clinics whether such testing will be done. During the process, which usually takes several months, the donor must abstain from alcohol, sexual intercourse, cigarettes, and drugs, both prescription and non-prescription.
Once the screening is complete and a legal contract signed, the donor will begin the donation cycle, which typically takes between three and six weeks. An egg retrieval procedure comprises both the egg donor's cycle and the recipient's cycle. Birth control pills are administered during the first few weeks of the egg donation process to synchronize the donor's cycle with her recipient's, followed by a series of injections which halt the normal functioning of the donor's ovaries. These injections may be self-administered on a daily basis for a period of one to three weeks. Next, FSH is given to the donor to stimulate egg production and increases the number of mature eggs produced by the ovaries. Throughout the cycle the donor is monitored often by a physician using blood tests and ultrasound exams to determine the donor's reaction to the hormones and the progress of follicle growth.
Once the doctor decides the follicles are mature, the doctor will establish the date and time for the egg retrieval procedure. Approximately 36 hours before retrieval, the donor must administer one last injection of hCG to ensure that her eggs are ready to be harvested. The egg retrieval itself is a minimally invasive surgical procedure lasting 20-30 minutes, performed under sedation (but sometimes without any). A small ultrasound-guided needle is inserted through the vagina to aspirate the follicles in both ovaries, which extracts the eggs. After resting in a recovery room for an hour or two, the donor is released. Most donors resume regular activities by the next day.
Laws by state
The legal status and compensation of egg donation has several models across states with examples:
During ICSI just one sperm is injected directly into the egg cytoplasm using a micromanipulative apparatus that transforms imperfect hand movements into fine and precise movements of micromanipulation tools.
Intracytoplasmic Sperm Injection (ICSI) is an assisted reproductive technique (ART) initially developed by Dr. Gianpiero D. Palermo in 1993 to treat male infertility. It is most commonly used in conjunction with in vitro fertilization (IVF). Following IVF procedure, the physician places the fertilized egg into the female’s uterus for implantation. Sperm are obtained by the same methods as with IVF: either through masturbation, by using a collection condom, or by surgically removing sperm from a testicle through a small incision (MESA, TESE). The females are treated with fertility medications for approximately two weeks prior to oocyte retrieval to stimulate superovulation, where the ovaries produce multiple oocytes rather than the normal one oocyte. The oocytes are retrieved by either laparoscopy, or more commonly, transvaginal oocyte retrieval. In the latter procedure, the physician inserts a thin needle through the cervix, guided by a sonogram and pierces the vaginal wall and then the ovaries to extract several mature ova. Before the embryologist can inject the sperm into the oocyte, the sperm must be prepared by washing and exposing it to various chemicals to slow the sperm movement and prevent it from sticking to the injection plate. Also, the oocytes are treated with hyaluronidase to single out the oocyte ready for fertilization by the presence of the first polar body. Then, one prepared sperm is injected into an oocyte with a thin needle. Often, embryologists try to fertilize several eggs so they can implant more than one into the uterus and increase the chance of at least one successful pregnancy. This also allows them to save extra embryos, using cryopreservation, in case later IVF rounds are needed.
After the embryologist manually fertilizes the oocytes, they are incubated for sixteen to eighteen hours and develop into a pronucleate eggs (successfully fertilized eggs about to divide into an embryo). The egg then grows for one to five days in the laboratory before the physician places it in the female’s uterus for implantation.
The chance of fertilization increases dramatically with ICSI compared to simply mixing the oocytes and sperm in a Petri dish and waiting for fertilization to occur unaided (classical IVF procedure). Studies have shown that successful fertilizations occur 50% to 80% of the time. Since the introduction of ICSI, intrauterine insemination (IUI) has decreased in popularity by 80%.See full description of ICSI
MESA was first described in 1985. This surgical technique requires testis delivery through a 2-3-cm transverse scrotal incision. The epididymal tunica is incised, and an enlarged tubule is selected. Then, the epididymal tubule is dissected and opened with sharp microsurgical scissors. The fluid that flows out of the tubule is aspirated with the aid of a silicone tube or a needle attached to a tuberculin syringe (Pic.1) The aspirate is flushed into a tube containing warm sperm medium and is transferred to the laboratory for examination. MESA can be repeated at a different site on the same epididymis (from the cauda to caput regions) and/or the contralateral epididymis until an adequate number of motile sperm is retrieved.
