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Has traditional sperm analysis lost its clinical relevance?
Letters-to-the-editor P a u l G. M c D o n o u g h ,
M.D., Associate Editor
Vol. 67. No. 3. March 1997
FERTILITY AND STERILITY ~'
P r i n t e d on acid-free p a p e r in U. S. A.
Copyright ' 1997 American Society fiw Reproductive Medicine
Has T r a d i t i o n a l S p e r m A n a l y s i s Lost Its Clinical R e l e v a n c e ?
To the Editor: A r e c e n t r e p o r t on i n t r a c y t o p l a s m i c s p e r m injection (ICSI) by P a l e r m o et al. (1) a d d r e s s e d t h e question of the u n k n o w n r i s k s a s s o c i a t e d with t h e use of poor q u a l i t y s p e r m , which is r e n d e r e d possible by this technique. In this l e t t e r we would like to consider t h e s a m e u n k n o w n r i s k s in a n e w d i f f e r e n t context, n a m e l y the use of s p e r m c r y o p r e s e r v a t i o n for p a t i e n t s w i t h s e v e r e disease. In F r a n c e , t h i s service is s y s t e m a t i cally offered to p a t i e n t s w i t h severe m e d i c a l disorders, such as t e s t i c u l a r c a n c e r a n d H o d g k i n ' s disease, t r e a t e d by s u r g e r y , r a d i o t h e r a p y , or chemot h e r a p y (all p o t e n t i a l l y s t e r i l i z i n g t r e a t m e n t s ) , to s a f e g u a r d the p a t i e n t s ' c h a n c e s of p r o c r e a t i o n (2, 3). Initially, only good q u a l i t y s p e r m a p p e a r e d to be usable, w h e n s i m p l e or i n t r a u t e r i n e artificial i n s e m i n a t i o n w e r e e n v i s a g e d for c u r e d p a t i e n t s who w a n t e d to h a v e a child. Now, h o w e v e r , a d v a n c e s in r e p r o d u c t i v e technologies (IVF a n d ICSI) h a v e enabled p r e g n a n c i e s to be a c h i e v e d w i t h poor q u a l i t y s p e r m , e v e n in s i t u a t i o n s of e x t r e m e o l i g o a s t h e n o s p e r m i a (4). O v e r t h e p a s t 10 y e a r s a n d m o r e , we h a v e found t h a t a s t e a d i l y i n c r e a s i n g p r o p o r t i o n of p a t i e n t s att e n d i n g c o n s u l t a t i o n s with a view to s p e r m c r y o p r e s e r v a t i o n are a c t u a l l y receiving this service. T h u s , in 1995 a l m o s t 90% of p a t i e n t s r e f e r r e d to C E C O S (the C e n t r e for the S t u d y a n d P r e s e r v a t i o n of H u m a n Ova and Sperm) actually had their sperm preserved, as c o m p a r e d w i t h 65% in 1983. In o t h e r words, provided a p a t i e n t is not a z o o s p e r m i c , all s p e r m is b e i n g p r e s e r v e d , i r r e s p e c t i v e of its quality. T h e r e h a v e b e e n s o m e cases w h e r e s p e r m c r y o p r e s e r v a t i o n h a s been carried out late, in p a t i e n t s who h a d a l r e a d y c o m m e n c e d t r e a t m e n t with c h e m o t h e r a p y or radiotherapy. T h e s e t r e n d s confront us w i t h the following considerations: T h e use of c r y o p r e s e r v e d s p e r m in this context r e p r e s e n t s a n e w a n d as y e t u n e v a l u a t e d indication for ICSI. T h e r i s k s a s s o c i a t e d w i t h t h e use of such s p e r m are u n k n o w n a n d r e m a i n to be defined. T h e y m a y include gene d a m a g e r e l a t e d to o l i g o a s t h e n o s p e r m i a , a b n o r m a l i t i e s r e l a t e d to cancer, a n d t h e effects of c h e m o t h e r a p y or r a d i o t h e r a p y (5). Vol. 1997, No. 3, March 1997
T h e use of s p e r m in this s i t u a t i o n , p a r t i c u l a r l y for I V F or I C S I , h a s not b e e n viewed by clinicians as a t r u e r e s e a r c h activity. I t h a s t h e r e f o r e not b e e n t h e subject of protocols or e v a l u a t i o n p r o c e d u r e s , n o r h a s it b e e n s u b j e c t e d to critical discussion by ethics committees. Medical practice, w i t h its p u r s u i t of cost-effective technologies, is n o w faced w i t h the p r o b l e m of t h e s e still u n q u a n t i f i e d risks. We would s t r e s s , once again, t h e n e e d to set up s y s t e m s for m o n i t o r i n g t h e c i r c u m s t a n c e s u n d e r which t h e s e n e w technologies a r e being applied. T h e y should not be a c c e p t e d too h a s t i l y as s t a n d a r d practice.
