There are many causes for male infertility which may need to be addressed prior to successful pregnancy. Some of the more common issues include:
- Past medical history, prior surgeries and medications used.
- Family history of infertility or birth defects.
- Social history and occupational hazards to evaluate potential exposure to hazardous substances that could impact fertility.
- Physical ailments or abnormalities particularly in the pelvic organs — the penis, testes, prostate and scrotum.
- Age related issues.
Couple with known male factor infertility prior to treatment
Diagnosing male infertility
Semen evaluation will assess sperm motility or movement, the shape and maturity of the sperm, the volume of the ejaculate, the actual sperm count, the presence of round cells which could be due to either immature sperm or white blood cells, indicating inflammation, and the liquidity of the ejaculate. If any of these parameters are abnormal, and evaluation by a urologist is warranted. At this visit, a physical exam will be performed and hormonal testing performed.
Hormonal tests evaluate levels of testosterone, Estradiol, Prolactin, Thyroid stimulating hormone, and follicle-stimulating hormone (FSH) to determine the overall balance of the hormonal system. When a diagnosis is not obvious after the initial evaluation, further testing may be required. One or more of the following tests may be recommended:
- Seminal Fructose Test to identify if fructose is being added properly to the semen by the seminal vesicles.
- Post-ejaculate Urinalysis to determine if obstruction or retrograde ejaculation exists.
- Semen Leukocyte Analysis to identity if there are white blood cells in the semen.
- Anti-sperm Antibodies Test to identify the presence of antibodies that may contribute to infertility.
- Ultrasound to detect varicoceles (varicose veins) or duct obstructions in the prostate, scrotum, seminal vesicles and ejaculatory ducts.
- Testicular biopsy to determine if sperm production is impaired or a blockage exists.
- Vasography to check the structure of the duct system and identify any obstructions.
- Genetic Testing to rule out underlying mutations in one or more gene regions of the Y chromosome or to test for cystic fibrosis in men missing the vas deferens.
Treatments for male infertility to assist reproduction
There are a limited number of medications that can be used to improve semen analysis parameters. If there is an infection, this would be treated with antibiotics. If there are low hormones, there are medications that can be given to improve the hormone profile in the hopes of improving the semen analysis and ultimately, the chances for fertility.
Several surgical methods exist for male infertility. For example, If a varicocele is detected and felt to be clinically significant, a procedure to eliminate this can be performed. If there is an obstruction, the option of bypassing the obstruction verses a surgical retrieval of sperm (sperm extraction procedure) can be performed.
Several techniques which assist the male fertility process by extracting the sperm can be considered including:
ICSI has revolutionized the treatment of male infertility. The sperm requirement for egg fertilization has dropped from hundreds of thousands for IVF, to one viable sperm required for ICSI when combined with IVF. This has led to the recent development of responsive new surgical techniques to provide viable sperm for egg fertilization from men with low or no sperm count. Sperm extractraction/aspiration techniques involve the use of minor surgical procedures to collect sperm from organs within the genital tract. These techniques are indicated for men in whom the transport of sperm is not possible because the ductal system that normally carries sperm to the ejaculate is absent. Situations like this include the congenital absence of the vas deferens which are unable to be reconstructed.
This procedure is used for patients who have congenital or acquired obstruction of the ductal system at the level of the prostate or in the abdominal or pelvic portions of the vas deferens . Patients who have undergone a vasectomy may be candidates. Vasal aspiration is a brief, same-day operation under local anesthesia. It can be done through a small scrotal incision or through incisionless techniques. Either way, the vas deferens is entered and a syringe is used to suction leaking sperm into a nourishing fluid. More sperm are brought to the opening by gently massaging the epididymis and vas deferens. The recovery period is 24 hours. Aspirated sperm are specially processed and prepared for IVF.
Epididymal sperm aspiration
This technique can be performed in situations in which the vas deferens is either not present or is scarred from prior surgery, trauma or infection. Sperm are directly collected from a single, isolated epididymal tubule (MESA) or by blind needle puncture (PESA) in much the same manner as the vasal procedure. Depending on the length of the epididymis that is available for aspiration, multiple, separate aspiration attempts can be made from one or both testicles. The sperm are processed for fertilization of the partner’s eggs. Epididymal sperm are not as “mature” as sperm that have traversed the entire length of the epididymis and reside in the vas deferens and, as a consequence, epididymal sperm require ICSI to fertilize eggs. Egg fertilization rates of 60 percent to 80 percent and pregnancy rates of approximately 45 percent to 55 percent have been reported with epididymal sperm.
Testicular Sperm Extraction (TESE)
Testicular Sperm Aspiration (TESA) is a procedure in which a small amount of testis tissue is taken by biopsy under local anesthesia. It is a breakthrough in that it demonstrates that sperm do not have to “mature” and pass through the epididymis in order to fertilize an egg. Because of their immaturity, however, testicular sperm need ICSI. Testicular sperm extraction is indicated for patients in whom there is a blockage in the epididymis very near the testis that is either from prior surgery, infection or from birth defects. Another cause can be a blockage within the ducts of the testes, called efferent ductules. It also is used for men with extremely poor sperm production, in which so few sperm are produced that they cannot reach the ejaculate. One drawback of testis sperm is that is does not freeze as readily as epididymal or vasal sperm and so it is more likely that the male partner will need to undergo repeated procedures for each IVF attempt.
The failing testes helps detect where ICSI-compatible, mature sperm exist within failing or atrophic testes. It was based on prior observations that sperm production can be “patchy” or “focal” within the failing testis. This led to the idea that the more sites that are sampled within the testis to look for sperm, the higher the chances of usable sperm. Information derived from “mapping” can be used:
- To help infertile couples decide whether or not to proceed to IVF and ICSI
- To actually locate and find sperm for ICSI within atrophic testes
This video shows the process of immobilizing and then picking up a sperm.
Andrology evaluation/semen analysis
Most men produce millions of sperm each day, however, many of these may be abnormal either in their shape, movement, or function. Many studies have shown that 50% of infertility is related to the sperm. An Andrology evaluation of the male provides much of the data needed to assess the male’s fertility potential. Tests assess the number, appearance, movement, and functional capacity of the sperm present in the man’s specimen.
Sperm quality/type of specimen
About 25% of all infertility is caused by a sperm defect and 40 to 50% of infertility cases have a sperm defects as the main cause or a contributing cause. Sperm counts may or may not be indicative of a male fertility issue. Typically a semen analysis will be performed on the male, which includes sperm count, motility, (sperm’s ability to swim and move quickly), shape and maturity of the sperm cells, volume of semen, pH balance, clumping (potential autoimmunity issues), and white and red blood cell count (potential infections).
Sperm Chromatin Structure Assay (SCSA)
Sperm Chromatin Structure Assay (SCSA) is a measurement of the proportion of sperm cells that have damaged DNA. Fewer than 15% is consistent with normal fertility, 15 to 30% can result in subfertility, and more than 30% may cause sterility or recurrent miscarriage.