MALE INFERTILITY - a patient's guide
This article discusses the latest technology in treatment options for male infertility, including the Intracytoplasmic Sperm Injection and donor insemination.
Male factors appear to be increasingly recognised as a cause of infertility. About 4 percent of men will have significantly abnormal semen tests. Some of these will be due to decrease in concentration and a significant number will be due to a decrease in motility (the ability of the sperm to move). More commonly these days we are recognising changes in morphology (the way sperm are structured) so that large numbers of abnormal forms of sperm are seen.
Not all men with abnormal semen tests will have problems conceiving and in fact many men whose random tests are abnormal have an entirely normal fertility history.
There is enormous variation from sample to sample and month to month in each of the parameters mentioned above. What is important is what range the counts are in rather than what the absolute number is. If a normal sperm count is above 20 million/ml and one month it is 25 million/ml and the next 35 million/ml, there is no real difference in the effect on fertility.
Equally if the count is reduced at 1 million/ml and two months later it is 5 million/ml, likewise, there is unlikely to be an effect. Random variation is the norm and small changes over time should not be seen as being progression or regression.
With a very few exceptions, in specific hormone problems, there are no recognised treatments that will improve sperm count motility or morphology. A vast array of injections, tablets, pills, herbs and vitamins have been tried without anything having been shown to be useful. The modern management of male-based fertility problems uses what sperm is present in new and inventive ways.
The introduction of Intracytoplasmic Sperm Injection (ICSI) over the past five years has revolutionised the management of male infertility. It offers hope of a genetic child to almost all couples with male-based infertility. However, since in about 75 percent of couples with male-based infertility the man has some sperm present in his ejaculate, the discussion revolves around when to move to treatment rather than what treatment.
Unfortunately it is still rare to be able to offer treatment to increase the sperm count or quality and so most treatment options are based on using the sperm that are available in the most likely way to cause fertilisation of an egg.
Cumulative pregnancy rates after 5 to 15 years reach 50 percent in many studies of untreated male infertility for all but the most impaired semen quality. Pregnancies still occur but at a lower rate than normal and the probability will be influenced by the female's fertility as well. Mild endometriosis that normally would have little impact on a woman's chance of becoming pregnant, may have a major effect if her partner has a low sperm count. Therefore, one must always investigate the woman as well to see if there is a factor that can be treated unless the sperm quality is very poor.
The variability that occurs in semen quality from day to day in an individual is poorly understood but the fluctuation may be of marked degree. This variability often leads to people believing that a treatment used has been effective. Although many treatments, ranging from hormonal through herbal to nutritional supplements such as zinc and vitamin E are used, there is little scientific evidence to support their use.
The "better" the semen quality, the higher will be the chances of a spontaneous pregnancy over time but as yet, there is no accurate method of assessing the chance of a pregnancy by time for a particular couple. Time "trying" is the best predictor but now this is often not useful since most couples see their doctor early on in their infertility.
Types of male infertility for which there are cures are uncommon and the treatments are not highly successful. Gluco-corticoid therapy for sperm auto-immunity and gonadotrophin treatment for gonadotrophin deficiency result in only about 50 percent of couples having children.
Although some problems with intercourse are treated easily and in others artificial insemination can be used with success, treatment results of neurological conditions such as spinal cord injury are poor.
Treatment of varicoceles, low-grade infections, stress or heat exposure, generally has no dramatic or continuing beneficial effect. Reconstructive surgery for epididymal obstruction should always be considered since a micro surgical vaso-epididymostomy can offer up to a 30 percent chance of a pregnancy and of course can be curative.
An increasing number of men are presenting for treatment who have had a vasectomy. There is a clear-cut correlation between the chance of a pregnancy and the length of time since the vasectomy - the shorter the interval the better the outcome. If the interval is less than three years one can expect 70 percent of couples to achieve a pregnancy whereas if over 14 years then only 30 percent will have success. However, whatever the interval length, a reversal is usually best tried before IVF and if the outlook is poor then sperm can be collected from the epididymis at the time of the reversal and frozen for later use in IVF.
The simplest "high tech" treatment for male infertility is artificial insemination of prepared sperm in conjunction with mild ovarian stimulation of the woman (AIH/S). When more than one million motile sperm can be retrieved after a sperm wash, it is associated with up to a 10 percent chance of a pregnancy per cycle. Most pregnancies occur within the first three cycles. Pregnancy rates depend on the number of sperm inseminated and the number of follicles stimulated.
Intracytoplasmic Sperm Injection (ICSI)
Unfortunately, for most couples with male-based infertility, sperm quality is too poor to consider AIH/S. Those who wish to have treatment have to decide between the high-tech, high-cost option of IVF/ICSI or the low-tech, low-cost option of donor insemination. Before the advent of ICSI, the difficulty with IVF was trying to predict whether or not fertilisation would occur. Now ICSI gives rise to the same fertilisation rate as conventional IVF and if there is any doubt as to sperm quality, we advise ICSI.
Most men with azoospermia have some sperm in the epididymis or testis that can be retrieved for ICSI. The difficulty is trying to predict in which men with "non-obstructive azoospermia" sperm can be retrieved. This term refers to men who may have sperm production in the testes but the number produced is too few for them to appear in the ejaculate. The differentiation between obstructive and non-obstructive can usually be made on physical examination and a FSH level. Occasionally, a testicular biopsy will be necessary to be sure.
At least some and perhaps half of male infertility has a genetic basis, and male children may inherit their fathers' infertility. There are already tests for some of these genetic causes, and more are expected in the coming years.
The chance of pregnancy per embryo is at least as high with ICSI as with conventional IVF. The cumulative chance of a live birth following four cycles of IVF is 70 percent but few couples are able to undergo this number of treatments because of the cost, either emotional or financial. Therefore, many couples will still choose donor insemination, either in preference to IVF or following one or two failed cycles of IVF.
Provided the couple is comfortable with the use of a donor, this option can be most successful with up to an 80 percent chance of a family. Semen from the donor must be frozen and the donor tested for HIV six months after his donation to exclude the possibility of transmission of HIV. Ovulation can be detected either through LH blood testing or the use of a urinary LH kit. Up to a 20 percent chance of a pregnancy per cycle is expected.
The passing of the Status of Children Amendment Act in 1987 enables donors to be identifiable and in fact, all donors recruited by clinics in New Zealand have to agree to be identifiable to the child at a later date. Most couples who request a second child reserve semen from the same donor so that the children are full siblings.
Although assisted reproductive technology will help many infertile men have children, it does not treat their condition. Over the last 20 years there has been a huge increase in the information available regarding the physiology of sperm production but unfortunately this has not been translated into cures for male-based infertility. Indeed, there is very strong evidence that the majority of male infertility is genetically based, so that for the foreseeable future we will continue to make better use of the sperm that there are, rather than improving their number or quality.