Male Problems

Infertility affects 12-15% of all couples in their reproductive years. As a result, one in eight couples will struggle with infertility regardless of whether the diagnosis is primary or secondary. Despite 40% of infertility causes attributed to the male and 30% due to both the male and female, most men are reluctant to appreciate the high prevalence of their contribution. This distribution of etiologies is maintained across cultural and ethnic boundaries.

The simplest evaluation of a male is the semen analysis (SA). Sperm density (greater than 20 million/mL), motility (greater than 50%), and morphology (greater than 30%) an integral screen of sperm fertilization potential. A persistently abnormal SA on two occasions obtained one month apart,

particularly if severely low, warrants a genital examination. An abnormal SA may be the first sign of significant pathology and may be life threatening in 2% of cases.

Causes

The leading causes of male infertility are

• varicocele (42%),
• idiopathic (23%),
• obstruction (14%) and
• cryptorchidism (3%).

Male Infertility Tests

The male infertility evaluation semen analysis is one of the most important tests conducted in the workup of the infertile couple.In addition to the standard semen analysis, other tests of sperm function might include tests for antisperm antibodies, cultures to detect microorganisms, and others. In addition to the semen analyses, a male hormonal evaluation is sometimes performed.

Sometimes more than one semen analyses is necessary as sperm quality and quantity can vary for numerous reasons. Reproductive labs use the “Kruger strict criteria” which assesses the following factors:

• Volume (amount of fluid which makes up the semen, usually expressed in milliliters).
• Sperm count (number of sperm in a standard given volume).
• Motility (percent of sperm that are moving when the semen is examined under the microscope).
• Progression (forward movement of sperm cells).
• Viability (percent of sperm that are shown to be alive by use of a special staining technique).
• Sperm morphology (shape) and additional semen contents, such as white blood cells (which can indicate the presence of infection).

In specialised centres, The Sperm Chromatin Structure Assay (SCSA) is a test that is offered to measure the level of DNA fragmentation in the sperm, to enhance the diagnosis of and treatment for male infertility. Research indicates that sperm with high-levels of DNA fragmentation have a lower probability of producing a successful pregnancy. A review of data on hundreds of semen samples show that patients with a DNA fragmentation level of greater than 30% are likely to have significantly – reduced fertility potential, including a significant reduction in term pregnancies and a doubling of miscarriages.

Treatment of Male Infertility

Varicocele, can be treated effectively with surgery performed by a urologist. A varicocele is a blockage of the veins leading to the testicles which are responsible for temperature regulation. When there is a blockage the temperature of the testicles increases thus inhibiting sperm development. A varicocele can also lead to the production of antisperm antibodies. The male’s immune system “mistakes” sperm for invading pathogens and seeks to destroy them. If this condition does not resolve after correcting the unde rlying cause, oral corticosteroids are often effective.

Male sperm counts can be reduced when FSH and LH levels are normal but the testosterone level is low (hypogonadism). This condition is sometimes treated with Clomid, however, improvements in sperm counts can be marginal and several months of therapy are required. This therapy is also very expensive.

Intrauterine insemination is often the treatment of first choice for mild male factor infertility.

The sperm are collected, washed, concentrated, and inserted into the uterus using a small catheter. This process insures that sufficient sperm reach the egg for fertilization to occur. Donor sperm can be used in cases of moderate to severe male factor infertility.

IVF with ICSI is often the treatment of choice for men with moderate to severe male factor

infertility who want genetically related children. Pregnancy rates are much higher with IVF combined with intracytoplasmic sperm injection, compared with those treated by IUI. Routine fertilization rates of more than 66% of oocytes are obtained with ICSI using sperm from men with triple sperm defects (i.e. count, motility, morphology). Clinical pregnancy rates are greater than 28% per cycle. To date there is no increased incidence of congenital malformations in children born as a result of ICSI. However, there are concerns that because some causes of male infertility are unexplained and may be genetic, male offspring might have reproductive problems as adults.

However, in a study of 700 in vitro fertilization (IVF) cases in which intracytoplasmic sperm injection (ICSI) was performed, pregnancy occurred in less than 1% of the cases when the percentage of sperm with damaged DNA was greater than 30% Since the introduction of ICSI, treatment of most men with azoospermia is now possible, even if the azoospermia is caused by testicular failure. Before initiating treatment it is important to determine whether the lack of sperm in the ejaculate is from retrograde ejaculation, an obstructive process, or a non-obstructive process. Evaluation of the post ejaculate urine is necessary to diagnose retrograde ejaculation. Sperm may be isolated from urine or catheterized from the bladder and used for IUI or IVF. Men with obstructive azoospermia typically have normal volume testis with bilaterally indurated epididmii or absent vas deferens, which is frequently fo und in men who carry the cystic fibrosis gene mutation. Men with non-obstructive azoospermia usually have small, soft testis and elevated FSH levels.

The two procedures that are most commonly used to retrieve sperm from azoospermic men are the testicular sperm aspiration (TESA) and the midepididymal sperm aspiration (MESA) procedures. TESA is an open testicular biopsy during which about 500 mgs of testicular tissue is excised using scissors. MESA involves puncturing individual epididymal tubules and aspirating the fluid. During both procedures specimens are examined in the operating room to insure an adequate number of sperm are retrieved. Similar variations are “Percutaneous epididymal sperm aspiration”or,”PESA.” and “Testicular sperm extraction,” or, “TESE.” In the past, sperm aspiration procedures were performed the same day as the oocyte aspiration. thus allowing the use of fresh sperm for ICSI. However, cryopreservation of epididymal and testicular sperm allows for temporary separation of sperm retrieval procedures from oocyte aspiration. It allows for multiple ICSI cycles without the need for additional sperm retrieval procedures. It also reassures a couple that they will not be cancelled the day of the oocyte aspiration due to inability to obtain sperm from TESA/MESA. Cryopreservation is known to impair motility and decrease the fertilization rate by detrimental effects on the sperm head (acrosome) structure and function. Fortunately, ICSI does not require sperm motility and acrosome function.