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Male Infertility

Male Infertility 

ICSI (Intra Cytoplasmic Sperm Injection)
TESE (Testicular Sperm Extraction-testicular biopsy)

ICSI (Intra Cytoplasmic Sperm Injection)
Method of gamete micro-manipulation where a single spermatozoa is injected into the cytoplasm of the oocyte. Applied mainly in cases of severe male infertility

This method increases the chance of fertilization mainly when the man has a low number of spermatozoa and or of sub standard motility.
For many years micromanipulation of gametes (oocytes / spermatozoa) has been used to increases the chances of fertilization success of couples with a mainly male factor problem.
The most important and most successful of these is ICSI, which was pioneered in Belgium with the first successful pregnancies in 1992.The couple undergo the same treatment as a "classic" IVF attempt except for an extra laboratory technique we call ICSI.
In these cases a single spermatozoa is immobilized and injected into the oocyte by the use of a tiny needle (micro-pipette). In this way the spermatozoa is not required to pass through the surrounding cells and penetrate the oocyte as is usually the case.

New: IMSI technique (intracytoplasmic morphologically selected sperm injection) - a recently-developed innovative technique in the area of in-vitro fertilization (IVF) and complements the existing ICSI technique (intracytoplasmic sperm injection). Read more

TESE (Testicular Sperm Extraction-testicular biopsy)
In cases of azospermia (the absence of spermatozoa in the ejaculate), a testicular biopsy can tell us if there spermatogenesis (sperm production) and if the presence of spermatozoa can be found in the testes.
Often if spermatozoa cannot be observed in a semen analysis, spermatozoa can be retrieved in several regions of the testes.
The biopsy can be performed prior to IVF treatment as a diagnostic means, with the tissue frozen. Alternatively the day before or on the actual day of oocyte retrieval.
If spermatozoa are recovered with TESE then the oocytes are fertilized by the method ICSI.

		The spermatozoa can been seen attached to a supporting cell
		Magnification of the picture above

Evaluation and testing

Commonest cause
Reproduction 101
Getting Help/Evaluation

Historically, infertility has largely been attributed to the female but infact male related factors account for about 40% -female related factors relate to another 40% while a combination of male & female factors account for 10%, and the remaining 10% is due to unexplained causes. Considerable advances of recent years have led to great advances in treating male infertily.

Male infertility can be caused by a number of factors, including problems, with sperm production, blockage of the sperm delivery system, antibodies against sperm, injury to the testicle, problems relating to hormone production, and anatomical problems.

Passed illness, infections and medications can also cause infertility.

Some of the commonest causes

Lifestyle factors

Any factors which raise the temperature of the scrotum (such as the use of long baths, a job involving long hours sitting down) can harm sperm production.
Certain medicines and recreational drugs can decrease male fertility. These include alcohol, marijuana, cocaine, cigarettes, anabolic steroids, some drugs used for ulcers, anti-hypertensive drugs (specifically calcium channel blockers), aspirin, some drugs for epilepsy, and antidepressants.
These drugs should never be simply discontinued, but substitutions can be made after consulting with your primary care physician.

Hormonal imbalances

Hormone problems affecting sperm count include thyroid problems, low testosterone levels, elevated FSH, and excess prolactin.

Immune problems

Immune reactions to sperm in the man (autoimmune) can be a problem post-vasectomy, but may also have other causes. Anti-sperm antibodies can "attack" the sperm, thus preventing it from being able to fertilize the egg.

Infection

Mumps contracted after childhood, and, occasionally, venereal diseases such as gonorrhea and chlamydia can harm male fertility. Also, recurrent infections of the prostate can lower sperm count and motility.

Exposure to certain chemicals, such as lead and arsenic, and many types of paints or varnishes, can also adversely affect male fertility.

Impotence/ Sexual Dysfunction

There are a variety of medical causes that can contribute, including diabetes mellitus, medications such as antidepressants, etc. Up to 20% of men may have decreased sexual desire, inability to maintain an erection, and premature ejaculation. This could result from low testosterone or performance anxiety.

Obstruction/Blockage

Due to prior surgery or infection the vas deferens may be damaged.

Trauma to testicles

Severe injury to the testicles can result in decreased sperm production

Varicocele

An enlarged vein in the scrotum, which causes pooling of blood and an elevated temperature. Although controversial, some argue it is one of the most common and readily treatable causes of male infertility. Others say that varicocele is also common among fertile men, and question the connection with infertility and the need for treatment. In general, very large or painful varicoceles that go untreated can cause permanent damage to the testicles.
The options are either surgery to close it off, or balloon insertion to block the blood flow.

Previous Vasectomy

Vasectomies can often be reversed. However, the more time has passed, the more likely it is that the man will have an immune reaction to his own sperm and the lower the chance of being able to produce a pregnancy.

