by Andre Denis, MD and Dr. Andre L.C. Denis
There are multiple causes of infertility. The three biggest individual causes are abnormalities of ovulation, abnormalities of the fallopian tubes, and factors that arise from the male ("male factor infertility"). These 3 factors account for about 80% of all cases of infertility. The male alone is the cause in 20-35% of cases of infertility. An evaluation of the male should be one of the very first tests carried out in the investigation of the infertile couple.
Sometimes, a man's medical history is suggestive of a potential male factor. Some men may have a history of sexual dysfunction or abnormal ejaculation. Alternatively, others may have had previous surgeries or injuries that may lead to problems in semen production. We find it extremely important to review the medical history of the male partner of an infertile couple.
The initial diagnostic study that most men have is the semen analysis. The semen analysis is one of the few tests which have withstood the test of time and which continue to be considered an integral and important part of the evaluation of the couple. The analysis is generally performed on a specimen that has been produced by means of masturbation into a sterile container.
For those men who are unable or unwilling to masturbate, special semen collection devices, which are used like condoms during intercourse, can also be used to collect sperm for analysis. Ideally the male should abstain from ejaculation for 2-7 days prior to the analysis. The specimen should be evaluated within one hour after collection.
The analysis consists of an evaluation of a number of factors. Basic measurements include the volume of semen ejaculated (in milliliters), the concentration of sperm within the ejaculate (usually expressed in number of sperm per milliliter of semen), the percentage of the sperm which are moving (motility), and the quality of the movement (wiggling, swimming in circles, swimming in straight lines), known as the progression.
Labs may also report other values such as the pH, viscosity, color of the semen, the viability (percentage of sperm which are alive and dead) and other parameters. Some laboratories will also analyze sperm with computer guided systems (CASA or Computer Assisted Semen Analysis).
Through tracking of each individual sperm, these analyses can provide extremely detailed data such as the speed of movement, the lateral head displacement of the sperm (how much "wiggling" there is) and other parameters. Although CASA has a role in research, it is not necessary for routine evaluations.
Another frequently performed test for males is the post-coital test (PCT), also called the Sims-Huhner test. The test consists of asking the couple to have intercourse during the middle of the woman's menstrual cycle and 2-12 hours later have the female come into the office for an exam.
At the time of the exam, which is done in the same fashion as a routine pap smear, some of the mucus present is examined under the microscope. In a normal test, sperm should be visible and swimming normally. This test is most useful when it is normal, which implies that enough sperm are available for fertilization to take place.
Unfortunately an abnormal result can be misleading. Many factors such as poor timing, low-grade vaginitis (inflammation of the vagina), etc. can make the test seem abnormal although the couple could still potentially achieve pregnancy. Given its simplicity and safety, however, we still frequently use this test to rule out a possible male factor.
Many male patients will be referred to an urologist for evaluation. The physician will do a physical exam and may do some blood tests to establish whether hormonal levels are normal. During the exam, urologists will generally try to establish whether a varicocele, an abnormal system of veins, is present in the scrotum.
Since a varicocele is a surgically correctable problem that may decrease sperm number and/or quality, most urologists will do either a physical exam or a specialized ultrasound evaluation of the scrotum to look for a varicocele. Unfortunately, in the majority of cases of abnormal sperm, a "cause" is never identified.
There are many other diagnostic tests available. Some may be useful in very specific situations, such as testing for anti-sperm antibodies. Historically, other tests have been used but these tests have limited roles current male evaluations due to a limited ability to predict fertilization outcomes. One test developed in the 70s -- the the Hamster Penetration Assay -- has been totally discredited scientifically, and should not be recommended to you. As a general statement, most couples will not need to have these older tests done because the results will not change the treatment.
The treatment of male factor infertility is dependent on the identified problem. Sexual dysfunction, for example, is often treated by counseling rather than by "medical" therapies. Most commonly, however, we will be treating male factor infertility with therapies such as inseminations or in vitro fertilization.
In order for fertilization and pregnancy to take place, a minimum number of sperm must "find" the egg. When everything is normal, fertilization will take place in the fallopian tube. Unlike the cartoon drawings of the female anatomy that we are accustomed to seeing, the fallopian tube is not just a straight tunnel-like connection; instead it is a complex organ with many "nooks and crannies" such that, from a sperm cell's perspective, it is like a maze. The egg will be hidden in this maze, so a huge number of sperm are necessary at the start in order for a few to find the egg.
