OVERVIEW: MALE FACTOR INFERTILITY
About 30-40% of all cases of infertility involve male factor. There can be problems with sperm production (low count), sperm motion (motility) or sperm quality (morphology). Some men have sperm that has impaired function, or is unable to fertilize. There are specific tests to evaluate these factors. Based on the results, your physician may recommend hormone therapy, intrauterine insemination, IVF and/or ICSI. Some men have problems with erectile dysfunction but can produce a sample for intrauterine insemination and some may have a blockage of sperm transport due to scar tissue or problems in the vas deferens due to previous vasectomy. These patients may attempt IVF with ICSI after sperm is retrieved non-surgically from the testicle by TESA.
Men may suffer from low sperm counts because of illness, personal lifestyle and/or other reasons. Any tobacco should be stopped if attempting pregnancy. Nicotine replacement can be used instead.
A sperm sample for a semen analysis may be requested to determine adequate sperm counts. A semen analysis also determines whether the man has poor quality sperm. If this is the case, it could mean that that sperm are unable to get to the egg or penetrate the zona pellucida (outer shell of egg). Additional testing can evaluate this factor. Specific therapy is offered based on the male factor involved.
Intrauterine insemination is a procedure to increase pregnancy potential for couples with:
- Male factor infertility – oligospermia (low count or motility)
- Poor cervical mucus
- Unexplained infertility
- Donor insemination
The male’s sperm is prepared by a special gradient procedure that separates the most fertile sperm for placement into the woman’s uterus. Other preparations of sperm may be required for very low counts or sperm antibodies. The insemination is performed with a gentle catheter placed through the cervix into the uterus, increasing the number of healthy sperm reaching the tube for spontaneous fertilization of the egg.
Intrauterine insemination aided with ovulation induction with gonadotropins (Bravelle, Repronex, Menopur, Follistim, and Gonal-F) may benefit those who have not conceived after an appropriate time with routine therapy and all infertility factors corrected. This applies to couples in which the female has one or more open tubes with an ovulatory problem, unexplained infertility, or minimal endometriosis.
Intrauterine insemination(s), along with ovulation induction with gonadotropins, appear to improve pregnancy chance due to increasing the number of available eggs and sperm to maximize the chance of pregnancy to approximately 15 to 20% per attempt. Multiple gestations occur at a rate of 20% twins, 3-5% triples, 2% quads or greater if combined with superovulation. If intrauterine insemination is combined with routine ovulation, lower pregnancy rates occur, as do very low multiple gestations.
Intracytoplasmic Sperm Injection (ICSI) is a form of assisted fertilization using micromanipulation, injecting a single sperm into the cytoplasm of the egg by using a microneedle. Certain groups of patients with a lesser chance of becoming pregnant with routine IVF may require this technologically advanced procedure. When the male’s sperm is considered to be suboptimal, ICSI is performed. ICSI is also performed in situations where characteristics of the egg may impair conventional in vitro fertilization, such as patients with endometriosis or unexplained infertility. Pregnancy rates depend on the number and quality of embryos transferred.
There can be no guarantee, however, that all eggs fertilized will produce an embryo, with or without the use of micromanipulation. IVF technology is not yet capable of determining which eggs will fertilize, or which ones will produce the most viable embryos. The expected fertilization rate is 70% of eggs for those who receive ICSI, similar to routine insemination with no fertilization factors.
TESA is one of the most successful and rewarding state-of-the-art technologies provided by the ART Fertility Program of Alabama. The TESA procedure removes sperm directly from a man’s testes (testicles), bypassing his reproductive tract. The ART Fertility Program has been successful in retrieving sperm in over 95% of cases, reporting no difference in fertilization rates in males requiring TESA compared to males with low sperm counts (total motile sperm < 20 million) when combined with Intracytoplasmic Sperm Injection and IVF. Delivery rates of over 45% per transfer are related to the age of the female (highest rates at age < 35).
Men who have a low or absent sperm count due to obstructive causes like failed or poor vasectomy reversal, vasectomy reversal candidates, absence of vas deferens or scar tissue in their outlet track can benefit the most from this new procedure. TESA may also benefit some men who make low levels of sperm due to problems in the testes (testicles).
When male factor infertility is the primary issue, some couples may choose insemination by donor as their option for therapy. The option of IVF with ICSI or TESA may not be cost-effective or may not be desired. Intrauterine insemination by donor is widely practiced throughout the world. The pregnancy rate is high; 70-80% of couples who choose DI have a child by this method. It is not any easier to make a decision about DI than it is about adoption, IVF, or remaining childless. We have an extensive information packet regarding the benefits and risks and options. More information is provided at your initial office visit, along with information on donor banks and deciding on donors. We also have counselors available to discuss issues regarding donation.
At the ART Fertility Program, we use the technology of sperm cryopreservation to help our patients for many reasons. The situations which may warrant cryopreservation and storage include the following:
- Severe oligospermic males (total motile sperm < 2 million) as a backup to an IVF cycle.
- The male may be planning to undergo surgery of the reproductive system which may result in diminishing or destroyed sperm production.
- Due to cancer treatment (chemotherapy or radiation) which can potentially leave the man infertile.
- The man may be out of town at the time of the procedure.
- Due to the stress that sometimes accompanies infertility treatment, it may be difficult to produce a semen specimen at a specific time.
- Oligospermic (sperm concentration fewer than 20 million per mL) males may find it beneficial to bank several samples for future use (i.e. cryoaccumulation).
- Shipment of sperm to another infertility or cryobank facility.
- Shipment of sperm to a research facility for various Andrology testing.
A comprehensive review of testing, costs and expected success rates will be provided at your initial visit. Sperm storage is charged yearly based on the number of vials in storage. This will be reviewed based on your personal needs.