Grdgoire Moutel, M.D. Medical Ethics and Public Health Laboratory Paris-Necker Faculty of Medicine Universiti Rend Descartes Paris, France Reproductive Medicine CECOS, CHU Reims, France Christian-Hervd, M.D., Ph.D. Medical Ethics and Public Health Laboratory Paris-Necker Faculty of Medicine Universiti Rend Descartes Paris, France Jean-Jacques Adnet, M.D., Ph.D. Reproductive Medicine CECOS, CHU Reims, France July 5, 1996 REFERENCES
1. Palermo GD, Cohen J, Rosenwaks Z. Intracytoplasmic sperm injection: a powerful tool to overcome fertilization failure. Fertil Steril 1996;65:899-908. 2. David G, Czyglik F. Tol6rance h la cong61ation du sperme humain en fonction de la qualit6 intiale du sperme. J Gynecol Obstet Biol Reprod 1977;6:601-5. 3. Moutel G, Herve C, Corviole K, Alcaraz M, Kuttenn F, Alnot MO. Information des patients canc6reux sur la fertilit6 induite par les traitements et sur I'autoconservation de sperme. Presse Med 1994;23:1637-41. 4. Van Steirteghem AC, Nagy Z, doris H. High fertilization and implantation rates after intraytoplasmic sperm injection. Hum Reprod 1993;8:1061-6. 5. AurotLx MR, Dulioust EM, Navar NY, Yacoub SG, Mayaux MJ, Schwartz D, et al. Antimitotic drugs in the mal rat: behavioral abnormalities in the second generation. J Androl 1988;9:153-6.
Letters-to-the-editor
583
M.D., Associate Editor
Vol. 67. No. 3. March 1997
FERTILITY AND STERILITY ~'
P r i n t e d on acid-free p a p e r in U. S. A.
Copyright ' 1997 American Society fiw Reproductive Medicine
Has T r a d i t i o n a l S p e r m A n a l y s i s Lost Its Clinical R e l e v a n c e ?
To the Editor: A r e c e n t r e p o r t on i n t r a c y t o p l a s m i c s p e r m injection (ICSI) by P a l e r m o et al. (1) a d d r e s s e d t h e question of the u n k n o w n r i s k s a s s o c i a t e d with t h e use of poor q u a l i t y s p e r m , which is r e n d e r e d possible by this technique. In this l e t t e r we would like to consider t h e s a m e u n k n o w n r i s k s in a n e w d i f f e r e n t context, n a m e l y the use of s p e r m c r y o p r e s e r v a t i o n for p a t i e n t s w i t h s e v e r e disease. In F r a n c e , t h i s service is s y s t e m a t i cally offered to p a t i e n t s w i t h severe m e d i c a l disorders, such as t e s t i c u l a r c a n c e r a n d H o d g k i n ' s disease, t r e a t e d by s u r g e r y , r a d i o t h e r a p y , or chemot h e r a p y (all p o t e n t i a l l y s t e r i l i z i n g t r e a t m e n t s ) , to s a f e g u a r d the p a t i e n t s ' c h a n c e s of p r o c r e a t i o n (2, 3). Initially, only good q u a l i t y s p e r m a p p e a r e d to be usable, w h e n s i m p l e or i n t r a u t e r i n e artificial i n s e m i n a t i o n w e r e e n v i s a g e d for c u r e d p a t i e n t s who w a n t e d to h a v e a child. Now, h o w e v e r , a d v a n c e s in r e p r o d u c t i v e technologies (IVF a n d ICSI) h a v e enabled p r e g n a n c i e s to be a c h i e v e d w i t h poor q u a l i t y s p e r m , e v e n in s i t u a t i o n s of e x t r e m e o l i g o a s t h e n o s p e r m i a (4). O v e r t h e p a s t 10 y e a r s a n d m o r e , we h a v e found t h a t a s t e a d i l y i n c r e a s i n g p r o p o r t i o n of p a t i e n t s att e n d i n g c o n s u l t a t i o n s with a view to s p e r m c r y o p r e s e r v a t i o n are a c t u a l l y receiving this