Retrograde ejaculation

Can be caused by certain medications, surgeries, and nerve damage (for example, from diabetes mellitus). Sperm goes in the wrong direction and is ejaculated into the bladder.
Sperm can be however collected in the urine, prepared and used in IVF.

Previous Cancer Treatment

Chemotherapy and radiation can cause abnormal sperm or sterility. Freezing of sperm before such therapy should be advised.

Genetic Abnormalities

Severe male factor problems can have genetic cause and a small percentage of infertile men have Klinefelter's Syndrome; they have two X chromosomes and one Y chromosome, rather than the normal one X and one Y.

Reproduction 101

How does Sperm Mature?

Sperm develop I specialized cells called sertoli cells which are found in the seminal tubules in the testes. The development process of the development process of the sperm begins with the division of very immature sperm cells called spermatogonia and proceed thru various stages to maturity. Mature cells are tadpole shaped and called spermatozoa. Spermatozoa leave the seminiferous tubules to pass into the epididimus where they acquire the ability to move.

The maturation time of spermatozoa is approximately 70 days.

Mature sperm remain in the vas deferens until the man ejaculates. As the man ejaculates, spermatozoa combine with fluid from the seminal vesicle and with a thick secretion from the prostate gland to creating sperm.
Semen is gel like but liquefies in approx 30 mins, enabling the sperm to move more effectively through the female reproductive tract to reach the oocyte.

The Egg and Sperm

Each month a single egg matures in side a follicle (cyst like structure) with the ovary. At mid-cycle the egg is released from the follicle (ovulation).
The egg travels down one of the fallopian tubes towards the uterus.
Fertilization usually takes place at the end of the fallopian tube near the uterus. It a highly random event, and at best the chance of conception is 25% in any month.

Normally millions of sperm are deposited in the vagina. However as they swim through the cervix and uterus, up the fallopian tube their numbers decline. Only a few hundred sperm will gat close to the egg.
Sperm must then penetrate the egg and fertilised the egg. Several will try but only one will succeed.

It is reported that sperm can survive for 2-3 days within the female repro tract and the length of time that a woman's egg can fertilise is from 12-24hrs.

Getting Help/Evaluation

Medical History

Consultation with a doctor will pay attention to history of diseases and illness such as viral infections, fevers or diabetes mellitus.
Also uncover childhood and development history including questions testicular abnormality or groin injury. Other factors may be important is exposure to chemicals or radiation, any recent illnesses or use of medication or recreational drugs. Laboratory Testing

A semen analysis is the study of freshly ejaculated semen sample, it does not determine whether the sperm can penetrate the egg but is useful in determining if the cause of infertility is an obvious male factor.

Tests differ from laboratory to laboratory- but generally
Normal values according to world health authority (WHO)

Volume: 2.0 ml
Sperm count per ml: 20, 000,000
Total sperm count: 40, 000,000
Total motility 50%
Rapid forward motility 25 %

The percent of morphologically normal sperm may vary dramatically according to the criteria of testing.
Human sperm has a high amount of abnormal forms of sperm even in a normal semen sample. WHO states normal ranges are 30%, while if a strict morphology method is used (viewing sperm stained with special stain to evaluate size and shape of head, mid-piece and tail) may assess a normal sample as being >14% normal forms!!!

And no significant agglutination.
And no significant levels of red and white blood cells.
PH 7.2-8.0
Although sperm count is important, sperm motility and forward progression appears to be more important factors in determining the fertilizing capability of sperm. Despite a low sperm count, many men with viable motile sperm may still be fertile.

More tests

Anti-sperm antibodies (MAR test)

Sometimes the immune system plays a role in infertility.
Antibodies attack foreign bodies in the body and fight disease and infections. Antisperm antibodies attack sperm, causing sperm to clump together loosing motility and interfering with the ability of sperm to function.
Treatments may include medication (steroids) to suppress these antibodies, sperm washing, IUI and ICSI.

Endocrine Tests

Blood test to measure the circulating hormones can give us valuable information.
FSH and LH are involved in the maintenance of sperm development and Testosterone levels.
LH stimulates the production of testosterone, while FSH is an indictor normal sperm function (in general, as sperm production decreases FSH levels increase in the blood).
Prolactin another hormone involved in influencing testosterone level may be investigated. An overproduction of this hormone results in lowered testosterone levels and impotence.
Many of these disorders can be treated by therapy such as treatment with HCG and HMG),

White blood cells

If an excess of white blood cells is found, an evaluation for possible genital tract infection is undertaken because the cells are associated with infection and/ or inflammation.
These can contribute to sperm damage but are usually easily treated.