An embryologist examines the sample for the presence of motile sperm. If no motile spermatozoa are found at the first site, the maneuver is repeated. Typically, only a few microliters of epididymal fluid are retrieved because sperm are highly concentrated in the epididymal fluid (approximately 1x106 sperm/ml). A MESA approach should provide more than adequate numbers of sperm for immediate use, as well as for cryopreservation.
If MESA fails to retrieve motile sperm, TESA or TESE can be performed as part of the same procedure. However, MESA often provides enough sperm for cryopreservation. A single MESA procedure usually enables the retrieval of a large number of high-quality sperm that can be used for ICSI or intentionally cryopreserved for subsequent ICSI attempts. As reported by Dr. Shlegel and colleagues, who used MESA and ICSI in a group of men with obstructive azoospermia, clinical pregnancies were detected by a fetal heartbeat in 75% (57/ 76) of attempts, and healthy deliveries occurred in 64% (49/ 76) of attempts.
ANESTHESIA FOR SPERM RETRIEVAL PROCEDURES Sperm retrievals are relatively simple surgeries that can be safely performed with general anesthesia or spinal blocks. However, because sperm retrievals are typically outpatient procedures, the latest trend is to employ local or locoregional anesthesia with or without intravenous sedation. In another study of 26 patients undergoing MESA, only 38% of the patients tolerated the procedure solely under spermatic cord block through the infiltration of 5-8 mL of 1% lidocaine; the remaining 62% required intravenous sedation. The percentage of patients who underwent a bilateral procedure and required intravenous sedation was as high as 75%.
General anesthesia may offer comfort and the efficient management of anxiety. However, when performed with inhalational agents such as N2O and halogenated agents, this approach is associated with a high incidence of postoperative nausea and vomiting. These two complaints are among the most frequent causes of hospitaliza-tion and the inability to discharge patients scheduled for ambulatory procedures. Additionally, these symptoms are among the most feared by patients undergoing minor surgery, surpassing even postoperative pain.
The technical procedure for PESA involves the insertion of a needle attached to a syringe through the scrotal skin into the epididymis (Pic 1). Originally, the use of a larger butterfly needle was described. Currently, most experts use a fine needle (26 gauge) attached to a tuberculin syringe containing sperm washing medium. After creating negative pressure by pulling the syringe plunger, the tip of the needle is gently and slowly moved in and out inside the epididymis until fluid is aspirated. If motile sperm are not obtained, PESA may be repeated at a different site (from the cauda to caput epididymis) until an adequate number of motile sperm is retrieved. These aspirations are usually performed in the corpus epididymis and then in the caput epididymis if needed, as aspirates from the cauda are often rich in poor-quality senescent spermatozoa, debris and macrophages. Because PESA is a blind procedure, multiple attempts may be needed before high-quality sperm are found. If PESA fails to enable the retrieval of motile sperm, testicular sperm retrieval can be attempted during the same operation.
Craft and Shrivastav, in 1994, first described the use of the percutaneous approach to retrieve sperm from the epididymis. Percutaneous retrievals are usually undertaken under local anesthesia only or in association with intravenous sedation. Percutaneous sperm retrieval can be either diagnostic or therapeutic. In the former, it is used to confirm the presence of viable spermatozoa prior to ICSI. In the latter, it is carried out at the same day of oocyte retrieval or at the day before.
