Anne Borkowski, MD, Board Certified Reproductive Endocrinologist,
North Shore Fertility, Skokie, ILL
Infertility
affects 1 in 12 couples. Male
factor infertility is a component of approximately
40% of these cases. Less that 10% of male factor infertility
can be treated successfully with medical or surgical
modalities. The best therapies for over 90% of male
infertility patients are controlled ovarian hyperstimulation
with intrauterine inseminations or in vitro fertilization.
The
problem for some couples is one of numbers. A normal
ejaculate contains over 40 million sperm. Of this large
number, only a few hundred will reach the fallopian
tubes. If there is a decrease in the initial number
of normal sperm, there may be too few sperm reaching
the fallopian tubes to make fertilization likely. The
purpose of intrauterine inseminations (IUIs) is to achieve
a higher concentration of sperm in the fallopian tubes.
Placing
sperm into the uterine cavity involves coordination
of the therapy with that of the female in one of three
ways: natural cycles, clomiphene citrate induced cycles,
or gonadotropin stimulated cycles. There is considerable
controversy over the use of unstimulated cycles with
IUIs for male factor infertility. Overall pregnancy
rates are low (approx. 4% per cycle). Most pregnancies
occur within the first three to four cycles; therefore
the number of unstimulated IUI cycles should be limited.
The
use of Clomid with IUIs
is based on the assumption that the release of more
oocytes leads to a greater chance for pregnancy. However,
pregnancy rates with clomiphene remain low (approx.
5% per cycle)), and occur within the first 3 cycles.
Gonadotropin stimulation with IUIs does offer an increased
pregnancy rate over other protocols (approx. 9%). Still,
pregnancies tend to occur within 3 cycles. Since pregnancy
rates are much higher with IVF combined with intracytoplasmic
sperm injection (ICSI)
for male factor infertility, couples often resort to
this as a first line therapy. ICSI has revolutionized
the treatment of male factor infertility so much that
when doing IVF with ICSI, female factors and not male
factors determine outcome. Routine fertilization rates
of more than 66% of oocytes are obtained with ICSI using
sperm from men with triple sperm defects (i.e. count,
motility, morphology). Clinical pregnancy rates are
greater than 28% per cycle. To date there is no increased
incidence of congenital malformations in children born
as a result of ICSI. However, there are concerns that
because some causes of male infertility are unexplained
and may be genetic, male offspring might have reproductive
problems as adults.
Since
the introduction of ICSI, treatment of most men with
azoospermia is now possible, even if the azoospermia
is caused by testicular failure. Before initiating treatment
it is important to determine whether the lack of sperm
in the ejaculate is from retrograde ejaculation, an
obstructive process, or a non-obstructive process. Evaluation
of the post ejaculate urine is necessary to diagnose
retrograde ejaculation. Sperm may be isolated from urine
or catheterized from the bladder and used for IUI or
IVF. Men with obstructive azoospermia typically have
normal volume testis with bilaterally indurated epididmii
or absent vas deferens, which is frequently found in
men who carry the cystic fibrosis gene mutation. Men
with non-obstructive azoospermia usually have small,
soft testis and elevated FSH levels.
The
two procedures that are most commonly used to retrieve
sperm from azoospermic men are the testicular sperm
aspiration (TESA) and the midepididymal sperm aspiration
(MESA) procedures. TESA is an open testicular biopsy
during which about 500 mgs of testicular tissue is excised
using scissors. MESA involves puncturing individual
epididymal tubules and aspiring the fluid. During both
procedures specimens are examined in the operating room
to insure an adequate number of sperm are retrieved.
In
the past, sperm aspiration procedures were performed
the same day as the oocyte aspiration. thus allowing
the use of fresh sperm for ICSI. However, cryopreservation
of epididymal and testicular sperm allows for temporal
separation of sperm retrieval procedures from oocyte
aspiration. It allows for multiple ICSI cycles without
the need for additional sperm retrieval procedures.
It also insures a couple that they will not be cancelled
the day of the oocyte aspiration due to inability to
obtain sperm from TESA/MESA.
Cryopreservation
is known to impair motility and decrease the fertilization
rate by detrimental effects on the acrosomal structure
and function. Fortunately, ICSI obviates the requirement
for sperm motility and acrosome function. Therefore,
it is not surprising that several recent studies have
shown fertilization rates using frozen-thawed sperm
combined with ICSI are as high as those with freshly
harvested sperm.
All
of the aforementioned techniques have significantly
increased the demand for male infertility services.
Sperm retrieval from men with azoospermia is now possible
with excellent pregnancy rates when combined with ICSI.
These advancements allow for fertility treatment where
the only options several years ago were donor sperm
or adoption.
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