When you consider that a fairly large proportion of infertility is due to the male factor, it is surprising that treatment options for the male have been limited until recently. Nearly 20 years ago, all we could offer the couple with significant male factor infertility was artificial insemination with semen from a donor, artificial insemination with the husband's semen into the cervical mucus, or repair of a varicocele.
During the last decade, we've seen a great deal of interest in the workup and treatment of the male. This interest has paralleled advances in ART and the need to prepare the sperm for these advanced techniques. It bears repeating that changes in habits, when possible, should be recommended first to try to maximize the couple's chances of conceiving. For the male partner these would include changes in sexual frequency and timing, eliminating heated spa-type baths, and avoiding drugs, body-building supplements, smoking, and exposure to toxins.
The basic test for male fertility is the semen analysis. Just as we need to learn that the woman is producing eggs, it is equally important to find out if the man is producing adequate sperm to achieve a pregnancy. To determine the man's status, a complete semen analysis will be obtained. If the doctor does not have his own reproductive laboratory, the male partner will usually be referred to a specific laboratory to have this done. At the lab or at home, he will masturbate a specimen into a special collection cup. It is best to have adequate sexual arousal before and during collection, otherwise a poor specimen could merely be an artifact of the collection procedure. The laboratory should provide reading materials or videos and an unhurried atmosphere. At home the wife may help with the collection.
It is advisable to abstain from ejaculation for two to three days before the test in order to get his best specimen. This is because with a shorter interval the sperm density may be lower. But more importantly, it will enable us to standardize the collection interval in order to compare results more accurately. With a longer period of abstinence the sperm may have lower motility. We usually recommend he give the specimen around the time of his wife's menstrual period since it is unlikely that she would get pregnant at that time.
We find that up to 40 percent of couples with an infertility problem have some male factor contributing to the couple's infertility. It does not make sense for the wife to go through tests that may involve some risk, discomfort, and expense if we don't at least find out if her partner's semen is adequate. In fact, physicians may obtain several samples since health and environmental factors such as fatigue, smoking, stress, and use of caffeine or drugs can affect the results.
We can categorize conditions causing male infertility according to the results of the semen analysis, as well as break down treatment into the same categories.
If the female's evaluation and the initial semen analyses were normal, the man may be tested with more sophisticated tests of sperm function. These may include a Sperm Chromatin Structure Assay (SCSA) to examine the degree of DNA fragmentation when treatments do not succeed as expected. Treatment may be related to the female partner's issues or empirically intrauterine insemination (IUI) or in vitro fertilization (IVF) may be recommended in case other treatments fail.
In the complete absence of sperm, a hormone workup will help reveal the nature of the problem. If the man's gonadotropins (FSH and LH) are very high, it can be assumed that he has testicular failure. Recently, retrieval of sperm from a testicular biopsy for use in intracytoplasmic sperm injection (ICSI) has been possible in one-half of such cases. The only other treatment available is artificial insemination with the semen of a donor. If the couple is unwilling to have donor insemination, or unable to afford ICSI, they could consider adoption.
If his gonadotropins are normal or slightly elevated, he may have an obstruction of the ductal system and could have an operation called a scrotal exploration to determine the location of the obstruction and attempt to correct it. This is major surgery, with all of its risks. It is an outpatient surgery procedure usually performed under general anesthesia. The variation in cost will generally reflect the complexity of the repair and the time required to perform the operation, from one and a half to five hours. Before the scrotal exploration, the urologist may recommend a biopsy of the testicle as a separate procedure to determine if enough sperm are present before proceeding on to the more serious scrotal exploration. The biopsy is also an outpatient procedure that can be performed under either local or general anesthesia.
In cases of congenital absence of portions of the tubular system, microsurgical procedures are now being used to retrieve sperm directly from the epididymis for use in conjunction with IVF procedures involving the direct injection of sperm into an egg, intracytoplasmic sperm injection (ICSI). In fact, now in any case of obstruction, whether congenital or acquired, epididymal sperm aspiration (MESA or PESA), or a testicular biopsy (TESE) usually yields sperm which can be used in ICSI. In percutaneous epididymal sperm aspiration (PESA) sperm can even be retrieved in the office by passing a tiny needle through the skin into the epididymis.