Sperm donation is the donation by a male (known as a sperm donor) of his sperm (known as donor sperm), principally for the purpose of inseminating a female who is not his sexual partner. Sperm donation is a form of third party reproduction including sperm donation, oocyte donation, embryo donation, surrogacy, or adoption. Number of births per donor sample will depend on the actual ART method used, the age and medical condition of the female bearing the child, and the quality of the embryos produced by fertilization. Donor sperm is more commonly used for artificial insemination (IUI or ICI) than for IVF treatments. This is because IVF treatments are usually required only when there is a problem with the female conceiving, or where there is a “male factor problem” involving the female's partner. Donor sperm is also used for IVF in surrogacy arrangements where an embryo may be created in an IVF procedure using donor sperm and this is then implanted in a surrogate. In a case where IVF treatments are employed using donor sperm, surplus embryos may be donated to other women or couples and used in embryo transfer procedures.
On the other hand, insemination may also be achieved by a donor having sexual intercourse with a female for the sole purpose of initiating conception. This method is known as natural insemination.
Donor sperm and fertility treatments using donor sperm may be obtained at a sperm bank or fertility clinic. Here, the recipient may select donor sperm on the basis of the donor's characteristics, e.g. looks, personality, academic ability, race, and many other factors. Sperm banks or clinics may be subject to state or professional regulations, including restrictions on donor anonymity and the number of offspring that may be produced, and there may be other legal protections of the rights and responsibilities of both recipient and donor. Some sperm banks, either by choice or regulation, limit the amount of information available to potential recipients; a desire to obtain more information on donors is one reason why recipients may choose to use a known donor and/or private donation.
A sperm donor will usually donate sperm to a sperm bank under a contract, which typically specifies the period during which the donor will be required to produce sperm, which generally ranges from 6–24 months depending on the number of pregnancies which the sperm bank intends to produce from the donor. Donors may or may not be paid for their samples, according to local laws and agreed arrangements. Even in unpaid arrangements, expenses are often reimbursed. Depending on local law and on private arrangements, men may donate anonymously or agree to provide identifying information to their offspring in the future. Private donations facilitated by an agency often use a "directed" donor, when a male directs that his sperm is to be used by a specific person. Non-anonymous donors are also called known donors, open donors or identity disclosure donors.
A sperm donate must generally meet specific requirements regarding age (most often up to 40) and medical history. Potential donors are typically screened for genetic diseases, chromosomal abnormalities and sexually transmitted infections that may be transmitted through sperm. The donor's sperm must also withstand the freezing and thawing process necessary to store and quarantine the sperm. Samples are stored for at least 6 months after which the donor will be re-tested for sexually transmitted infections. This is to ensure no new infections have been acquired or have developed during the period of donation. If the result is negative, the sperm samples can be released from quarantine and used in treatments.
Preparing the samples
A sperm donor is usually advised not to ejaculate for two to three days before providing the sample, to increase sperm count and to maximize the conception rate. A sperm donor produces and collects sperm by masturbation or during sexual intercourse with the use of a collection condom.
Sperm banks and clinics usually "wash" the sperm sample to extract sperm from the rest of the material in the semen. A cryoprotectant semen extender is added if the sperm is to be placed in frozen storage in liquid nitrogen, and the sample is then frozen in a number of vials or straws. One sample will be divided into 1-20 vials or straws depending on the quantity of the ejaculate and whether the sample is washed or unwashed. Following the necessary quarantine period, the samples are thawed and used to inseminate women through artificial insemination or other ART treatments. Unwashed samples are used for ICI treatments, and washed samples are used in IUI and IVF procedures.
Anonymous sperm donation occurs where the child and/or receiving couple will never learn the identity of the donor, and non-anonymous when they will. Non-anonymous sperm donors are, to a substantially higher degree, driven by altruistic motives for their donations.
Even with anonymous donation, some information about the donor may be released to the female/couple at the time of treatment. Limited donor information includes height, weight, eye, skin and hair color. In Sweden, this is all the information a receiver gets. In the US, on the other hand, additional information may be given, such as a comprehensive biography and sound/video samples.
