Male Infertility Treatment
Perhaps because the woman carries the baby, we often consider infertility solely a female problem. In fact, up to 50 percent of all infertility cases involve the male partner. If male fertility issues are suspected based on the results of a semen analysis, we may refer him to a male fertility specialist or an andrologist, who specializes in male reproductive problems. Just as reproductive endocrinologists are gynecologists sub-specialized in treating female infertility, andrologists are urologists specially trained to treat male infertility. PFC works closely with the only two andrologists in San Francisco, Dr. Paul Turek and Dr. Ira Sharlip.
As with female infertility, there are a number of treatments to successfully address various male infertility diagnoses. When recommending a given male fertility treatment option, we consider three important factors:
- Cause of infertility, if identifiable
- Severity of the sperm abnormality
- Age of the female partner
Because male infertility may require months of treatment, any treatment plan will consider age of the female partner, as this is a crucial element in fertility success.
The male fertility evaluation will include a sperm count, and usually a panel of hormone blood tests, a physical and urogenital examination, and possibly genetic tests and/or sperm function testing. Learn more about diagnosis of fertility problem.
Most men will initially be diagnosed with a potential male factor problem based on the results of an ejaculated sperm specimen.
Normal values for the sperm analysis, as defined by the World Health Organization (WHO):
Semen Analysis-WHO Minimal Standards of Adequacy
Ejaculate volume----------1.5-5.0cc (milliliters)
Sperm Concentration----->20 million sperm per cc
Forward Progression------2 (scale 1-4)
Morphology----------------30% normal forms (WHO criteria)
Morphology---------------->4% normal forms (Krueger criteria)
Total Motile Count. Sometimes only one sperm parameter is abnormal and sometimes several are abnormal. An indicator useful in determining overall fertility is called the total motile count. This number represents the total number of motile sperm in the ejaculate. The total motile count is calculated thus:
Ejaculate volume X Sperm Concentration X %Motility = TMC. If the TMC is 20 million sperm or less, there is likely to be a 'significant' male factor problem. Men with a TMC consistently less than 5 million are said to have 'severe' male factor infertility.
Morphology. Another important parameter in the semen analysis is the morphology, or shape of the sperm. The shape of the sperm is a reflection of proper sperm development in the testicle, or spermatogenesis. Men with a defect in sperm maturation tend to have problems with sperm morphology and may then be at risk for failure of their sperm to fertilize their partner's eggs.
There are two methods for performing a semen analysis. Most clinical laboratories perform a crude estimation of the percentage of sperm in the ejaculated specimen that appear to have normal shape. Only specialized andrology laboratories have trained technicians that can perform a "strict" semen analysis. Only these "strict criteria" (also known as Krueger criteria) have been studied with regard to fertilization success or failure. If a man has a decreased number of normally shaped sperm on the Krueger strict morphology analysis, he is at risk of fertilization failure or at least low rates of fertilization. However, an increased number of abnormally shaped sperm with 'non-strict' criteria may indicate a fertilization problem, but to be certain this test should probably be repeated in a laboratory that performs strict analysis. Strict morphology is a useful test to perform with couples that have unexplained infertility, even if the semen analysis and non-strict morphology are otherwise normal
Fertility Treatment Options
Varicocele Surgery. A varicocele, or dilated complex of veins in the scrotum, can overheat the testicle(s), negatively impacting sperm production and quality. Varicocele surgery involves tying off or ligating the abnormally dilated veins, thus allowing for a healthy sperm production environment. This surgery seems to be most effective in men whose varicocele is of significant size; and in cases where sperm count and motility are not too severely impaired.
What to expect from the procedure. Varicocele surgery is performed under local anesthesia and light (‘twilight’) sedation, usually taking a little over an hour. The patient will return home and may be advised to take it easy for a day.
Results. If the varicocele is of significant size (‘grade II or III’), about two thirds of men undergoing the infertility treatment surgery will see some improvement in the sperm quality, most typically seen as an improvement in motility. The reported pregnancy rates following surgery are in the range of 40%. However, it is important to note that most pregnancies occur 6-9 months following surgery, so age of the female partner needs to be considered before undergoing surgery. Learn more about varicocele.
Clomid therapy for unexplained low sperm count. If there is a mild decrease in the male partner’s sperm count or motility, a urologist may prescribe Clomid, an infertility pill commonly used to treat women who fail to ovulate. Clomid can stimulate the hormones responsible for sperm production. Sperm counts are re-analyzed 3-6 months after medication is started to evaluate any improvement in sperm production.
