Male Infertility

Male infertility accounts for 30-40% of infertility. Male infertility is usually related to abnormal sperm production or function. Problems can occur anywhere in the production of sperm including hormonal regulation, storage, and transport of sperm. Genetic abnormalities can also contribute to decreased sperm or abnormal function. Fortunately, there are treatments that can help improve a couple's chances of becoming pregnant. Intracytoplasmic Sperm Injection (ICSI) is one of the most commonly performed procedures for male infertility. Other procedures including aspirations, biopsies, and varicocele repair can also be useful. Once you have a diagnosis of male factor infertility, let California IVF help you in selecting the best options available.

Male evaluations
Usually, the first step in evaluating for male infertility is a semen analysis. This is an analysis for the assessment of morphology, sperm count, motility, and total motile sperm. Two samples may be required to establish the diagnosis of male infertility. An abnormal semen analysis will usually prompt further investigation. Additional tests may include hormonal evaluation, testicular examination, and in some instances, a chromosome analysis. Types of hormone problems that can lead to male infertility include, but are not limited to, high prolactin levels, abnormal testosterone levels, or absent FSH/LH (the hormones that regulate sperm production. An examination for physical abnormalities can be conducted by a urologist.

Normal parameters for a semen analysis:

Total Sperm Count	> 40 million		Morphology (WHO)	> 30% normal shape
Volume	> 2 milliliters		Morphology (Kruger)	> 14% normal shape
Motility	> 50% motile		Liquefaction	complete by 60 min

Total motile sperm count is the amount of moving sperm in the entire sample. This value is also used as an indicator of the overall assessment of the semen. Generally, total motile counts above 20 million are not associated with significant problems with fertilization as long as the other parameters are not significantly low. Many couples will still consider ICSI in the setting of a borderline semen analysis. Fertilization is the biggest concern with borderline counts. The lower the semen analysis parameters, the higher likelihood of encountering fertilization failure. Fertilization failure is the situation where there are fewer than expected fertilized eggs. This is often avoided by performing ICSI which is a process of injecting a single sperm into an egg. Fertilization rates are often higher with ICSI so women with low numbers of eggs may also elect to do ICSI to maximize the number of fertilized eggs.

Physiology
Sperm production is regulated by hormones called gonadotropins. These hormones include follicle stimulating hormone (FSH) and lutenizing hormone (LH). FSH is mostly responsible for sperm production, whereas LH is mostly responsible for testosterone production. These hormones can be evaluated for abnormalities which cause inadequate sperm production. Excessive testosterone or other androgens such as DHEA can cause a reduction in sperm production by decreasing circulating levels of FSH and LH. Men should avoid supplements containing unknown substances, especially androgen containing supplements. In addition to supplements, hormonal imbalances may result from effects of other hormones with the body. Prolactinomas (pituitary tumors that secrete prolactin) and thyroid abnormalities can also lead to abnormalites in sperm production. Transient events such as illness and infections may also alter the hormonal regulation of sperm. These effects are usually temporary and resolve with time.

Anatomy
Hormones stimulate the production of sperm within the testicle. As the sperm matures, they are moved towards collecting tubules which allow passage of the mature sperm to the storage area known as the epididymus. The sperm remain there until they are broken down or ejaculated. Ejaculated sperm traverses a tube known as the vas deferens. The vas deferens passes through the prostate gland where the sperm is mixed with additional fluid from the seminal vesicle. The sperm then enters the urethra and out the opening of the penis. Obstructions or anatomical abnormalites along this pathway can lead to male infertility.

Physical abnormalities
Physical abnormalites that can lead to male infertility include problems with the testicles, vas deferens, and prostate. Testicular death (atrophy) or chryptorchidism (non-descended testicle) can happen spontaneously or be associated with chromosomal abnormalites. Excessive dilation of the blood supply around the testicle known as a varicocele can lead to excessive heating of the testicle and cause problems with the sperm. In men with congenital absence of the vas deferens (CAVD), the tube carrying sperm to the penis is absent. This condition has a high association with cystic fibrosis. The tubes and other anatomy of the male reproductive tract may also be blocked due to scar tissue from infections or previous surgery. Prostatitis, an infection of the prostate gland, can lead to high white blood cell counts and an altered acidity (pH) of the semen. This can have an effect on sperm function and survival. Less commonly, the testis do not produce any sperm due to cellular abnormalites of the testicle. If the anatomical problems are not correctable, some couples may need to use donor sperm or consider an aspiration procedure.

Procedures
When physical barriers to sperm production exist, there are specific procedures that can help. Below is a brief sample of some of the procedures performed for male infertility:

• Vasectomy reversal - for men using a vasectomy for birth control, their vas deferens has been interrupted to prevent the passage of sperm. A vasectomy reversal can restore the opening in some cases. Sperm may also be retrieved by testicular aspiration and combined with ICSI. Antisperm antibodies can often be a problem. It is not uncommon to see declining sperm counts over time with a vasectomy reversal. Despite this, many couples are able to acheive pregnancy through a vasectomy reversal.
• Varicocele ligation - when excessive dilation of the blood vessels around the testicles occurs, excessive heat builds up. The vessels, or varicocele, can be ligated and allow the testis to return to normal temperatures. Often there is an appreciable increase in sperm parameters yet there is still some debate about varicocele ligation improving pregnancy rates. ICSI can frequently overcome the problems with sperm parameters caused by having a varicocele.
• Testicular biopsy - this is a procedure where a portion of testicular tissue is collected. This can serve as a diagnostic tool in the setting that testicular tissue is abnormal. It can also be one of the last remaining sources of sperm for some men. There is a higher likelihood of immature sperm and the sperm retrieved will likely be in low numbers. ICSI is essential following most biopsy and aspiration procedures.
• TEsticular Sperm Extraction (TESE) - this term is applied to the procedure involving sperm aspiration or retrieval from the testicle. Essentially this is a testicular biopsy performed for treatment purposes as opposed to diagnostic purposes.
• Micro-Epididymal Sperm Aspiration (MESA) or Percutaneous Epididymal Sperm Aspiration (PESA) are procedures where sperm is retrieved from the epididymus. Epididymal sperm usually contains more mature sperm.

The correct procedure and options will be discussed with you prior to proceeding with any treatment. The procedures can usually be performed right in our office with the assistance of a urologist and anesthesiologist. Sperm aspiration techniques and surgical correction of anatomical problems has given many couples hope. Donor sperm represents an alternative to these surgical procedures. Couples should make an informed decision about the options that are right for them. We are happy to answer any questions.

ICSI
Intrycytoplasmic sperm injection (ICSI) is a procedure used when sperm counts or other parameters are below the normal threshold. A single sperm is isolated under the microscope and used to inject directly into an egg. Ideally there are enough sperm to fertilize all of the oocytes. Motile, forward moving, and normal appearing sperm are preferred in the process of choosing a sperm.

Click here for more information on ICSI.