What is male infertility?
Reproduction (or making a baby) is a simple and natural experience for most couples. However, for some couples it is very difficult to conceive.
A man’s fertility generally relies on the quantity and quality of his sperm. If the number of sperm a man ejaculates is low or if the sperm are of a poor quality, it will be difficult, and sometimes impossible, for him to cause a pregnancy.
Male infertility is diagnosed when, after testing both partners, reproductive problems have been found in the male.
How common is male infertility?
Infertility is a widespread problem. For about one in five infertile couples the problem lies solely in the male partner.
It is estimated that one in 20 men has some kind of fertility problem with low numbers of sperm in his ejaculate. However, only about one in every 100 men has no sperm in his ejaculate.
Diagnosis of Male Infertility
General Physical Examination and Medical History : This includes examining your genitals and questions about any inherited conditions, chronic health problems, illnesses, injuries or surgeries that could affect fertility.
Scrotal Ultrasound : This test uses high-frequency sound waves to produce images inside your body. A scrotal ultrasound can help your doctor see obstructions or other problems in the testicles and supporting structures.
Transrectal Ultrasound : A small, lubricated wand is inserted into your rectum. It allows your doctor to check your prostate, and look for blockages of the tubes that carry semen (ejaculatory ducts and seminal vesicles).
Hormone Testing : Hormones produced by the pituitary, hypothalamus and testicles play a key role in sexual development and sperm production. Abnormalities in other hormonal or organ systems may also contribute to infertility.
Testicular Biopsy : This test involves removing samples from the testicle with a needle. The results of the testicular biopsy will tell if sperm production is normal.
Anti-Sperm Antibody Tests These tests are used to check for immune cells (antibodies) that attack sperm. You are especially likely to have anti-sperm antibodies if you've had a vasectomy reversal.
Specialized Sperm Function Tests : A number of tests can be used to check how well your sperm survive after ejaculation, how well they can penetrate an egg, and whether there's any problem attaching to the egg.
Intracytoplasmic Sperm Injection (ICSI)
The introduction of Intracytoplasmic Sperm Injection (ICSI) has revolutionized the management of male infertility. Here, a single sperm is injected directly into an egg; this procedure is most commonly used to overcome male infertility problems.
Following egg retrieval, sperm is injected into the egg. About 70 percent of eggs get fertilized. Fertilization is confirmed 18-24 hours after retrieval. ICSI is a highly successful technique used to help couples who have previously failed to achieve conception with standard IVF.
Why is ICSI Done?
- Very Low Sperm Count
- Abnormally Shaped Sperm
- Poor Sperm Movement
If a man does not have any sperm in his ejaculate, but he is producing sperm, they may be retrieved through testicular sperm extraction, or TESE. Sperm retrieved through TESE require the use of ICSI. ICSI is also used in cases of retrograde ejaculation, if the sperm are retrieved from the man’s urine.
PESA (Percutaneous Epididymal Sperm Aspiration) Male Fertility Treatment in India
PESA (percutaneous epidydimal sperm aspiration) and TESA (testicular sperm aspiration) are procedures that are performed to obtain sperm in certain cases of male infertility. PESA or TESA can be performed on men that have zero sperm counts due to either a sperm production problem or a blockage in their reproductive tract, such as the result of a vasectomy, congenital absence of vas deferens, or infection.
Once a diagnosis of azoospermia (zero sperm count) has been made, we work closely with a urologist with specialized training in male infertility who will retrieve the sperm. The urologist will first perform an exam and further testing which may involve blood work and/or a testicular biopsy. The result of these studies determines which procedure is more appropriate and more likely to yield sperm.
While PESA is usually performed in our Center the morning of the egg retrieval, TESA may be done the day prior to the egg retrieval to allow in vitro maturation of immature sperm. With PESA, a small needle is placed into the epidydimis, which is a reservoir of sperm that sits atop each testicle, using local anesthesia. During TESA, sperm is obtained by means of a biopsy of the testicle. The sperm obtained from these procedures is then injected directly into the eggs (ICSI).
PESA / TESA procedure should be used when there is no sperm in ejaculate (so called ‘azoospermia) confirmed in two independent semen assessments.
The procedure can be done under local anaesthesia or short intravenous sedation. For aspiration of sperm from the epidydymis (so called PESA) as well as for aspiration of sperm directly from the testicles (so called TESA) we use special, fine needles which make the procedure less invasive.
