Male Infertility 6

Question 1

What are some general principles of treatment of male infertility?

Answer 1

• Assisted reproductive techniques (IUI, IVF/ICSI) are often weighed against other forms of treatment
• Multiple factors come into play for patients as they make their decisions
• Financial, religious, social, moral, ethical considerations may enter the decision making process
• Clinicians should fully inform patients of all of their options and to guide them through this process.
• Female fertility specialists and male fertility specialists typically work together, taking both patients’ clinical status into account.
• Concurrent treatment or a multi-pronged approach has been shown in some instances to enhance fertility potential and potentially decrease the level of assisted reproductive techniques required. [i.e. varicocele ligation + IUI (Cayan et al 2002)].

Question 2

What are common medical treatments for male infertility?

Answer 2

• The mainstay of medical therapy involves treating endocrine disorders
• hCG and clomiphene citrate (off label use) are used to treat men with abnormally low serum testosterone levels; the aim is to thus increase intratesticular testosterone levels, which are typically 100-1000 times greater than serum levels
• Recombinant FSH is given to men with FSH deficits. Hyperprolactinemia is treated with carbergoline or bromocriptine
• Estradiol excess is treated with aromatase inhibitors (i.e. anastrozole, letrozole)
• Ejaculatory dysfunction is treated with sympathomimetic agents such as pseudoephedrine

Question 3

What is varicocele ligation and how does it treat male infertility?

Answer 3

• Dilation of the veins in the scrotal pampiniform plexus
• Disruption of spermatogenesis is primarily related to venous stasis with disruption of the scrotal countercurrent heat exchange mechanism
• This leads to overheating of the testis through a “radiator” effect from the engorged internal spermatic veins within the pampiniform plexus
• Ligation or embolization of the internal spermatic vessels corrects the venous stasis and thus often optimizes the pathophysiology

Question 4

What is the role of Transurethral Resection of Ejaculatory Duct(TURED) in treating male infertility?

Answer 4

• For men with documented ejaculatory duct blockage
• Much like a TURP, except one loop of tissue resected at the level of the ejaculatory ducts
  
  • Outpatient surgical procedure
• Concurrent rectal pressure should be applied with extrusion of seminal vesicle fluid to demonstrate patency
• Can sample the fluid and inspect under microscope to detect sperm and thus demonstrate ejaculatory duct patency after TURED

Question 5

What is the role of testicular sperm extraction in treatment of male infertility?

Answer 5

• In the setting of azoospermia, sperm can be isolated from the male reproductive tract and subsequently used in the setting of IVF/ICSI to achieve pregnancies
• As noted below, this is the case whether the azoospermia is obstructive or nonobstructive in nature
  
  • Nonobstructive Azoospermia: In the era of IVF/ICSI, even very low numbers of sperm can be sufficient to generate a pregnancy
    
    • In patients with impaired spermatogenesis (testicular failure), sperm production in the testis can be very heterogeneous
    • Patients may have rare and scant areas of focal spermatogenesis
    • It is crucial to find these areas—sperm can be used for IVF/ICSI. Micro-TESE (Microdissection testicular sperm extraction) procedure now used → operating microscope helps identify normal looking seminiferous tubules
    • Often like looking for a “needle in a haystack.” Sperm can be used fresh for IVF/ICSI or cryopreserved for later use in IVF/ICSI
  • Obstructive Azoospermia: Sperm may be obtained from either the epididymis or the testicle and used in assisted reproductive techniques
    
    • The key is to be “upstream” of the point of blockage in the male reproductive tract
    • These procedures are typically office-based and can usually be performed under intravenous sedation and/or local anesthesia

Question 6

What is the role of intrauterine insemination in the treatment of male infertility?

Answer 6

• Typically requires at least 5 million total motile sperm
• Ejaculate is collected, processed (cleared of dead cells, debris), and inserted into partner’s uterus with a special catheter
• This is generally well tolerated, but success rates (overall 12-15% per attempt) are considerably lower than IVF/ICSI (overall 40-50% per attempt)
• Must consider the risk of multiple gestation pregnancies, especially with concurrent pharmacologic ovarian hyperstimulation in the female
• Often the first assisted reproductive technique used prior to IVF/ICSI due to lower cost, lower degree of invasiveness

Question 7

What is the role of In Vitro Fertilization(IVF)/Intracytoplasmic Sperm Injection(ICSI) in treatment of male infertility?

Answer 7

• The female is placed on ovarian hyperstimulation agents to drive the production of many follicles
• Oocytes are aspirated transvaginally from the follicles, and one sperm is injected into each egg to achieve fertilization and thus create an embryo
• Embryos are allowed to mature 3-5 days in laboratory incubator, then typically 1-2 embryos are replaced into the female’s uterus transvaginally with a special catheter
• Female age (i.e. age of the oocytes) is a critical factor in determining success
• Remaining or extra embryos can be cryopreserved for future use