Anti-Oxidants and Micronutrients. Most cases of male factor infertility, even after full evaluation, will be labeled “idiopathic,” which means that we do not know why there is a low count, low motility, or poor sperm morphology (poorly formed, abnormally shaped sperm). It may be environmental (pollutants, toxins) or related to lifestyle (hot tub or hot bath use, smoking). When the causative factor can be found and changed, of course this will be advised. However, even men without known toxic exposures or lifestyle factors can have low sperm parameters. There are many dietary supplements that are known to improve sperm production and function (such as L-carnitine and zinc). A reproductive endocrinologist or andrologist may recommend beginning a vitamin and mineral supplement to help make the sperm as good as it can be.
IUI (intrauterine insemination cycle). When there is mild, unexplained low sperm count or motility, we may recommend an intrauterine insemination cycle (IUI). Sperm is processed and placed into the female partner’s uterus around the time of ovulation, giving sluggish sperm a big head start towards the egg or eggs.
What to expect from the IUI procedure. The male partner will be asked to provide a sperm sample through masturbation either at home or in our clinic. His sperm is then sent to our laboratory where it is prepared for transfer into the female partner’s uterus. The most active, motile (normal, forward moving) and healthy sperm are extracted and this optimal sperm sample placed into the uterus via a catheter.
Prior to the IUI procedure, the male partner will be asked to abstain from ejaculation for 1 to 3 days (however, abstaining for more than 5 days can result in decreased motility).
Learn more about the IUI procedure.
IVF with ICSI for moderate to severe male factor, unexplained cause. When surgical and medical treatment does not improve sperm production, many couples find success through in vitro fertilization with intra-cytoplasmic sperm injection (IVF with ICSI). To aid in the IVF process, the embryologist injects the healthiest, most motile sperm directly into each egg. Learn more about IVF Treament and ICSI.
If the male partner has had a prior vasectomy, we may recommend a surgical procedure to reverse it. Vasectomy reversal re-connects the tubes that carry sperm from the testicles into the semen. After successful vasectomy reversal, sperm are again present and pregnancy may be possible.
What to expect. Because it is possible for scarring and re-obstruction to occur after surgery, we strongly recommend that during the procedure, the surgeon retrieve any vassal sperm. This sample may be frozen for later use if needed. The procedure is performed by an andrologist, using micro-surgical techniques. It generally requires general anesthesia but can be done as a day surgery procedure and may require 2-5 days for recovery.
Results. While pregnancy rates following vasectomy reversal surgery are in the 40 percent range, there are a couple of key considerations with this option. Because it can take 6-9 months to recover adequate sperm counts following surgery, the age of the female partner must be considered. Also, the greater the length of time between vasectomy and reversal, the more likely it is that surgery will be unsuccessful or that ‘anti-sperm antibodies’ will form, preventing sperm from successfully penetrating the woman’s eggs.
IVF-ICSI infertility treatment with sperm extraction MESA and TESE. Two procedures known as MESA and TESE are very effective at treating more problematic male infertility diagnosis, by enabling doctors to obtain healthy sperm directly from the male reproductive tract in cases where sperm is not able to travel on its own. After sperm is retrieved, it is injected directly into individual eggs, through the ICSI procedure.
The doctor may recommend MESA or TESE if reverse vasectomy is not advised; in a diagnosis of Congenital Absence of the Vas Deferens or a diagnosis of Non-obstructive Azoospermia.
What to expect. The MESA (microsurgical epididymal sperm aspiration) procedure is performed under local anesthesia and general sedation and is usually performed in an outpatient surgical center. Here, a small incision is made above the testicle, enabling millions of sperm to be collected. While this sperm may be perfectly healthy and strong, it is not yet mature, so embryologists help it along by injecting it into the egg in an ICSI procedure. Sperm collected in this manner can also be frozen, should the patient and his partner undergo further IVF cycles.
In TESE (testicular sperm extraction) sperm is either removed directly from the testicles or obtained through a biopsy (tissue sample). This surgery is usually performed under local anesthesia with no general sedation and can be done in the procedure area at Pacific Fertility Center. As with MESA, retrieved sperm is injected into the egg (ICSI). TESE is often recommended for men with poor sperm production in the testicles and no sperm in the ejaculate. It is also recommended in cases of Azoospermia, where there are no sperm in the epididymus, the tube connecting the testicle with the vas deferens. Usually, the TESE procedure releases only enough sperm for one round of IVF, thus it may need to be repeated for subsequent rounds.
As mentioned earlier, with most cases of male factor infertility, a Pacific Fertility Center doctor will be recommending that a patient see one of the two andrologists we work with: