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Infertility Encyclopedia
Assisted Reproductive Technologies (ART)
Evaluation
| You can order a semen analysis to know your baseline fertility. |
Neurologic Evaluation
Neurologic evaluation is essential in men who are infertile because of impotence, spinal cord injury, other injury involving the nervous system (for example, surgical damage of the nerves that supply the penis), or suspected neurologic disease. To assess risk factors for neurologic disease, the physician first will take a careful medical history. This will help to identify related disorders such as hypertension (high blood pressure), diabetes, cardiovascular disease, and bowel or bladder disease.
Next, tests for neurologic deficit (reduced nerve activity) will be performed. Deep tendon reflexes will be measured in the lower limbs. In addition, the physician may want to measure "evoked responses" - electrically stimulated responses that indicate the function of the nerve pathways. The sacral evoked response, also known as sacral latency, measures the bulbocavernosus (penis muscle) reflex.
Nocturnal penile tumescence test (NPT)
If there is still doubt about a man's neurological status, the physician may perform the nocturnal penile tumescence test (NPT). A strain gauge device is used to measure normal tumescence (swelling) and rigidity of the individual's penis during sleep. In general, vascular (blood vessel-related) impotence is unlikely if there is normal tumescence and rigidity during sleep. The NPT is particularly helpful to physicians who are trying to distinguish psychological from nonpsychological causes of erectile dysfunction.
Drug Therapy
Drug therapy for male infertility includes substances designed to improve sperm production such as hormone supplements for endocrine system disorders, antibiotics for fertility-impairing infections and immunologic agents, and medication to promote and control ejaculation.
Testosterone
Hormonal abnormalities as the primary cause of male infertility occur in some men presenting for evaluation. Symptoms associated with low testosterone include fatigue, decresased sexual interest, and poor concentration. A low testosterone causes low sperm production and can cause problems with erections and ejaculation. Testosterone replacement is very important because it restores sperm production and significantly increases the quality of life.
Clomiphene Citrate
Clomiphene citrate, a synthetic steroid drug related to estrogen (female sex hormone), has both anti-estrogenic and estrogenic effects. In men with oligospermia (low sperm count), clomiphene has been used to increase gonadotropin secretion, which, in turn, may stimulate testosterone release and improve sperm output. Yet the male response to the drug is not as pronounced as that seen in women. Clomiphene usually is given in oral daily doses of 25-50 mg for a 3- to 6-month period. However, the results from clomiphene trials are extremely variable, with differing success rates for conception. Therefore, this drug needs to be used very selectively in the inferfile male.
Tamoxifen
Tamoxifen, like clomiphene citrate, is an oral anti-estrogen compound that has been used to treat male infertility. But, unlike clomiphene, tamoxifen has no estrogenic activity. Tamoxifen stimulates sperm output by increasing the release of gonadotropins. In current studies, the most common oral dosage is 20 mg daily. As with clomiphene, some men respond favorably to tamoxifen and show improved semen quality and increased rates of conception; however, there are still questions regarding which patient groups are most likely to be helped by tamoxifen therapy. Recent findings suggest that pregnancy may occur in up to one-third of couples in whom the male partner has received tamoxifen therapy.
Gonadotropins
Gonadotropins are gonad-stimulating hormones. The gonadotropins human chorionic gonadotropin (HCG), human menopausal gonadotropin (HMG), and their combinations very successfully treat men with hypogonadotropic hypogonadism (delayed sexual maturity due to sex hormone deficiency). Both HCG and HMG stimulate testosterone synthesis, which, in turn, improves sperm production and pregnancy rates. Gonadotropin therapy also has been tested in men with oligospermia (low sperm count) due to unknown causes. For these men, HCG and/or HMG therapy may or may not improve fertility. Given the expense of such therapy and potential difficulty of administration (HMG requires injection), most specialists do not recommend gonadotropin therapy for oligospermic patients.
Antibiotics
Antibiotics frequently are prescribed to eliminate infections that could impair fertility, such as infections of the urinary tract and prostate. The physician will be especially inclined to prescribe an antibiotic if leukocytes (white blood cells) are detected in the man's semen sample. Antibiotics usually are administered for intervals of 1 to 3 months. Nitrofuran antibiotics are avoided, since they may impair sperm maturation. STDs, such as gonorrhea or ureaplasma, commonly are treated with ceftriaxone sodium or doxycycline.
Methylprednisolone
Methylprednisolone is a corticosteroid medication that has been prescribed as a treatment for immunologic infertility. In particular, methylprednisone is used to suppress blood levels of antisperm antibodies. In men, the drug is given a specific number of days before the female partner's time of ovulation (fertile period). Methylprednisolone therapy is very controversial, since, with the high doses required (96 mg daily), it can produce many side effects that are associated with other forms of steroid therapy - that is, worsened peptic ulcer disease, skin disorders, glucose intolerance (inability to metabolize the sugar glucose) and mental disorders. Success rates are varied, but very few studies have shown much benefit.