Information made available by a sperm bank will usually include the race, height, weight, blood group, health, and eye color of the donor. Sometimes information about his age, family history and educational achievements will also be given.
Different factors motivate individuals to seek sperm from outside their home state. For example, some jurisdictions do not allow unmarried women to receive donor sperm. Jurisdictional regulatory choices as well as cultural factors that discourage sperm donation have also led to international fertility tourism and sperm markets.
A sperm donor is generally not intended to be the legal or de jure father of a child produced from his sperm. Depending on the jurisdiction and its laws, he may or may not later be eligible to seek parental rights or be held responsible for parental obligations. Generally, a male who provides sperm as a sperm donor gives up all legal and other rights over the biological children produced from his sperm. However, in private arrangements, some degree of co-parenting may be agreed, although the enforceability of those agreements varies by jurisdiction.
Laws prohibits sperm donation in several countries: Algeria, Bahrain, Costa Rica, Egypt, Hong Kong, Jordan, Lebanon, Lithuania, Libya, Maldives, Oman, Pakistan, Philippines, Qatar, Saudi Arabia, Syria, Tajikistan, Tunisia, Turkey, UnitedArab Emirates, and Yemen.See full description of Sperm donation
Sperm freezing is a procedure used to safe and storage sperm cell in a liquid nitrogen for a relatively long period of time (up to 23 years with proven fertilization ability retained). The process is also called as cryopreservation of sperm and it may help to accomplish fertilization while specific medical conditions leading to male infertility are present. Therefore, sperm cryopreservation is an important component of fertility management and much of its successful application seems to affect the reproductive outcome of assisted reproduction technologies (ART). Long-term storage of a sperm cell can be achieved by lowering the temperature of the cell below zero Celsius degrees, so its metabolic activity is reduced to minimum until abiosis (the cessation of all living processes) is obtained. To protect the cell from harm done by the freeze in most cases is necessary to use specific chemical substances called cryoprotectants.
Generally, cryoprotectants can be described as chemical substances soluble in the water. Their purpose is to lower the freezing temperature of solutions and to prevent damage done by ice crystallization during freezing process. The cryoprotectants can be divided into two groups. The permeating cryoprotectants are chemical substances of low molecular weight with high capacity of penetration into a cell. The non-permeating cryoprotectants does not enter into a cell, they rather create a hyperosmotic ambient around a cell to drain the water from the cell. Usually these two types of cryoprotectants are combined. There are four main well-known cryoprotectants: glycerol, ethylene glycol, dimethyl sulphoxide, and 1,2-propanediol. Glycerol is the permeating cryoprotectant most widely used for human sperm acting on several aspects of a sperm cell such as: the membrane structure, permeability and stability of the lipid bilayer, the association of surface proteins and the cellular metabolism. Its employment gives an unfavorable outcome on membrane and acrosome structure, although allowing the freezing of poor quality sperm.
Sperm freezing methods
Basically there are two main conventional methods to perform sperm freezing distinguished by freezing speed/rate, one is called slow freezing and the second one is called rapid freezing or the vitrification. The cryopreservation methods can by also divided by the storage medium of sperm cells. Most common storage medium is a straw (Pic. 1) used in straw method, which is a default technique for sperm freezing. With some specific modification of a straw, straw method can be also used in vitrification. Lately some new techniques/storage mediums of semen cryopreservation, were developed offering a new possibilities of usage. For example, there is the cryoloop method or a sperm cryopreservation method of freezing single sperm cell using zona pellucida. A very specific method of freezing a sperm without cryoprotectants is a freezing-drying method, but it is still an empiric method under research.
This method consists of progressive sperm cooling over a period of 2 – 4 hours in up to three steps. It can be performed manually or automatically using a device called semiprogrammable freezer. While the temperature is being decreased a cryoprotectant is gradually added to the semen. First the sample of semen is cooled to 5°C with a low cooling rate (0,5 – 1°C/min), in the next step the cooling rate is increased (1-10°C) until the temperature of -80°C is reached. After that the sample is ready to be plunged into liquid nitrogen at -196°C. Since the procedure is quiet complicated to perform manually, the programmable freezer is often used as it can reproduce exact desired conditions of the freezing process.
