By fertility experts from Spain.
Infertility is often thought of as a mainly female problem. Well, nothing could be further from the truth. It is estimated that 30% of fertility issues are due to male fertility factors, 30% due to female fertility factors and the remaining 40% is either the result of these two combining or… unexplained. So whenever a couple experiences difficulties getting pregnant, male-related infertility issues should be considered equally important and relevant. When facing infertility, men – similarly as women – also experience emotional distress, anxiety and overwhelming grief. However, in their case, those feelings might be slightly better hidden.
As sperm plays a vital role in the process of conception, it is very important to have it evaluated already at the beginning of any fertility treatment in order to assure maximum effectiveness. The problem is that male infertility does not generally manifest itself clearly – most infertile men do not have any symptoms apart from their inability to conceive. The good news, on the other hand, is that once diagnosed, infertility in men can be successfully treated and eliminated in most cases.
Proper medicines or surgical procedures are often used to fix male infertility causes. However, these are the assisted reproductive techniques such as IUI (Intrauterine Insemination) and – especially – IVF with Intracytoplasmic Sperm Injection (ICSI) that are proved to be the most effective treatment for severe male factor infertility and sperm defects.
The clinical definition of male factor infertility is the presence of abnormal semen parameters in the man who together with his female partner is unable to conceive after one year of regular unprotected intercourse. According to the World Health Organisation, male factor infertility is defined as either the presence of abnormalities in the semen analysis or the presence of inadequate sexual or ejaculatory function. The male infertility can be complete or partial (subfertility). The most significant sperm parameters associated with male infertility are low sperm concentration (oligospermia), poor sperm motility (asthenospermia) and abnormal sperm morphology (teratospermia).
The causes of male infertility may be complex and diverse. The primary ones include disorders and abnormal conditions in the male reproductive tract. Blocked and enlarged veins around the testes, called varicoceles, are thought to cause infertility by raising the temperature in the scrotum and thus, decreasing sperm production. Retrograde ejaculation occurs when semen goes backwards in the body, making the chances of sperm fertilising an egg very low.
Another serious reason is sperm morphology (meaning the size, shape and appearance of a man’s sperm) – when it’s abnormal, it can decrease fertility and make it more difficult to fertilise the egg. Fertility in a man may be affected by the changes in the number and structure of chromosomes as well as by low sperm motility (movement) that makes it difficult for sperm to travel inside a woman’s egg. Natural physical blockages from infections or surgeries – such as vasectomy – prevent sperm from leaving the testicles, while hormonal imbalances cause poor sperm growth. Male fertility can be also negatively affected by health and lifestyle factors (stress, weight, drug and alcohol consumption), cancer treatment (chemotherapy and radiation) and – last but not least – man’s age. Although it is thought that men, as contrary to women, are able to have kids till the end of their lives, the fact is that man’s fertility starts declining around the age of 35 as the sperm quality and motility diminishes.
The evaluation for male infertility should be completed during the early stages of fertility treatment – at the same time as testing of the female partner. The most common test is general semen analysis which is used to determine a male infertility problem by measuring the number and quality of sperms. Typically evaluated parameters include ejaculate volume, sperm density, sperm motility, and sperm morphology. The World Health Organisation defined the following lower limits of normal: semen volume 1.5 mL, total sperm number 39 million/ejaculate, sperm concentration 15 M/mL, total motility 40%, progressive motility 32%, and morphologically normal forms 4%.
Other male infertility screening tests include DNA fragmentation assay, sperm antibodies test, hyaluronan binding assay (HBA), chromatin dispersion test or oxidative stress measurement. Apart from semen testing, it is also possible to diagnose infertility using genetic testing, hormonal testing or early embryo development observation.
The development of assisted reproductive techniques has revolutionised the treatment of male infertility. Nowadays most couples who are facing male factor infertility may be successfully treated with IUI or IVF with ICSI.
Generally, intrauterine insemination (IUI) can bring positive effects in couples when there is a slight abnormality in sperm counts. However, in case of severe impairment of sperm count, motility, or shape, it is IVF with ICSI treatment that becomes the most effective option. It can help men with low sperm quality or quantity, by extracting a single normal sperm and injecting it directly into the centre of the egg – all of it under a specially fitted microscope. In case of ICSI, success rates depend solely on the skill and experience of an embryologist performing the procedure.
There is also a modified form of ICSI called PICSI (Physiological Intracytoplasmic Sperm Injection). It additionally involves selecting mature sperm which bind to hyaluronic acid. During the natural process of fertilisation in the body, hyaluronic acid (found in the cumulus complex surrounding the egg) is responsible for excluding functionally deficient sperm and “identifying” sperm’s maturity and DNA integrity.
Whenever a man is not able to produce sperm on ejaculation, there are several safe procedures of retrieving healthy sperm from the testes or the epididymis. The examples of sperm retrieval procedures are: Testicular Sperm Aspiration (TESA), Testicular Sperm Extraction (TESE) or Microsurgical Epididymal Sperm Aspiration (MESA).
When patients fail to fail to conceive through IVF with ICSI, there is always a donor sperm option that can be used as a backup in the most severe cases. Donor sperm always undergoes a complete analysis that includes the assessment of many parameters. Donor sperm can be used for IUI or IVF fertilisation, too.
Until recently, donor sperm seemed to be the most popular way to overcome male factor infertility. Fortunately, nowadays the assisted reproductive technology has advanced rapidly in providing assistance to patients facing that challenge in every day life. What’s more interesting, IVF can have not only a therapeutic role but it can also be a diagnostic procedure. Not earlier than after the IVF cycle, embryologists know more about infertility problems a particular couple is struggling with. Only armed with such knowledge, they can provide patients with individualised treatment plans that rule out other underlying conditions and help them move toward the ultimate goal of conception.