Male Factor Treatments
Treatments for male factor infertility
will be influenced by at least three important factors: - Cause of infertility, if identifiable
- Severity of the sperm defect
- Age of the female partner
Mild male factor, unexplained cause:
Intrauterine
insemination (IUI): Concentrated sperm are placed directly into the
uterine cavity, thus eliminating their passage through the vagina and cervix.
Recent data suggest that the pregnancy success rates following IUI in
cases of mild male factor or unexplained infertility are reported to be
approximately 5% per insemination cycle. This rate can be improved to about 9%
per cycle if the female partner is induced to "super-ovulate" with injectable
fertility medications such as Gonal-F. It is important to note that the average
age of the female patients in the research study that reported these results
was 32.4 years of age. Rates for success would likely decrease as the age of
the female partner increases. Most authorities consider (IUI) to
be ineffective in cases of severe male infertility. The ideal treatment, when
surgical and medical management fails to improve sperm function, is
in vitro
fertilization and embryo transfer (IVF/ET), usually accompanied
by Intra-cytoplasmic sperm injection (ICSI).
Intracytoplasmic Sperm Injection (ICSI) has revolutionized the
treatment of male factor infertility.
It allows men who were previously
incapable of producing adequate sperm, to father genetically related children.
ICSI involves the placement of a single sperm directly into the egg using a
microscopic pipette.
Men normally produce millions of sperm in each ejaculate. These sperm "swim"
through the cervical opening and into the tubes to the site of fertilization.
Some men have sperm defects such as a reduced sperm count, deformed sperm, or
sperm that cannot swim effectively. When any one of these abnormalities are
present it can prevent normal fertilization.
ICSI bypasses sperm defects
because a single sperm is "selected" and placed inside the egg. ICSI is
performed as a part of the IVF cycle. During IVF, the eggs are retrieved
from the ovaries and taken to the embryology laboratory. In ICSI, a
stereomicroscope is used to manipulate the egg(s). The egg is held in place
while it is punctured by the micro pipette and the sperm is inserted. IVF/ICSI
is used in cases of severe male factor infertility and in other conditions such
as failed fertilization in previous IVF cycles.
Prior Vasectomy:
Couples have the option of a vasectomy reversal or IVF-ICSI with epididymal
or testicular sperm extraction. Age of female partner and length of time since
prior vasectomy are important factors in decision-making. It can sometimes take
6-9 months to recover adequate sperm counts following vasectomy reversal. Also,
the greater the length of time between the vasectomy and the reversal, the
greater the chances are that the surgery will be unsuccessful or that
anti-sperm antibodies will form, preventing the recovered sperm from
penetrating the eggs without IVF-ICSI.
Prior vasectomy, congenital
absence of the vas deferens (i.e. no sperm in the ejaculate but normal
testicular sperm production, also referred to as obstructive azoospermia):
IVF-ICSI with either Microsurgical Epididymal Sperm Aspiration (MESA) or
Testicular Sperm Extraction (TESE).
With a MESA procedure, under
local anesthesia and general sedation, an incision is made in the scrotum,
exposing the epididymus, the tubules immediately adjacent to the testicles that
collect the sperm. Using an operating microscope, an incision is made into
these tubules and sperm is aspirated. Although millions of motile sperm can
often be collected, this sperm has not acquired the ability to penetrate an egg
and must be injected into eggs via the IVF-ICSI technique. The advantage of
MESA over TESE for men with obstructive azoospermia is that sperm collected in
this manner can usually be frozen, and even if his partner has to undergo more
than one IVF procedure, the MESA should
provide adequate sperm for all subsequent IVF procedures.
A TESE or
testicular sperm extraction is a procedure that involves directly
aspirating the sperm from the testes or obtaining sperm from a testicular
biopsy. It is usually performed under local anesthesia block and can be done as
an office surgical procedure. The disadvantage is that in many cases,
testicular sperm is much more scarce and therefore difficult to freeze.
Usually, there is only enough sperm recovered for one IVF case and if further IVF
attempts are needed, the TESE procedure needs to be repeated.
Non-obstructive Azoospermia: Men with very poor sperm production
in the testicles and no sperm in the ejaculate often demonstrate high blood FSH
levels and sometimes low testosterone levels. The testicular size may be small.
These men are usually considered to have relative testicular failure. TESE or
testicular biopsy is usually the only option for them as there are no sperm in
the epididymus and even testicular sperm production can be "patchy" and scarce
within the testes. Men with this diagnosis who have been told they have no
sperm on routine testicular biopsy frequently can be found, on further
investigation, to have sperm present in a scattered distribution within the
testicle. If so, these areas can be re-aspirated for IVF-ICSI with some degree
of success, depending on the amount of sperm obtained.
Sertoli Cell
Only syndrome: Complete absence of sperm progenitor cells and absence of
spermatogenesis is a rare condition. Sperm donation or adoption are the only
options in these cases.
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