First thing, semen is mixed with cryoprotectant of same volume as the sample. After that the mixture is filled into straws and left to incubate at 4°C for 10 minutes. Then straws can be put in direct contact with nitrogen vapours in horizontal position for about 10 minutes at -80°C. Right after they are immersed into the liquid nitrogen at -196°C. This procedure has some disadvantages such as low reproducibility, since the drop of temperature in the middle step is hard to control meaning that freezing temperatures can vary relatively a lot.
It is the most commonly used method for cryopreservation. The sperm is held in a small straw that is chemically inert (does not undergo any chemical reactions), biocompatible with sperm sample and resistant to ultra-low temperatures. The volume of classical straws used in cryopreservation is 0,25 ml or 0,5 ml. Specially modified mini-straws of about 1 μl volume are used in new technique of sperm cryopreservation called open pulled straw method. The straw method represents sterile, simple and convenient method of cryopreservation. The disadvantage may be the fact that some sperm cells tend to adhere to the vessel (straw). This fact implicates that straw method shouldn’t be used to storage severely impaired specimens of sperm.
Cryopreservation of sperm using the cryoloop method
Another way to freeze very low numbers of sperm cells is to use a very small loop (0,5-0,7mm), that can hold a thin layer of cryoprotectant. It is possible to mount a single sperm cell on the film in the loop by micromanipulation. The cryoloop method has excellent recovery rates of frozen sperm. With a micropipette, sperm cells are loaded onto the film in the loop. The cryoloop is screwed onto the specific kind of vial (cryovial; Pic. 2), and the vial is exposed to liquid nitrogen vapor for up to 30 minutes before being plunged into liquid nitrogen for storage. Same way as the method mentioned above, it takes a lot of time and intensive labour to perform the procedure. It also requires extensive training and experience so it is no wonder that up today it is rarely practiced.
Cryopreservation of a single human sperm using a zona pellucida
This technique consists of the cryopreservation of individual spermatozoa inside an empty zona pellucida. This method requires an intensive labour and a lot of time to perform but on the other hand it offers an opportunity to retrieve and store sperm in extreme cases of male factor infertility. To gain an empty zona pellucida an oocyte must be processed in specific way. The oocyte is exposed to an enzyme called hyaluronidase to remove protective cellular layers, cumulus and corona radiata cells. This stripped oocyte is held by a holding pipette (Pic. 3) so two small holes can be drilled into it. The ooplasm filling the oocyte is aspirated by suction leaving the zona pellucida empty of all its contents. Once the zona pellucida is obtained, healthy sperm cells are selected for freezing. Any healthy sperm cell found in sample is transferred into specific medium that immobilize the cell. After that one or more (up to 15) sperm cells can be inserted into empty zona pellucida using a special kind of very thin needle called intracytoplasmic sperm injection (ICSI) needle (Pic. 3). In the next step the zona pellucida is inserted into a cryoprotectant and each single piece is put into individual straw. The heat-sealed straws are then exposed to liquid nitrogen vapour for about two hours and storage in liquid nitrogen.See full description of Sperm freezing
In vitro fertilization (IVF) is a process by which an egg is fertilised by sperm outside the body: in vitro . The process involves monitoring and stimulating a woman's ovulatory process, removing an ovum or ova (egg or eggs) from the woman's ovaries and letting sperm fertilise them in a liquid in a laboratory. The fertilised egg (zygote) is cultured for 2–6 days in a growth medium and is then implanted in the same or another woman's uterus, with the intention of establishing a successful pregnancy.