Once the sperm find the egg, many are needed to break through the layers of cells and the protein coat that surround the egg before the final step of fertilization by a single sperm can take place. When it comes to working with male factor patients, then, the question boils down to one of numbers. We must determine whether there are enough sperm available at the beginning so that one is likely to ultimately find and fertilize the egg. In normal situations, at least 50 million sperm are ejaculated into the vagina during intercourse. Of these, only 5-10 million will make it out of the vagina into the uterine cavity.
It has been shown that we can easily place sperm directly into the uterine cavity by means of an intrauterine insemination (IUI). This involves passing a small flexible catheter through the cervical canal into the uterus and then injecting the sperm into the uterus. In order for intrauterine insemination (IUI) to be successful, we generally need to have 3-5 million normal, motile sperm available for injection into the uterus.
The procedure of IUI is very straightforward. The husband will produce a specimen that is then processed in the laboratory. Using any number of different techniques, the sperm is processed to remove the sperm cells from the semen (the fluid part of the ejaculate). Then, the best, most normal sperm are concentrated into a droplet which is placed into the uterus. Processing of a sperm specimen will typically take 1-2 hours depending on the method used. The actual IUI is done in the office and is similar to a routine pap smear. Using a speculum to see the opening of the cervical canal, a thin flexible plastic catheter is introduced into the uterine cavity. Once in place, the sperm-containing droplet is injected through the catheter. Most women do not feel this at all, though some may experience a slight cramp when the catheter enters the uterine cavity.
Although we usually must have 3-5 million sperm available for IUI to work, there are exceptions to this rule. Occasionally a pregnancy may occur after an insemination with only a few hundred thousand sperm. However, if less than 3 million sperm are present in a sample, the couple should really consider alternatives because IUI may be unsuccessful and multiple attempts become quite expensive. Usually, if a couple has less than the minimum number of sperm available, more aggressive therapies are used to avoid low success rates.
In the past, couples who had less than a few million sperm in a sample had to consider inseminations using donor sperm. Many couples have used inseminations with donor sperm and produced happy, healthy babies. The process is very straightforward. We identify the time of ovulation and on that day place a thawed sperm specimen into the cervical canal or uterus. Success rates are excellent and cost is reasonable. The obvious downside is that the child will not be genetically linked to the husband. Nonetheless, insemination using donor sperm remains a very viable alternative for many couples.
Intracytoplasmic sperm injection
In 1992, the technique of intracytoplasmic sperm injection (ICSI) was developed in Belgium. This technique involves injecting a single sperm into the egg at the time of in vitro fertilization (a process whereby an egg is removed from the mother, fertilized by sperm in a laboratory, and then returned to the mother). This technology has revolutionized the treatment of male factor infertility.
Now, as long as the husband has sperm, pregnancy is possible. ICSI has been used successfully in situations where the husband has extremely low counts and even in situations where there are no sperm in the ejaculate (as long as there is sperm production in the testes). Men who had unsuccessful reversals of vasectomies, were born without the vas deferens (the tubular structure connecting the testes to the urethra and the .outside world.), or have abnormal development of sperm can all be helped by this technique. While ICSI does require the couple to undergo in vitro fertilization, it allows men to establish pregnancies who previously would never have been able to do so.
Male factors taken as a whole are one of the most common causes of infertility. It is extremely important to evaluate the male early on in the investigation of the infertile couple. A number of diagnostic tests are available, but generally the work-up of the male can be as simple as a semen analysis and possibly a post-coital test or other lab test. Examination by an urologist may be useful in certain circumstances. Sometimes a cause for the male infertility can be identified, but often no explanation is found.
Although the lack of diagnosis can be frustrating, the success with treatment is usually very good. The type of treatment used will depend directly on the number of good quality sperm available. Depending on the circumstances, intrauterine insemination, intracytoplasmic sperm injection, or insemination with donor sperm may be used. There have been many developments in the treatment of the infertile male in the last few years and there should be many more new options in this vibrant area in the future.
Dr. Alan Copperman is an Assistant Professor of Obstetrics, Gynecology, and Reproductive Medicine at the Mount Sinai Medical Center, and is Director of the Division of Reproductive Endocrinology.
Dr. Andre L.C. Denis is a Board Certified Reproductive Endocrinologist and Infertility Specialist practicing in Atlanta at the Atlanta Center for Reproductive Medicine.
Copyright © Alan Copperman and Andre L.C. Denis. Permission to republish granted to Pregnancy.org, LLC.