Male Factor Infertility
Male infertility is more common than many people realize. Fortunately, through advances like ICSI, even a man with severe male factor infertility can conceive.
At a Glance
- Approximately 30-40% of infertility problems may be due to male factor infertility.
- Even men with very low sperm counts can conceive through IVF with PESA, TESE, MESA and ICSI.
- Vasectomy reversal can take a long time for results so many of these patients choose PESA or MESA with IVF instead.
Causes of Male Factor Infertility
When a couple is trying to conceive and male factor infertility is identified, there are a variety of risk factors that may be associated.
- Age: Although many men can be fertile at very advanced ages, there is some decline in the sperm with age.
- Drugs/Alcohol: Smoking cigarettes, heavy use of alcohol, and heavy use of marijuana have adverse influences on the sperm quality.
- Obesity: Extreme obesity does not always cause men's sperm count to lower but does in some cases.
- Exposure to chemicals: It is not common, but men who work in industries that involve exposures to chemicals such as pesticides, herbicides, and heavy metals may have adverse influences on their fertility.
- Steroid use: Men who have been diagnosed with low testosterone or who take anabolic steroids or male hormones to improve their athletic performance or their libido can be shocked to find this very detrimental to their fertility. Sometimes sperm counts can drop to zero and stay there for a year or more in men who take steroids.
- Medical conditions: Medical conditions which can cause infertility include diabetes, which can be associated with abnormal ejaculation, called retrograde, when the sperm goes into the bladder instead of being emitted.
- Varicoceles: There are men who have varicoceles, an enlarged vein around the testicles. Repair of varicoceles is a controversial topic.
- Undescended testicles: Infertility plagues men who were born with their testicles undescended if the repair was not done early enough in their life before damage occurred to the testicles. Typically, these men have no active sperm production. There is no corrective treatment.
- Cancer treatments: The use of chemotherapy or radiation therapy for cancer can destroy sperm.
- Medication: Certain sulfa drugs which are used for rheumatoid arthritis or ulcerative colitis can interfere with the sperm. Calcium channel blockers are controversial and should be avoided if there is another drug that can be used for advanced high blood pressure and the couple is infertile. Tricyclic antidepressants can also be a problem.
Men who have extremely low sperm counts, for example under 5 million, should be screened with chromosomal testing to be sure that they do not have an adverse gene which could be passed to the baby and cause a condition more serious than infertility.
There are two classifications of patients where the semen analysis reveals no sperm at all. The first is blockages of the tubes connecting the testicles to the lower tract. Previous vasectomy or failed vasectomy reversals can cause the same problem. Not uncommonly, infections can cause scarring and blockage.
The other more complex classification, azoospermia, is caused by problems which are not related to obstruction. These are the most difficult to treat directly. In the case of azoospermia, if there is a blockage, often sperm can be retrieved by surgical procedures. If azoospermia is due to non-obstructive causes, then the success rate of surgical procedures may be only 50%.
Some men have ejaculation problems, sometimes psychological and sometimes due to conditions such as diabetes or spinal cord injury.
In severe cases of azoospermia where sperm cannot be retrieved, sperm donation provides a pathway to a child or children.
Percutaneous Epididymal Sperm Aspiration for IVF (PESA)
Particularly in cases of obstruction of the vas deferens due to previous vasectomy, sperm can be retrieved without an incision. A small needle is inserted into the epididymis, which is inside the testicle. A reproductive-trained urologist can do this readily.
Testicular Excisional Sperm Extraction (TESE)
Performed by an expert in male reproduction, this surgical procedure involves taking a small portion of testicular tissue and examining it under the microscope for immature sperm that can be used with intracytoplasmic sperm injection (ICSI) in IVF. This is a very specialized procedure best done by a specialist urologist and is not always successful.
Microscopic Epididymal Sperm Aspiration for IVF (MESA)
Reproductive-trained urologists perform this surgical procedure to obtain sperm from the epididymis with the guidance of an operating microscope. This is very successful in cases of obstruction. Sperm retrieved by this method can be injected by intracytoplasmic sperm injection (ICSI) directly into the egg and they function just as well as normal sperm. However, sometimes the fluid does not contain any sperm.
Intracytoplasmic Sperm Injection (ICSI)
Intracytoplasmic sperm injection or ICSI is a procedure done in the lab at the time of fertilization, primarily when there is male factor infertility. A tiny needle is used to inject a single sperm into the center of an egg to begin fertilization. This is a procedure, developed in Belgium and conducted first in the United States at the Reproductive Biology Associates laboratory. Dr. Peter Nagy, the lab director, was a part of the pioneering team in Belgium. The RBA laboratory has wide experience with ICSI to improve the success of in-vitro fertilization.
ICSI fertilizes 50%-80% of eggs. The use of ICSI for patients with borderline or even normal semen parameters has become more common in cases of unexplained infertility, poor-quality eggs, low number of eggs retrieved, advanced maternal age, and prior fertilization failure with conventional insemination.
Vasectomy is a procedure that men have to prevent them from having future children. The tube from the testis to the penis is cut. It is sometimes possible to repair this using a surgical approach under a microscope. We can refer you to a highly trained urologist for this procedure.
Vasectomy reversal is an option which is not always chosen in the days of IVF because it requires much patience. Once vasectomy is reversed, you must wait three months to a year to see if enough sperm are coming through the repaired duct to allow pregnancy. If pregnancy does not occur quickly, semen analysis should be done to check how many sperm are being produced. Sometimes success can occur in an interval up to a year later, but if the sperm count shows no sperm, then scarring has occurred, and pregnancy is unlikely without IVF.
Vasectomy reversal is sometimes bypassed in favor of IVF, especially when partnered with a woman over age 35. Testicular sperm extraction, or epididymal sperm aspiration can be performed to obtain sperm for ICSI in IVF to achieve a pregnancy. The results of IVF are dependent, for the most part, on the woman's age and other factors since we only need a few sperm to do IVF.