Male Infertility

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.

Donor sperm
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.

Summary

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.