IVF techniques can be used in different types of situations. It is a technique of assisted reproductive technology for treatment of infertility. IVF techniques are also employed in gestational surrogacy, in which case the fertilised egg is implanted into a surrogate's uterus, and the resulting child is genetically unrelated to the surrogate. In some situations, donated eggs or sperms may be used. Some countries ban or otherwise regulate the availability of IVF treatment, giving raise to fertility tourism. Restrictions on availability of IVF include to single females, to lesbians and to surrogacy arrangements. Due to the costs of the procedure, IVF is mostly attempted only after less expensive options have failed.
The first successful birth of a "test tube baby", Louise Brown, occurred in 1978. Louise Brown was born as a result of natural cycle IVF where no stimulation was made. Robert G. Edwards, the physiologist who developed the treatment, was awarded the Nobel Prize in Physiology or Medicine in 2010. With egg donation and IVF, women who are past their reproductive years or menopause can still become pregnant. Adriana Iliescu held the record as the oldest woman to give birth using IVF and donated egg, when she gave birth in 2004 at the age of 66, a record passed in 2006.
Testicular sperm extraction (TESE) is the process of removing a small portion of tissue from the testicle under local anesthesia and extracting the few viable sperm cells present in that tissue for intracytoplasmic sperm injection (ICSI).
The testicular sperm extraction process is recommended to men who cannot produce sperm by ejaculation due to azoospermia, such as that caused by primary testicular failure, congenital absence of the vas deferens or non-reconstructed vasectomy.
The introduction of the technique of intracytoplasmic sperm injection to achieve fertilization, especially using surgically retrieved testicular or epididymal sperm from men with obstructive or non-obstructive azoospermia, has revolutionized the field of assisted reproduction. Testicular sperm retrieval techniques associated with intracytoplasmic sperm injection have reduced the need for donor sperm and given many azoospermic men the chance to become biological fathers.
The extraction of the testicular parenchyma for sperm search and isolation was first described in 1995. For conventional TESE, a standard open surgical biopsy technique is used to remove the testicular parenchyma without the aid of optical magnification. This procedure is usually carried out without delivering the testis. Briefly, a 2-cm transverse incision is made through the anterior scrotal skin, dartos and tunica vaginalis. A small self-retaining retractor can be used to ensure proper exposure of the tunica albuginea. A 1-cm incision is made in the albuginea, and gentle pressure is applied to the testis to aid the extrusion of the testicular parenchyma. A fragment of approximately 5x5 mm is excised with sharp scissors and placed in sperm culture media. Single or multiple specimens can be extracted from the same incision. Alternatively, individual albuginea incisions can be made in the upper, middle and lower testicular poles in an organized manner for the sampling of different areas. The testicular specimens are sent to the laboratory for processing and immediate microscopic examination. The tunica albuginea is closed with a running, non-absorbable suture.
See full description of TESE
The low levels of testosterone lead to reduced fertility. Androgen deficiency affects testicular sperm nursing cell (Sertoli cells) which are responsible for conducting the sperm development. Insufficient stimulation of Sertoli cells by testosterone may manifest by decreased sperm production or by arrest of spermatogenesis. Klinefelter’s syndrome is associated with complete infertility.
Androgen deficiency may also cause sexual dysfunction in men. As testosterone affects the sexual desire, its low concentrations may be responsible for reduced libido. Erectile dysfunction is a common symptom related to reduced libido and male sex hormones imbalance.
In case of non-hormonal causes, such as missing germ cells within the seminiferous tubules (SCOS), there is no fertility potential in affected person. The germ cells represent the first stage of sperm cell development; without them the spermatogenesis cannot proceed.
In case of physical trauma/inflammation in the testicular area, the common reaction is a local inflammation of the tissues. This increases the blood flow and temperature within the testicles. There is also higher concentration of so called reactive oxygen species (ROS). As successful spermatogenesis requires quite specific temperature, even small changes may induce sperm damage. ROS has also negative impact on sperm cell quality negatively influencing its membrane and genetic information held within. The impact of physical trauma on testicular function depend on its severity.