PESA/TESA takes about 15-20 minutes and sperm aspirated during that procedure are usually cyropreserved and are to be used for ICSI (IVF with injection of a single, selected sperm) on the day of the egg collection.
MESA (Microsurgical Epididymal Sperm Aspiration) Male Fertility Treatment in India
Microscopic Epididymal Sperm Aspiration (MESA) is a technique for the retrieval of sperm from the epididymis of men in whom transport of sperm from the testicle to the ejaculate is not possible because the drainage (ductal) system is absent or is not subject to reconstruction. This problem most commonly occurs in men with vasal agenesis, a condition in which the vas deferens or drainage system of the testicle fails to develop prior to birth. The majority of these men have mutations of the Cystic Fibrosis (CF) gene; therefore, their female partners require CF testing.
In some circumstances the obstruction may be acquired after a failed epididymovasal anastomosis; here again, MESA may be indicated. While the male is being evaluated as a candidate for MESA, his wife is being screened in our IVF program where ICSI is also offered. MESA and IVF-ICSI complement each other and are an essential component of our assisted reproduction laboratories.
Epididymal aspiration may be performed on the day of the wife’s egg retrieval, or preferably ahead of time, and the aspirated sperm cryopreserved. The success of pregnancy from this procedure is reported to be 25%-60% depending on female factors. It is a complex process, requiring significant manipulation of the human gametes (eggs and sperm) but one that offers a previously sterile couple the chance of establishing a pregnancy using their own genetic material.
Male Fertility Treatment - TESE (Testicular Sperm Extraction) Surgical Sperm Retrieval
Testicular failure affects approximately 1% of the male population and 10% of men who seek fertility evaluation. Azoospermic men with testicular failure (non-obstructive azoospermia) have either Sertoli cell-only pattern, maturation arrest, or hypospermatogenesis on testis biopsy. Until recently, it was assumed that men with non-obstructive azoospermia were untreatable. The only options offered to these couples to have children were the use of donor spermatozoa or adoption. Several clinically relevant findings have changed our approach to this condition. First, we have observed that direct evaluation of testis biopsy specimens often demonstrates sperm in men with non-obstructive azoospermia, despite severe defects in spermatogenesis.
Retrieval of sperm from the testis or epididymis is associated with good pregnancy rates using in vitro fertilization. Micromanipulation of gametes during assisted reproduction could improve these pregnancy rates. Subsequently, we have observed that optimized in vitro micromanipulation techniques can further enhance fertilization and pregnancy rates using epididymal or testicular sperm. Sperm can be retrieved from the testes of men with obstructive azoospermia and used with the assisted reproductive procedure of intracytoplasmic sperm injection (ICSI) during in vitro fertilization (IVF) with a high chance of achieving pregnancies and deliveries of normal children. These findings have led investigators from Belgium and elsewhere to perform testicular sperm extraction (TESE) with ICSI for men with non-obstructive azoospermia. Low pregnancy rates of 20 to 21% per attempt have been reported.
Laparoscopic Varicocelectomy
Varicocele is dilatation of pampiniform plexus (collection of small veins) in the scrotum. It is one of the most commoncauses of male infertility.
Advantages of Laparoscopic Varicocelectomy include: increased magnification, facilitating more accurate identification of vessels, such as spermatic collateral veins, (i.e. veins running alongside the spermatic cord and together entering the internal ring, a possible cause of recurrence if left alone), lymphatics (the ligation of which can lead to hydrocele formation) and the internal spermatic artery . Moreover, laparoscopic varicocelectomy is safe even after prior inguinal surgery. The characteristic supra-inguinal access allows for high ligation of fewer veins as compared to a more labour-intensive subinguinal approach.
Semen Cryopreservation
Semen cryopreservation (the freezing of sperm) is a way to store sperm for future use. Men who must undergo medical procedures that may leave them sterile may wish to consider semen cryopreservation e.g. cancer chemotherapy, radiotherapy. Semen cryopreservation is also used before IVF to acquire multiple semen samples in men.
Donor Sperm
Donor sperm are recommended when sperm is not produced from the semen, often due to genetic causes, chemotherapy, radiation therapy or vasectomy. Donor sperm are also an option for single women, couples with genetic disorders, and couples in which the woman is Rh-sensitized and the man is Rh-positive. In most cases, anonymous donors provide semen to sperm banks. All donor sperm and embryos derived from donated oocytes are frozen and quarantined as the donor undergoes screening for infectious diseases such as HIV.
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