CAUSES OF MALE INFERTILITY
Male Factor Treatment
Male partners with low sperm counts and/or low sperm motility and/or abnormally shaped sperm and/or have antibodies against their own sperm, are classified as “male factor” patients.
Specialists in male infertility are called Andrologists and you may need to consult one prior to commencing IVF treatment.
Causes of Male Infertility
Male infertility is very common. About one in twenty men is sub fertile and a male factor is present in half of all infertile couples. About one third of all IVF procedures are performed for male factor infertility. For most men the discovery that they are infertile comes as a total surprise.
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 well being. All these things can be described as ‘virility’. The second function of the testis is to produce millions of sperms everyday, 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.
Most infertile men produce low number of sperms which may also show both poor swimming ability (called motility) and be abnormally shaped. In such men, only a small number of normally shaped motile sperm are likely to swim up the woman’s fallopian tube into the vicinity of the egg and even then may be unable to fertilise the egg.
Why does this problem develop? We now believe that most cases are genetic. In other words, these men are born without the genetic information which would allow sperm production to occur normally. In collaboration with Monash University we have been researching this issue. In some infertile men, small pieces of the Y (so called male) chromosome are missing that include genetic information essential for sperm production, or other chromosomal problems are discovered. Yet in the majority we don’t know the genes involved and more research is needed. 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 diseases 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. Such antibodies can only be found using a special test on fresh sperm and is available only in specialised laboratories including that at PFRC. The testis can be damaged by a wide number of treatments including chemotherapy or X-Ray therapy.
Some men have difficulties in obtaining an erection or in ejaculation due to a wide range of problems such as diabetes, MS, or previous prostate surgery. in such settings, other treatments may not be available but sperm can be often found and successfully 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.
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.
Artificial insemination involves the insertion of the male partner’s semen into the female partner’s uterus in order to improve the chances of pregnancy.
INDICATIONS FOR AI INCLUDE
Mechanical difficulties with intercourse, eg failure to achieve an erection, structural problems of the penis following trauma, etc. The semen analysis needs to be normal Contact allergy to semen (very rarely) Using stored frozen semen if male partner is absent for long periods of time. It is not the method of choice where there is any severe problem with the semen analysis
The female partner’s menstrual cycles are tracked to ensure insemination is performed on the day of ovulation. This is done by detecting the LH surge in blood or urine. Drug stimulation is not used unless the woman does not have regular menstrual cycles.
Blood test to assess hormones & semen analysis done for male partner and if found defective, Scrotal Doppler is done.
INTRA CYTOPLASMIC SPERM INJECTION – (ICSI)
- Medical treatment with hormones, antioxidants, coenzyme-Q have been tried with varying degrees of success.
- Intra-cytoplasmic sperm injection, commonly referred to as ICSI, is a well-established microinjection technique, which has resulted in additional options for male fertility treatement.
- ICSI involves the injection of a single selected sperm directly into the cytoplasm of a mature egg, bypassing all the preliminary steps of sperm binding.
- This procedure overcomes many barriers to fertilisation which can include failed fertilisation from repeated use of conventional IVF, severe male factor infertility, very low sperm counts and/or motility, high number of morphologically abnormal sperm, utilisation of surgically retrieved sperm, use of frozen sperm when limited in number and quality.
- The first human pregnancy with ICSI was reported in 1992 and since this time thousands of babies have been born as a result of the ICSI procedure, providing many couples with hope which was previously not available.
Semen specimens are usually produced by masturbation into a small sterile container. Specimens may be collected at PFRC Collection room or off – site, provided the Specimen is delivered to the laboratory within 45 minutes of collection. We have four special collection rooms where you can take your wife along with you. The ambience will be good and comfortable for you to produce your semen sample. Please contact our staff directly over phone if your circumstances require alternate arrangements.
Storage of semen can be done for those patients whose husbands cannot be present on the day of egg collection, for those who have to undergo chemotherapy and also for those who have difficulty in producing the semen sample,. It can be stored for many years with periodical renewal. It is recommended that you have another semen analysis done about 2 years after your treatment or after having a baby. If analysis results are satisfactory, you may wish to cease storage.
To minimize the risks of viral contamination during storage, it is necessary to have screening tests like semen culture, Hepatitis B, Hepatitis C and HIV ( AIDS) performed prior to storage. Your specialist might have already performed those, otherwise we will organize testing for you.
Semen freezing and storage fee information is available from PFRC. Costs for Semen analysis, freezing and 6 monthly storage can be obtained from PFRC on request.
Sperms can be obtained directly from the testis using testicular biopsy. The most common reason for this procedure to be undertaken is the obstruction to the sperm transport system.