Bromocriptine
Bromocriptine is a drug that is classified as a dopamine agonist. This means that bromocriptine acts like dopamine, a catecholamine (sympathetic nervous system chemical) that stops the release of prolactin hormone from the pituitary gland. Bromocriptine therapy is useful for men in whom impaired sperm production is due to hyperprolactinemia (high blood level of prolactin) (see also Hyperprolactinemia).The customary daily dose of bromocriptine is 5-10 mg. The side effects of bromocriptine therapy include high blood pressure, headache, dizziness, nausea, and vomiting.
Surgical Therapy
Surgery is appropriate for the treatment of male infertility due to genital tract obstruction, varicocele (enlarged, "varicose" vein in the scrotum), or previous vasectomy.
Vasoepididymostomy
Vasoepididymostomoy is a microsurgical procedure that uses a microscopic camera and very small operative tools to correct obstructions in the genital tract. The procedure requires removal of the blockage in the epididymis (the coiled tube that extends the length of each testis and connects with a larger duct - the vas deferens) and re-attachment of the epididymis to the vas deferens. Vasoepididymostomy may improve pregnancy rates by up to one-third of all patients; however, the success of vasoepididymostomy is dependent upon the experience and technical expertise of the microsurgeon. Classic signs of epididymal "blockage" are a swollen top of the epididymis, the presence of sperm in semen drawn from the obstructed segment, and otherwise normal testes. Blockages frequently arise in the epididymis because of inflammation due to sexually transmitted diseases (STDs). Gonorrhea is an STD that, if left untreated, is likely to damage the epididymis and produce obstruction. Other, rarer causes of obstruction include cysts, inherited atresia (tubal closure), and genital tuberculosis. Vasectomy (a contraceptive procedure involving surgical removal of a portion of the vas deferens) currently is the leading cause of infertility secondary to genital tract obstruction. There is an increased likelihood of epididymal blockage among men who have had vasectomies of more than 10 years duration.
Varicocelectomy
Varicocelectomy - the cutting away of a varicocele - is usually performed with regional or general anesthesia. The surgeon makes an incision into the groin, and the problematic venous system then is repaired. The venous channels are divided to prevent varicocele recurrence, and the external cremasteric vessels (the veins associated with the testis-elevating muscle) also are tied off and divided. Varicocele repair often dramatically increases semen quality and pregnancy rates in infertile couples. The major complications of varicocelectomy are varicocele recurrence and formation of hydrocele (collection of fluid in a contained area). However, newer microsurgical techniques have substantially limited these complications.
Vasovasostomy
Vasovasostomy, otherwise known as vasectomy reversal, is the re-connection of the severed ends of the vas deferens. This procedure, like vasoepididymostomy, commonly is conducted using microsurgical methods. However, nonmicroscopic, "macrosurgical" techniques also are successfully employed. Most vasectomy reversal procedures are conducted on an outpatient basis.
During microsurgical vasovasostomy, most surgeons use a "two-layer" technique in which both the inside and outside layers of the severed tubules are reconnected with tiny sutures. Close attention is paid to the character of the fluid that is obtained from the testicular end of the vas: if the fluid is clear and colorless and if sperm are present, the results of vasovasostomy usually are favorable. By contrast, if the fluid is thick or creamy and if sperm are absent, a vasoepididymostomy usually is performed rather than a vasovasostomy.
The complications experienced after vasovasostomy are infrequent and minor. After vasovasostomy, some men are found to produce antisperm antibodies - immune system molecules that lessen the fertilizing potential of sperm. The antibody production is a result of the vasectomy. Some physicians recommend the collection and freezing of sperm from the site of vasectomy reversal in the event that sperm are abnormal or sperm output is inadequate after successful reconnection of the vas. The Male Reproductive Clinic provides sperm freezing services after vasectomy reversal.
Assisted Reproductive Technologies (ART)
The new forms of fertility treatment - collectively known as Assisted Reproductive Technologies (ART) - incorporate many methods of sperm retrieval and preparation. Once the sperm have been processed to ensure optimal fertilizing potential, they are used in a variety of procedures that aid the process of conception. These procedures include artificial insemination (AI), in vitro fertilization (IVF), and sperm microinjection techniques.
Sperm Retrieval
Sperm retrieval is not limited to ejaculated semen. With today's technology, sperm can be obtained from men with azoospermia (lack of sperm) that is caused by an obstructive lesion, failed vasectomy reversal, inherited absence of the vas deferens, or other uncorrectable blockage.
For example, applying microsurgical methods in a process known as micro epididymal sperm aspiration (MESA), sperm can be gathered close to the blocked portion of the epididymis, the elongated, coiled duct that provides for the maturation, storage, and passage of sperm from each testis. Similarly, percutaneous epididymal sperm aspiration (PESA) uses a small needle to penetrate the testicular skin and draw sperm from the area near the epididymal obstruction. Testicular sperm extraction (TESE), the removal of a small amount of testicular tissue under local anesthesia, also can be a source of sperm. Sperm retrieval methods usually are scheduled to coincide with the female partner's time of ovulation, so that they may be used for in vitro fertilization (IVF) of a retrieved egg. Sperm that is retrieved by MESA, PESA or TESE then can be processed for use in procedures such as intracytoplasmic sperm injection (ICSI) (see also Intracytoplasmic Sperm Injection). While excess sperm from MESA or PESA usually can be frozen for future use, most TESE-derived sperm are not of sufficient quality or quantity for frozen storage (cryopreservation). Multiple MESA or PESA procedures are not recommended, since repeated surgery can lead to scarring around the site of incision.