service. T h u s , in 1995 a l m o s t 90% of p a t i e n t s r e f e r r e d to C E C O S (the C e n t r e for the S t u d y a n d P r e s e r v a t i o n of H u m a n Ova and Sperm) actually had their sperm preserved, as c o m p a r e d w i t h 65% in 1983. In o t h e r words, provided a p a t i e n t is not a z o o s p e r m i c , all s p e r m is b e i n g p r e s e r v e d , i r r e s p e c t i v e of its quality. T h e r e h a v e b e e n s o m e cases w h e r e s p e r m c r y o p r e s e r v a t i o n h a s been carried out late, in p a t i e n t s who h a d a l r e a d y c o m m e n c e d t r e a t m e n t with c h e m o t h e r a p y or radiotherapy. T h e s e t r e n d s confront us w i t h the following considerations: T h e use of c r y o p r e s e r v e d s p e r m in this context r e p r e s e n t s a n e w a n d as y e t u n e v a l u a t e d indication for ICSI. T h e r i s k s a s s o c i a t e d w i t h t h e use of such s p e r m are u n k n o w n a n d r e m a i n to be defined. T h e y m a y include gene d a m a g e r e l a t e d to o l i g o a s t h e n o s p e r m i a , a b n o r m a l i t i e s r e l a t e d to cancer, a n d t h e effects of c h e m o t h e r a p y or r a d i o t h e r a p y (5). Vol. 1997, No. 3, March 1997
T h e use of s p e r m in this s i t u a t i o n , p a r t i c u l a r l y for I V F or I C S I , h a s not b e e n viewed by clinicians as a t r u e r e s e a r c h activity. I t h a s t h e r e f o r e not b e e n t h e subject of protocols or e v a l u a t i o n p r o c e d u r e s , n o r h a s it b e e n s u b j e c t e d to critical discussion by ethics committees. Medical practice, w i t h its p u r s u i t of cost-effective technologies, is n o w faced w i t h the p r o b l e m of t h e s e still u n q u a n t i f i e d risks. We would s t r e s s , once again, t h e n e e d to set up s y s t e m s for m o n i t o r i n g t h e c i r c u m s t a n c e s u n d e r which t h e s e n e w technologies a r e being applied. T h e y should not be a c c e p t e d too h a s t i l y as s t a n d a r d practice.
Grdgoire Moutel, M.D. Medical Ethics and Public Health Laboratory Paris-Necker Faculty of Medicine Universiti Rend Descartes Paris, France Reproductive Medicine CECOS, CHU Reims, France Christian-Hervd, M.D., Ph.D. Medical Ethics and Public Health Laboratory Paris-Necker Faculty of Medicine Universiti Rend Descartes Paris, France Jean-Jacques Adnet, M.D., Ph.D. Reproductive Medicine CECOS, CHU Reims, France July 5, 1996 REFERENCES
1. Palermo GD, Cohen J, Rosenwaks Z. Intracytoplasmic sperm injection: a powerful tool to overcome fertilization failure. Fertil Steril 1996;65:899-908. 2. David G, Czyglik F. Tol6rance h la cong61ation du sperme humain en fonction de la qualit6 intiale du sperme. J Gynecol Obstet Biol Reprod 1977;6:601-5. 3. Moutel G, Herve C, Corviole K, Alcaraz M, Kuttenn F, Alnot MO. Information des patients canc6reux sur la fertilit6 induite par les traitements et sur I'autoconservation de sperme. Presse Med 1994;23:1637-41. 4. Van Steirteghem AC, Nagy Z, doris H. High fertilization and implantation rates after intraytoplasmic sperm injection. Hum Reprod 1993;8:1061-6. 5. AurotLx MR, Dulioust EM, Navar NY, Yacoub SG, Mayaux MJ, Schwartz D, et al. Antimitotic drugs in the mal rat: behavioral abnormalities in the second generation. J Androl 1988;9:153-6.
Letters-to-the-editor
583