As a result, no sperm are present in the ejaculate, However, large number of sperms may still be produced in the testis. This situation can be congenital or can follow scarring and blocking of the fine tubules that lead from the testis as a result of infection or after vasectomy.
In some patients, a fine needle biopsy is performed. Local anaesthetic is placed above the testis and as a result, the skin and the testis itself becomes numb. A fine needle is then placed through the skin into the testis and a small piece of tissue (perhaps the size of half a grain of rice) is removed, or sperm may be removed directly from the epididymis. The embryologist then examines the fine tubes contained in the biopsy sample and removes sperm for the microinjection procedure. The fine needle biopsy takes about fifteen minutes. Occasionally left over sperm can be frozen and used for subsequent microinjection cycles. Alternatively the biopsy can be performed again. The results of the microinjection procedure using testicular sperm in such cases are good (approximately 55% clinical pregnancy rate per cycle).
This procedure performed under local anaesthetic may not be used at all sites.
Another indication for testicular biopsy is in men with severely damaged testis in whom few sperm are produced and none are available in the ejaculate. In this setting a larger biopsy of the testis is performed under a general anaesthetic and in 50% of cases, adequate sperm numbers can be obtained by carefully processing the biopsy tissue to find the small “islands” of sperm production that persist, despite damage elsewhere in the testis. In cases where no sperms are found, couples must consider whether to discard the eggs , freeze the eggs or use donor sperm.
THE RANGE OF TESTS INCLUDE
- Reproductive Endocrinology : Progesterone, LH, FSH, Prolactin, Testosterone, HCG and pregnancy testing. Additional tests are continually being evaluated and added to our reproductive hormone menu.
- Serology : Hepatitis B Surface Antigen, Hepatitis C, HIV, Rubella, Varicella and CA-125.
- Semen Analysis : Is done according to World Health Organization guidelines including sperm morphology and competence leucocyte assessments etc.
- CASA(Computer Aided Semen Analysis): CASA is designed with phase contrast microscope and is provided for performing reliable assessment of sperm movement pattern and morphological characteristics in semen.
- Sperm Antibody Testing : An essential first line of investigation using the immunobead testing of spermatozoa (direct assessment) and serum (indirect assessment). The laboratory provides a referral service for sperm antibody assessments from other major diagnostic laboratories nearby.
- Specialised Andrology Procedures : Retrograde Ejaculation Assessments.
- SPERM DNA FRAGMENTATION Sperm DNA fragmentation is the physical breaking of one or both DNA strands in sperm chromosomes. So a DNA test is done to find the DNA Integrity to identify men who are at risk of failing to initiate pregnancy. This is treatable if it was induced by life style, smoking, alcohol or by varicocele.
- Scrotal Doppler to assess blood flow and diagnose varicocele.
- Y Chromosome Deletion Test : Loss of large regions of the Y chromosome (called deletions) are the most significant genetic cause of male infertility after Klinefelter’s Syndrome (XXY). Up to 15% of men with sperm counts of less than 5 million per ml have Y chromosome deletions. Monash Reproductive Pathology and Genetics offers Y chromosome testing to many IVF clinics throughout Australia. Our test requires a 10ml of blood and testing is performed according to European guidelines using a technique called multiplex PCR. The finding of a Y chromosome deletion has important implications. First, a positive test will provide a firm diagnosis of the man’s problem which for some couples with long standing infertility can help resolve stress, blame or feelings of guilt. Second, Y chromosome deletions are transmitted to male offspring by ICSI and thus may cause a similar infertility problem in boys as they approach adulthood. If the male partner is found to be positive for a Y chromosome deletion, genetic counseling is highly recommended prior to commencing an ART cycle.
- Semen Cryopreservation : For patients who are undergoing a procedure that may impair fertility for example, prior to vasectomy or chemo-/ radio-therapy. This large cryostorage service has been in operation for 20 years and complies with Infertility Treatment Authority and Reproductive Technology Accreditation Committee requirements.
NEWER TECHNOLOGY IN MALE INFERTILITY
Azoospermia is a condition in which there are no sperms seen in semen analysis even after pellet preparation. Some of these patients undergo testicular biopsy for diagnostic and therapeutic purposes. Until now biopsy was done only in a single site however recently it has been shown that even if the majority of the testes does not have spermatogenesis there can be focal areas of sperm production which can be missed with single site biopsy technique. Now we have started doing testicular mapping which is taking biopsy from multiple sites to enable us to identify these focal areas of sperm production. As the technique of assisted reproduction is advancing even a few sperms can be utilised for ICSI/IMSI. At Prashanth fertility centre we have started doing testicular mapping with the aid of an operating microscope. The advantage of this is the trauma to the testis is minimised and the incisions on the testis are small. With this technique we will be able to map the testis more extensively thus increasing the chance of finding these focal areas of sperm production.