Most patients are advised to wear scrotal supports for 1 week following MESA, PESA or TESE. Side effects are rare, although postoperative pain and swelling may persist for up to 2 weeks.
Details about the options for sperm retrieval, including success rates and cost differences, are available on a separate page developed by Dr. Williams.
Sperm Washing
Sperm washing is used extensively for the treatment of semen with low sperm counts, abnormal sperm forms, antibodies, and other fertility-impairing features. The "washing" is accomplished by adding culture medium (a fluid containing nutrients and buffers) to the semen and spinning the entire sample in a centrifuge (a machine that uses centrifugal force to separate heavier and lighter elements in a solution). The heavy sperm "pellet" is then rewashed in culture medium. If the physician needs a "rise" or "swim-up" fraction of the most active sperm, the concentrated sperm sample is incubated for about 1 hour, and the swimming sperm are extracted from the top of the test tube. If the physician wants to enhance the fertile potential of the sperm, TEST-yolk buffer (a special solution containing buffers, chicken egg yolk, glucose and antibiotics) may be used during the washing and pellet dilution procedures. The sperm that are gathered from such washing methods are subsequently used for artificial insemination and in vitro fertilization procedures.
Artificial Insemination
Artificial insemination (AI) is a process which deposits a large number of healthy sperm in a woman by artificial means. The sperm are placed either at the entrance to the cervix or directly into the uterus near the fallopian tubes (intrauterine insemination or IUI). Artificial insemination is useful when the male partner's sperm count is low or when sperm quality is below average (e.g., in cases of spinal cord injury, ejaculation disorder or impotence). The sperm can be prepared by washing and concentration to ensure the best chance of conception. Artificial insemination can be performed using sperm from a donor.
Intrauterine inseminations are performed at the Male Reproductive Clinic after the sperm has been maximized. This can be accomplished by treating any male condition causing a poor semen sample or by special processing of the sperm. The best quality sperm is needed for intrauterine insemination because the success of intrauterine insemination is directly related to the quality of sperm.
In Vitro Fertilization
In vitro fertilization (IVF) is the fertilization of an egg in the laboratory. Using a variety of hormonal drugs, the woman's ovaries are "super stimulated" to produce eggs. Then, many mature eggs are gathered from the ovaries, and they are fertilized in the laboratory using the man's sperm. Two methods are used to collect the eggs. Transvaginal aspiration is an ultrasound-guided technique in which the eggs are aspirated (drawn out) via the vagina; this procedure also is known as TV collection. Laparoscopy is a second method in which an incision through the abdomen is made to extract the eggs.
Once the eggs have been collected, they are placed in a special fluid and are incubated with the man's semen. After the eggs are fertilized (roughly 48 hours after collection), they are replaced inside the woman's uterus.
| IVF success rates can vary significantly amongst clinics and patient age groups. To understand if in vitro fertilization is right for you, please visit the national reporting data bank website for success rates. |
Intracytoplasmic Sperm Injection
Intracytoplasmic sperm injection (ICSI) is an IVF procedure in which a single healthy sperm is injected directly into the egg. ICSI is useful when the man's sperm count is very low or many sperm are abnormal or immotile. A tiny injection pipette is used to pass the sperm through the zona pellucida (outside layer) of the egg into its ooplasm (central substance). In general, ICSI is performed on several eggs. Once they have been fertilized, they are replaced inside the woman's uterus after a period of about 48 hours.
Gamete Intrafallopian Transfer
Gamete intrafallopian transfer (GIFT) is an ART procedure in which the egg and sperm (gametes) are placed together within the fallopian tubes. Like IVF, GIFT requires prior, hormone-induced "super stimulation" of the woman's ovaries to produce mature eggs. The eggs then are retrieved from the woman by laparotomy, a surgical incision through the abdomen. After a number of mature eggs have been collected, they are combined with sperm which, as in IVF, has been treated to concentrate the most healthy and active cells. Finally, the gametes are transferred back into the fallopian tubes, where fertilization should take place. Any embryos that result from this procedure will naturally descend into the uterus for implantation.
Electroejaculation
Electroejaculation - ejaculation that is stimulated by an electrode - is a successful form of therapy for men who have normal testes but who cannot emit semen or ejaculate because of a fault in the sympathetic nervous system. Candidates for electroejaculation include men who have undergone orchiectomy (testis removal for cancer) and retroperitoneal lymph node dissection (RPLND) or spinal cord injury. The technique of electroejaculation involves the placement of a probe in the rectum. Electrical current from the probe then causes the emission of semen due to direct stimulation of nerve fibers within the male reproductive tract. Forceful ejaculation generally does not occur during this procedure, and semen may be released through the urethra, or it may be released backward into the bladder. Because semen may need to be retrieved from the urine, the urine will be made alkaline (nonacidic) by having the patient take sodium bicarbonate tablets (600 mg) during the day before the procedure.
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