Male Fertility Evaluation & Treatments
The male role in fertility by itself affects up to 40 percent of couples. An additional 20 percent of infertile couples have combined male-female factor infertility.
These figures suggest that the relative incidence of male-related infertility problems may be approximately the same as female problems. Recent studies have suggested that the incidence of male related infertility in on the rise. There have also been reports of genetic defects in the sperm from men over the age of 50 years old.
The most important goal in male infertility is to establish the correct diagnosis. We usually work with each male patient’s urologist to reach this goal. Some infertility problems could suggest a more serious medical condition that if not diagnosed properly may become life altering or may affect the offspring.
The problem may be a simple as a hormone imbalance requiring hormone therapy. If so, we can routinely treat any hormonal problem and utilize other specialists if needed. If there is a structural or anatomical problem, a urologist traditionally treats those issues.
Semen analysis is very helpful in evaluating the quality of a man’s sperm.
The sample is measured to determine sperm count, sperm motility, and sperm morphology. While this test will help assess male fertility, the fertilizing ability of a man’s sperm cannot be proven until conception is achieved.
Age-Related Male Infertility
There are a limited number of studies on age-related infertility in men, although some suggest that older men are less fertile. As men age, testosterone production does decline, but scientists don’t really know whether this translates into reduced sperm production.
However, doctors do know that aging has been linked to reduced fertilization potential and a greater number of abnormally shaped sperm. Research has also indicated that some genetic disorders are increased with paternal age. Men should be counseled appropriately about this issue if they are over 50 years old.
Male-Factor Infertility: Effects on offspring
Some male-factor infertility causes have no added effects on offspring over naturally occurring rates. These include Acquired Obstructive Azoospermia from a vasectomy or failed vasectomy reversal; infection; the inability to ejaculate due to a spinal cord injury; psychological causes; and retrograde ejaculation.
However, in cases where congenital absence of the vas-deferens or testicular insufficiency/failure (low to zero sperm counts and motility), additional tests may help rule out a genetic cause for problems that may affect offspring. This can be important because there are many more genetic abnormalities associated with male infertility, than in the female.
Male infertility treatment
Information from the quantitative tests help individualize a man’s infertility treatment. Depending on the severity of male infertility, sometimes the best course is one of the least invasive treatments for infertility such as intrauterine inseminations (IUI), or in-vitro fertilization (IVF), if sperm motility renders IUI as ineffective.
Usually these treatments require that the male partner should be able to provide at least a total motile count of 500,000 sperm for IVF, or five million motile sperm for IUI. If the sperm counts are below the above limits, there is still an option of sperm banking to overcome this problem or to consider donor semen.
Treating male infertility with ICSI
Of course, some patients may not be able to benefit from IUI or conventional IVF due to inadequate numbers of motile sperm. In the past, the only alternative treatment for these couples was to use donor sperm or to consider adoption.
However, in recent years, fertility specialists have perfected a procedure called intracytoplasmic sperm injection (ICSI). In ICSI, a laboratory specialist uses a tiny instrument and a microscope to directly inject a single sperm into an egg.
ICSI enhances the probability of achieving a genetically similar offspring even in the most difficult of male infertility cases.
Sperm can be collected by traditional methods or by performing a urological surgical procedure, MESA and TESE.
Since there is a low number of sperm obtained, the oocytes (eggs) are fertilized by ICSI. This procedure optimizes the sperm number since only one motile sperm cell is required per oocyte.
Without this method the probability of fertilization and pregnancy for such men is less than 1 percent. When combined with ICSI, the probability of fertilization and pregnancy reaches those observed in conventional IVF.
Special collection techniques
Men with complete azoospermia (no sperm) can also be helped by a choice of two techniques, microepididymal sperm aspiration (MESA) and testicular excisional sperm extraction (TESE). But first the underlying cause of azoospermia needs to be established.
For obstructive problems such as vasectomy, congenital absence of the vas deferens or scarring of the vas deferens can be treated by MESA. In this technique an urologist performs a surgical procedure where sperm are obtained from the epididymis (prior to the blocked area) and transferred to our laboratory.
The sperm are cryopreserved (frozen) and subsequently thawed when the oocytes are available. Cryopreservation of MESA obtained sperm does not decrease the success of the treatment.
Use of TESE is necessary if the man has no sperm in the epididymis or if the cause of azoospermia is testicular failure rather than obstruction. This technique requires urologic surgery in which a small portion of testicle tissue is removed.
The tissue is then explored for immature sperm that can then be utilized for ICSI. Success with TESE is limited by the quality of the sperm and cryopreservation of the TESE obtained sperm seems to decrease the success. Therefore, the TESE procedure is performed on the day of the egg retrieval.
When is ICSI used?
Moderate cases of male factor infertility may be successfully treated by conventional IVF treatment. However, ICSI now offers a new dimension of treatment for all more severe forms of male infertility. ICSI may be the best choice when:
- Patients present with low sperm density (less than 5 million), motility (less than 25 percent), poor morphology (less than 15 percent by the WHO criteria or less than 4 percent using the Kruger criteria) and/or sperm antibodies.
- Cases with less than 50 percent fertilization or total fertilization failure in previous IVF attempts.
- For azoospermia with sperm retrieved by sperm aspiration.