It must be remembered that the testis has two distinct roles. The first is to produce
the male sex hormone, testosterone, which is important for providing sex drive,
erections, strong muscles and basically giving a man a general feeling of wellbeing.
The second function of the testis is to produce millions of sperm every day, a process
which occurs inside the approximately 150 metres of fine tubes in each testis. For
most infertile men it is only this process which is at fault and a reduced number
or poor quality of sperm are produced.
Why does this problem develop? We now believe that many of these cases are genetic.
In other words, these men are born without the genetic information which would allow
sperm production to occur normally. Small pieces of the Y, or so called male chromosome
are often missing in men with severe infertility. Presumably these missing pieces
of genetic information are the cause for the poor sperm production. But we need
much more research before we can point to particular genes. Without that knowledge
no treatment for men to improve sperm counts is likely to become available. IVF
techniques offer hope now as they require very much fewer normal sperm than does
Nature.
In the remaining one third of infertile men, we can find a likely cause for
their infertility including
- Obstruction to the passage of
sperm from the back of the testis to the outside can result from blockage or absence
of the vas deferens. Common causes include, obviously, vasectomy, but any history
of injury, and other surgery or sexually transmitted disease may be important.
- Men can make antibodies to their
sperm following vasectomy or other trauma or infection. These antibodies are a common
cause of infertility and prevent sperm swimming or sticking to the egg. The testis
can be damaged by a wide number of treatments including chemotherapy or X-Ray therapy..
- Some men have difficulties obtaining
an erection, or in ejaculating due to a wide range of problems such as diabetes,
MS, or previous prostate surgery. In these cases sperm can be found and used for
IVF.
- Rarely, a deficiency in the brain
pituitary hormones may result in low sperm counts. Its detection is important as
it is readily treated with hormone injections.
- Finally there remains great controversy
as to whether sperm counts have declined worldwide. The alleged change is quite
small (about 15%) and no cause has been confidently identified.
- In conclusion while the causes
of infertility are uncertain in many men, certain conditions can be identified and
treated. These facts make it essential that all infertile men have their situation
thoroughly investigated.
The basic male investigation begins with a detailed history and physical examination
by our Andrologist. Semen analysis and serum hormonal profile (FSH, LH, Testosterone,
Prolactin and TSH) represent the first line investigations. History of hernia surgery
or mumps in childhood, lifestyle (excessive exercise or steam/sauna), sexually transmitted
infections or trauma will all be noted. Use of medication, alcohol, drugs and occupational
and environmental exposure to toxins such as heat and other chemicals will also
be recorded.
The semen analysis is the first basic investigation. The sample should be collected
by masturbation after 2-7 days of abstinence (no sexual intercourse or masturbation).
In exceptional circumstances, semen may be produced at home or during sexual intercourse
using a special condom. The sample must be submitted within an hour after ejaculation.
Sperm counts of > 15 million/ml with >40% motility and > 4% normal morphology forms
are considered normal.
The andrologist might suggest further investigations such as a color Doppler of
the scrotum or certain dye tests such as vasography for accurate diagnosis.
From an IVF perspective we often recommend testing of the sperm DNA fragmentation (SDF) also known as DNA fragmentation index (DFI) especially for cases of poor sperm count, motility and morphology, patients with unexplained infertility, recurrent miscarriages or even unexplained repeated IVF failures.
Some conditions can be treated medically (such as hormone deficiencies) or surgically (varicocelectomy). If these fail to result in pregnancy you would be advised further treatment with IUI or finally ICSI which is the most successful treatment for almost all types of male factor infertility.
IVF RELATED TREATMENT OPTIONS
PESA-ICSI: In case of congenital absence of vas deferens (zero sperm counts with normal sperm production in testes) and other obstructive pathologies, sperm can be retrieved from the epididymis by a procedure called PESA. These sperm are then injected into the eggs with ICSI to produce embryos
TESA-ICSI: In case of testicular failure (zero sperm counts with normal or elevated FSH levels), sperm can be retrieved by needle biopsies (up to 6 per testicle) directly from the testes and used for ICSI.
Elevated Sperm DNA Fragmentation: Here, the husband would be prescribed antioxidants and other medication. Also, he would need to quit smoking and control his sugars if any. Thereafter, for these men, we ask for two ejaculates on the day of the egg retrieval. Usually the second sample will contain sperms with better DNA integrity. These are then processed on a special ZYMOT chip (micro cell sorter) to separate good and bad sperm. The good sperm are then used for ICSI. If the DNA fragmentation is very high then TESA sperm is often better than ejaculated sperm for best outcomes.
MICROTESA – ICSI: For severe cases of azoospermia where FSH levels are very high and testicles are very small in size, microtesa using an operating microscope could help retrieve sperm.
Very rarely, in some cases of primary testicular failure with elevated FSH levels
where even microdissection TESA fails to yield sperm you might have to resort to
a semen bank and avail of donor sperm for pregnancy.