In the face of low gonadotropins with low testosterone levels and the presence of the sugar fructose in the semen, the man would need further evaluation of his pituitary hormones. Fructose is produced by the seminal vesicles, and its presence in the semen makes blockage of the tubular system unlikely. As in the woman, if his prolactin is significantly elevated with or without evidence of a pituitary microadenoma, he would be treated with bromocriptine. If his gonadotropins are low, he can be treated with hCG and hMG.
A special category of obstruction is the case of a man who has had a vasectomy and wants it reversed. This can be accomplished by microscopic surgery or laser-assisted microsurgery. In addition to the area of the vasectomy's intentional blockage, other areas of obstruction may develop in adjacent locations and must be searched for and bypassed. In general, the success of vasovasostomy will be related to the length of time that has elapsed between the vasectomy and its repair, and the skill and experience of the surgeon performing the procedure. Now PESA in conjunction with ICSI is yielding excellent results in couples in which the man has had a vasectomy, obviating the need for the major surgery required to reverse the vasectomy. If sperm cannot be found in the epididymis, testicular biopsy (TESE or Testicular Sperm Extraction) can often be used to obtain sperm for use in ICSI. This can also sometimes be done with a needle rather than a surgical biopsy, but sperm are not as reliably obtained.
A more subtle abnormality that may be found is a varicocele. If detected, surgery may be considered after other nonsurgical problems, such as hormonal or environmental causes, have been looked for and corrected. A well-designed study from Israel published in 1995 showed distinct improvements in semen quality and fertility over the one to two years after surgery to repair varicoceles.
Of course, our basic premise applies here: that the simple, safe, and less expensive treatments must be explored first. Therefore, in the face of consistently abnormal semen analyses and normal tests of pituitary function, other causes of the abnormal semen must be considered: chronic use of drugs, infection, stress, and exposure to toxic agents such as X-rays, pesticides, body-building supplements, industrial chemicals, or heat. Then if there are no other apparent causes for the abnormal semen analysis or there are other abnormal tests of sperm function, a varicocele should be searched for and surgery should be considered.
Improvement in the semen analysis or fertility cannot be expected for at least three months. In properly selected men there will be a 60 to 70 percent chance for improvement in the semen analysis, but possibly not until up to one year after surgery. The pregnancy rate reaches 40 to 45 percent, while men not treated have rates in the range of 15 to 20 percent. So, at best, varicocelectomy can improve pregnancy rates by two to three times. Most urologists would recommend varicocelectomy in the case of an obvious varicocele with indications of abnormal semen and especially if the affected testicle is smaller than its mate. With all treatments of the female, including IVF procedures, the chance of success will be better with the male factor improved as much as possible.
If the semen analysis reveals agglutination (clumping), high doses of steroids may rarely be prescribed for short periods because many practitioners are concerned about potentially serious complications from steroids. More often the partner's sperm can be used for artificial insemination into the uterus after washing (IUI), as is commonly done for cervical mucus problems. If conventional treatments for sperm antibodies are not successful, then IVF with ICSI may be done and is highly successful.
Small volume or the complete absence of semen can occur as the result of retrograde ejaculation, or ejaculation backward into the bladder. If the retrograde ejaculation is due to medical conditions such as diabetes, semen can be obtained by use of drugs that close the bladder neck. If retrograde ejaculation is the result of a complication of trauma, spinal injury or previous surgery, sperm can be harvested from a urine specimen (after masturbation) and then prepared for artificial insemination. If the specimen is voided into culture medium and the acidity of the urine is adjusted by adding baking soda, the sperm will survive for a brief period of time in the urine. In some instances it is necessary to adjust the concentration of the urine.
In many men with reduced count, motility, and/or morphology, no apparent cause is found. Intrauterine insemination (IUI) following sperm washing can be successful, particularly with mild to moderate abnormal sperm. Most pregnancies will occur within four to six cycles of IUI. IUI in conjunction with hMG or pure FSH increases the chance of fertilization because there are more eggs available. Finally, IVF is highly effective, since 50,000 to 500,000 sperm are concentrated around the egg. If more than a mild male factor is present, ICSI is generally advised. ICSI may be particularly important with low strict morphology since implantation rate is reduced with regular IVF, but is normal with ICSI. This may be because placing a large number of abnormal sperm around the egg may adversely affect embryo quality, causing a toxic effect on the embryo.