Male Infertility Treatment
What Is Male Infertility?
There are multiple causes of infertility. The three most frequent individual causes are abnormalities of ovulation, abnormalities of the fallopian tubes and male factors. These three causes account for some 80% of infertility cases; male factors make up 20-35% of these cases. An evaluation of the male should be one of the very first tests carried out in the diagnostic process of the couple experiencing infertility.
ACRM works with several Board certified urologists specializing in male fertility throughout the Atlanta area.
Treatment of Male Factor Infertility
The type of treatment used will depend directly on how many good quality sperm are available. In situations where sperm numbers are low but close to normal, the option of intrauterine insemination (IUI) of the sperm is available. In situations where sperm numbers are markedly reduced, the best option is ICSI during a cycle of in vitro fertilization. Although the option of insemination using donor sperm is always available, its usage has decreased dramatically as ICSI has allowed many more men to establish their own genetic pregnancy.
We are very excited with the developments in the treatment of the infertile male in the last few years and look forward to many more new options in this vibrant area.
How to Treat Male Factor Infertility?
The treatment of male factor infertility is of course dependent on the identified problem. Sexual dysfunction, for example, is often treated by infertility counseling rather than by "medical" therapies. Most commonly, however, we will be treating male factor infertility with therapies such as inseminations or in vitro fertilization. We begin the evaluation with a semen analysis. If the count, motility, or shape of the sperm are consistently low, blood work for hormonal status and genetic abnormalities are undertaken. Remedies can include lifestyle changes or hormonal treatment. However, testosterone replacement is avoided as testosterone suppresses sperm production.
In order for fertilization and subsequently pregnancy to take place, a minimum number of sperm must "find" the egg. When everything is normal, fertilization will take place in the fallopian tube. Unlike the cartoon drawings of the female anatomy that we are accustomed to seeing, the fallopian tube is not just a straight tunnel-like connection; instead, it is a complex organ with many "nooks and crannies". From a sperm cell's perspective, it is a labyrinth. The egg will be hidden in one of these areas so a huge number of sperm are necessary at the beginning of the journey in order for a few to find the egg. Once the sperm finds the egg, the effort of many is necessary to break through the layers of cells and protein coat that surround the egg before the final step of fertilization by a single sperm can take place. When it comes to working with male factor patients, then, the question boils down to one of numbers. We must determine whether there are enough sperm available at the beginning so that one can ultimately find and fertilize the egg at the end.
What Is IUI (Intrauterine Insemination)?
In normal situations at least 50 million sperm are ejaculated into the vagina during intercourse. Of these, only 5-10 million will make it out of the vagina into the uterine cavity. It has been shown that we can easily place sperm directly into the uterine cavity by means of an intrauterine insemination wherein a small flexible catheter is passed through the cervical canal into the uterus, and the sperm can then be injected through that catheter. In order for intrauterine insemination (IUI) to be successful, as a general statement we need to have 3-5 million normal, motile sperm available for insemination into the uterus.
The IUI Procedure
The procedure of IUI is very straightforward. The husband will produce a specimen, which is then processed in the laboratory. There are many different techniques to process sperm but in all cases the purpose is to remove the sperm cells from the semen and ideally to concentrate the best, most normal sperm into the droplet of culture media which will then be placed into the uterus. Processing of a sperm specimen will typically take 1-2 hours depending on the method used. The actual IUI is done in the office and is similar to a routine pap smear. Using a speculum to see the opening of the cervical canal, a thin flexible plastic catheter can be introduced into the uterine cavity. Once in place, the sperm containing droplet is injected through the catheter. Most women do not feel this at all, some however may experience a slight cramp when the catheter enters the uterine cavity.
Although we usually must have 3-5 million sperm available for IUI success, there are always exceptions to this. Occasionally we will see a pregnancy from an insemination where only a few hundred thousand sperm were available, but if less that 3 million sperm are present the couple really needs to consider alternatives because IUI may be frustrating, expensive and unsuccessful. We must also keep in mind the likelihood of success of the various procedures that we recommend to our patients, so if a couple has less than this minimum number of sperm available, it is appropriate to move on to more aggressive therapies.
In the past, couples who had less than a couple million sperm available realistically had to consider inseminations using donor sperm. Of course, this is still an option today and many couples will undergo a series of inseminations using donor sperm. The process is very straightforward. We identify the time of ovulation and on that day place a thawed sperm specimen into the cervical canal or uterus. Success rates are excellent and cost is reasonable. The obvious downside is that the child will not be genetically linked to the husband. Nonetheless, insemination using donor sperm remains a very viable alternative for many couples.
What Is ICSI (Intracytoplasmic Sperm Injection)?
In 1992, the technique of Intracytoplasmic Sperm Injection (ICSI) was developed in Belgium. This technique involves injecting a single sperm into the egg at the time of in vitro fertilization. This technology has revolutionized the treatment of male factor infertility. Now, as long as the husband has sperm, pregnancy is possible. ICSI has been used successfully in situations where the husband has extremely low counts, and even in situations where there are no sperm in the ejaculate although there may be sperm production in the testis. As examples, this is the case in men who had unsuccessful reversals of vasectomies, men who are born without the vas deferens (the tubular structure connecting the testis to the urethra and the "outside world"), and men who have abnormal development of sperm such that they do not fully develop. Today, the factor which determines whether a couple will have babies in male factor infertility cases treated by ICSI is actually not how abnormal the male is but rather how normal the female is. The obvious downside of ICSI is that it requires the couple to undergo in vitro fertilization, but the advantage is that the technique allows men to establish pregnancies who previously would never have been able to do so.