Treatments for male factor infertility are influenced by at least 3 significant factors:
- Is the cause of infertility identifiable?
- What is the severity of the sperm defect?
- What is the age of the female partner?
For mild male factor, unexplained cause, intrauterine insemination (IUI) is usually the first-line recommendation. Concentrated sperm are placed directly into the uterine cavity, thus eliminating their passage through the vagina and cervix. Recent data suggests 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 essential 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.
Intracytoplasmic Sperm Injection (ICSI)
Intracytoplasmic Sperm Injection (ICSI) has revolutionized the treatment of male-factor infertility. The ideal treatment, when surgical and medical management fails to improve sperm function, is in vitro fertilization (IVF) and embryo transfer (IVF/ET), usually accompanied by Intra-cytoplasmic sperm injection (ICSI). 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. 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 is 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 utilized to manipulate the egg(s). The egg is held in place while it is punctured by the micropipette, 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.
Couples have the option of a vasectomy reversal or IVF-ICSI with epididymal or testicular sperm extraction. 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.
Microepididymal sperm aspiration (MESA) and testicular sperm extraction (TESE) are outpatient surgical procedures used to harvest sperm from men in special circumstances as part of IVF-ICSI. The age of the female partner and length of time since prior vasectomy are critical factors in decision-making. The physicians at Fertility Specialists of Texas work closely with many urologists to coordinate these procedures which are done in our facility.
When a physician performs MESA procedure, they will put the patient under local anesthesia and general sedation. Then an incision is made in the scrotum, exposing the epididymis and the tubules immediately adjacent to the testicles that collect the sperm. Utilizing 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.
Testicular Sperm Extraction (TESE)
A TESE or testicular sperm extraction is a procedure that entails directly aspirating the sperm from the testes or retrieving sperm from a testicular biopsy. Generally, it is performed under local anesthesia block and can be performed as an office surgical procedure. In many cases, the disadvantage is that testicular sperm are much more scarce and consequently more difficult to freeze. Typically, there is only enough sperm recovered for 1 IVF procedure, and if further IVF attempts are needed, the TESE procedure will need to be repeated.
Non-obstructive Azoospermia (NOA)
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.
The andrology department at Fertility Specialists of Texas performs semen analysis, semen cryopreservations, intrauterine insemination (IUI) preparations, and in vitro fertilization (IVF) sperm preparations. Having an in-house andrology department ensures the safety of the sample and allows it to be analyzed and processed under optimum and sterile conditions.Haley
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