Approximately 40% of infertility in couples is attributable to male factors, and another 20% of infertility cases involve both female and male issues. Some of the factors may be suspected or known to the couple prior to attempting conception, while most might not be anticipated. Certain medical conditions or exposure to toxins can lead to damage to the sperm producing cells or affect release of the sperm. Conditions such as undescended testes not corrected within the 1 st year of life, cystic fibrosis, diabetes, cancer or other chronic illnesses may affect sperm production and/or release. Exposure to chemotherapy, radiation, use of androgens including testosterone, DHEA and gym supplements, certain herbs as well as some prescribed over the counter medications can also inhibit sperm production. In some cases, toxin exposure or ingestion can permanently destroy the cells that produce sperm resulting in sterility. The use of hot tubs, alcohol ingestion (in excess of 7-10 drinks/week), tobacco and marijuana all have adverse effects on sperm production and function. However, in many cases, there are no known exposures, health issues or family history to account for abnormalities found at the time of a semen analysis.
Given the significant percentage of infertility cases associated with sperm abnormalities, a semen analysis should be among the first tests performed in couples experiencing infertility. As many minor, transient conditions can affect the sperm, if an abnormality is detected, generally a second semen collection and analysis is recommended to confirm the initial result.
The evaluation of the semen sample includes numerous factors including concentration (number) of sperm, motility (percentage of sperm moving or swimming) and morphology (sperm shape). Significant abnormalities in any of these parameters will decrease the likelihood of a sufficient number of sperm being able to reach or penetrate the egg.
If significant abnormalities are detected on repeated semen analysis studies, a consultation with a urologist who has special training in male infertility may be recommended. Blood work, and a physical exam and possibly a scrotal ultrasound could be suggested.
Treatment options very depending upon the results of the evaluation and degree or severity of the abnormalities found on the semen test. The most important initial steps include eliminating toxin exposures including alcohol, tobacco, illegal drugs and any form of male hormone precursers or supplements, avoiding excess heat exposure and maintaining a healthy diet including foods rich in folic acid and antioxidants (green leafy vegetables, whole grains as well as colorful fruits and vegetables). A urologic evaluation may reveal a problem that can be treated medically or surgically. If alterations in lifestyle do not improve semen parameters and no medical or physical problem contributing to the poor sperm qualities can be identified, then treatment options can include sperm concentration and placement into the uterus (intrauterine insemination/IUI) or in vitro fertilization (IVF) with injection of a single sperm into each egg (intracytoplasmic sperm injection/ICSI).
Intrauterine insemination (IUI)
Intrauterine insemination (IUI) is a process that includes collection of semen, washing away the fluids surrounding the sperm, concentrating the sperm into a small amount of media and placing the sperm through the cervix into the uterus. The sperm washing procedure can take 1 – 2 hours depending on the technique utilized. The actual insemination procedure for the woman is relatively quick and painless and feels similar to having a pap smear. The sperm is placed into the uterus past the cervix and cervical mucous. However, the sperm still must swim from the uterus to the correct fallopian tube, find the egg, attach to the egg, penetrate the egg’s shell (the zona), enter the egg and fertilize the egg. Each of these steps still requires a sufficient number of swimming sperm that are shaped normally to have a reasonable chance for success.
In Vitro Fertilization with Intracytoplasmic Sperm Injection (IVF with ICSI)
If sperm number, percentage swimming forward or normally shaped is too low the chance for successful conception with IUI will be significantly decreased. Options at that point include either the use of donor sperm or proceeding with IVF and ICSI. The procedure involves removing eggs directly from the woman’s ovaries through the vagina under ultrasound guidance using sedation anesthesia. Usually medications that stimulate the ovaries to produce numerous eggs are utilized to prepare for the procedure. After the eggs are retrieved, a single sperm, selected based on shape and motility, is drawn into a glass needle (the diameter of which is smaller than a human hair) and then injected directly into the egg. The embryologists must be highly skilled and trained in micromanipulation techniques to perform ICSI correctly. RMG’s embryologists have successfully performed thousands of ICSI procedures.
Even when no sperm is present on a semen analysis, viable sperm may be produced but remain within the testes. Men who have under gone a vasectomy or are born without a vas deferens will almost always have sperm production within the testes that is has not been released due to an obstruction that was created or exists from birth. The majority of men who do not have any sperm found on semen analysis do not have an obstruction but instead produce an insufficient amount of sperm to be present in the ejaculate or the sperm maturation process is interrupted and does not reach the level of maturity to be released. Although in some cases no sperm is produced by the testes, in many cases sufficient numbers of healthy sperm can be extracted directly from the tests to allow for fertilization of the egg during IVF with ICSI. The techniques involved with MESA/TESE are remarkable because in these cases, men who could not have fathered children naturally are now able to become a biologic parent. The sperm extraction procedure is performed under general anesthesia and must be performed by a skilled urologic surgeon with special training in testicular surgical sperm extraction techniques in a facility where the sperm can be identified and then processed appropriately, all of which is available at the RMG/IVF and Surgery Center.
Vasectomy Reversal/Sperm Freezing
The Reproductive Medicine Group offers their patients the option of freezing their sperm at the time of a scheduled vasectomy reversal. The frozen sample is sent to an approved storage facility. The Reproductive Medicine Group is the only facility in the Tampa Bay area to offer this service. By freezing the sample, the patient is assured that the specimen is available for future use in the event that the vasectomy reversal was not successful.
The Reproductive Medicine Group is pleased to announce affiliation with Dr. Howard Heidenberg, a board certified urologist with specialized training in male infertility. He trained at Walter Reed Army Medical Center, and operates a private practice in Tampa. In addition to general urology, Dr. Heidenberg is trained in the evaluation and treatment of male infertility including: vasectomy reversal, varicocele repair, and testicular biopsy and aspiration procedures for TESE and MESA.