Approximately 30 – 40% of infertility is related to male factors. The standard test for evaluation of a man’s fertility is the semen analysis. This test measures the volume of the ejaculate, concentration of the sperm, movement of the sperm, morphology (appearance of the sperm), and for the presence of antisperm antibodies. All male patients are required to have a semen analysis done at the Diagnostic Semen Laboratory (DSL) regardless of any known problems with themselves or their partner.
Causes of male infertility include:
– obstruction of the flow of sperm due to:
- failure of the sperm transport tubes to develop (cystic fibrosis – bilateral absence of the vas)
- vasectomy – some men regret having had a vasectomy
- pelvic surgery or trauma
– failure to produce sperm due to:
- genetic causes such as abnormal chromosomes or missing genetic information on the Y chromosome
- hormone problems
- history of using anabolic steroids like testosterone
- previous radiation and/or chemotherapy
- undescended testicles
- mumps orchitis
– difficulties with the delivery of sperm due to ejaculation failure as a result of:
- sexual dysfunction:
- nerve problems due to uncontrolled diabetes and other neurological disorders
- erectile dysfunction
- pelvic surgery or trauma
- spinal cord injuries
- retrograde ejaculation
The evaluation and treatment of male factor infertility depends on the suspected cause. The diagnosis is made on the basis of the physical examination and the results of various tests. In cases where men are not making any sperm, sperm donation is an option. If there are any normal sperm at all available then it may be possible for that man to have a biological child using intracytoplasmic sperm injection (ICSI). ICSI overcomes male factor infertility by directly injecting a single sperm into the cytoplasm of a mature egg obtained through in vitro fertilization (IVF). This is a technique performed on a microscope stage by specially trained embryologists.
The first successful fertilization of an egg by ICSI in 1991 ushered in a new era in the treatment of male infertility. Since that time pregnancies are possible even in cases where there are extremely low numbers of living sperm available. Sperm used for ICSI can be obtained in a number of ways including ejaculation by masturbation, PESA, microsurgical testicular biopsy, core biopsy, vibrostimulation, electroejaculation and retrograde ejaculation.
Percutaneous Epididymal Sperm Aspiration (PESA)
Percutaneous epididymal sperm aspiration is a procedure to obtain sperm from the epididymis for use with ICSI. This technique is often used for men who have had a prior vasectomy and in those who have other congenital or acquired obstructions of the genital tract. Men that carry certain genes associated with cystic fibrosis and have congenital absence of the vas deferens can also have sperm retrieved by this method.
PESA is performed in the clinic under local anaesthesia. It involves placing a small needle into the epididymis and applying negative pressure with a syringe to recover the sperm sample. Sperm retrieved by PESA can only be used for intracytoplasmic sperm injection (ICSI). Men with obstruction to the flow of sperm will have a very high chance of a successful sperm retrieval using either PESA or testicular biopsy. Recovery from this surgery is usually one to three days.
Microsurgical Testicular Biopsy (MicroTESE)
MicroTESE is a surgical procedure that requires removing the testicle from the scrotum and opening it widely while the patient is under general anesthesia. It involves selective testicular biopsies using a operating microscope to identify candidate areas of possible sperm production. The biopsied tissue is dissected to release the sperm that are present within the seminiferous tubules. This procedure is generally used when other methods of retrieving sperm are not possible. Sperm retrieved by this method is normally frozen and at a later date used for intracytoplasmic sperm injection (ICSI). The testicle will be sore after surgery and patients are given a prescription for pain medication. Recovery from this surgery normally requires a week off of work.
Percutaneous Core Biopsy
Men that do not have sperm in their ejaculates due to obstructions may have sperm retrieved by using a special core biopsy gun. The tissue core removed is dissected to release the sperm that are present within the seminiferous tubules. This is an office procedure performed under a local anesthetic. The number of sperm collected by this method is small and they are used for ICSI only. Recovery from this surgery is usually one to three days.
Vibrostimulation is a procedure performed using a special vibrator applied directly to the head of the penis. When successful the ejaculate is collected in a sterile container and may be used for artificial insemination, IUI or in vitro fertilization/ICSI depending on the quality of the semen sample obtained. Vibrostimulation is typically used as a first line procedure for patients with high spinal cord lesions. Depending on the quality of the sample the sperm may be used for artificial insemination, intrauterine insemination or ICSI.
The first time vibrostimulation is attempted it is performed under medical supervision with constant monitoring of the blood pressure as some men will develop a condition known as autonomic dysreflexia. Autonomic dysreflexia is characterized by high blood pressure, headache and even the possibility of having a stroke. Medications may be used to block or correct this reaction. Men that do not develop autonomic dysreflexia and successfully vibrostimulate can be taught to perform this procedure at home and the couple can try to conceive through artificial insemination.
Men with spinal cord injuries, neurological disorders, diabetes and post surgical ejaculation problems can usually have electroejaculation to successfully retrieve sperm. Electroejaculation is a procedure whereby a special probe is inserted into the rectum to stimulate the pelvic nerves, which causes ejaculation to occur. This procedure is nearly always successful in producing a sample. The ejaculate is collected in a sterile container, which occasionally may be used for artificial insemination or intrauterine insemination (IUI) but more often is used for in vitro fertilization or ICSI. Men with complete spinal cord lesions are candidates for electroejaculation without anesthesia. In those with incomplete lesions and other neurological disorders a general or spinal anesthetic is required.
Retrograde ejaculation refers to the entry of semen into the bladder at the time of ejaculation instead of traveling out through the urethra. In this condition little or no semen is discharged from the penis at the time of orgasm. Retrograde ejaculation may occur after prostate or pelvic surgery, pelvic trauma, as well as in some neurological conditions including poorly controlled diabetes.
In some circumstances sperm ejaculated into the bladder can be retrieved for the urine. This procedure is preceded by a nighttime and morning dose of sodium bicarbonate to make the urine alkaline. Prior to masturbation the bladder is emptied by catheterization and special media left in the bladder to protect the sperm and enhances and preserves sperm motility and viability. Following ejaculation the man empties his bladder into a sterile container and the sperm is removed for the fluid. Samples collected after retrograde ejaculation may be used for artificial insemination, IUI or ICSI depending on the quality of the sample.