What are the treatments for male infertility?
Low sperm counts can be treated by collecting and concentrating healthy sperm for insemination or assisted reproductive technology (ART) treatment. Semen without sperm can be treated by using either mature or immature sperm surgically removed from the testicles. Conception is then attempted by injecting a sperm into an egg (intracytoplasmic sperm injection) and transferring the fertilized egg into the uterus or a fallopian tube. If semen is ejaculated into the bladder (retrograde ejaculation) instead of out through the penis, sperm can be recovered from the bladder, washed, and used for insemination. Structural problems can be treated surgically, increasing the chances of natural conception.
Surgery can sometimes reverse a vasectomy, repair an enlarged vein in the scrotum (varicocele repair), or correct blockages in or absence of the vas deferens. Sperm production problems caused by hormonal imbalances (affecting about 2% of infertile men) can be treated with medication or hormones that help the hypothalamus and pituitary gland start normal sperm production. Treatments include hormones and medications such as GnRH, gonadotropins, and bromocriptine. When no healthy sperm are available using the above means, some couples use donor sperm combined with insemination or assisted reproductive technology. Other couples choose adoption.
Drug therapy includes medications to improve sperm production, treat hormonal dysfunction, cure infections that compromise sperm, and fight sperm antibodies. The administration of testosterone is similar to that used to treat testosterone deficiency. Tamoxifen (Nolvadex, an antiestrogen agent, may be used to stimulate gonadotropin (a male hormone) release, which leads to testosterone production. Antibiotics, like levofloxacin (Levaquin? and doxycycline (Periostat?, are used to treat fertility-impairing infections of the urinary tract, testes, and prostate, and STDs.
Surgery is performed to treat reproductive tract obstruction and varicocele. Vasoepididymostomy is a microsurgical procedure that corrects obstruction in the coiled tube that connects the testes with the vas deferens (epididymis). Obstructions commonly result from STDs and also include cysts and tubal closure (atresia), which is usually genetic. Vericocelectomy, the removal of a varicocele from the testes, often results in increased sperm count.
Electroejaculation procedure can be used to produce ejaculation when neurological dysfunction prevents it. An electrical rectal probe generates a current that stimulates nerves and induces ejaculation; semen dribbles out through the urethra and is collected. Retrograde ejaculation is associated with the procedure and sodium bicarbonate is usually taken the day before to make the urine alkaline (nonacidic) and nondetrimental to sperm. Candidates for electroejaculation include men who have undergone testis removal (orchiectomy), retroperitoneal lymph node dissection (RPLND), and those with spinal cord injuries.
Sperm retrieval technique is used to obtain sperm from the testes or epididymis when obstruction, congenital absence of the vas deferens, failed vasectomy reversal, or inadequate sperm production causes azoospermia. Using a technique called micro epididymal sperm aspiration (MESA), a surgeon makes an incision in the scrotum and gathers sperm from the epididymis, the elongated, coiled duct that provides for the maturation, storage, and passage of sperm from the testes. Percutaneous epididymal sperm aspiration (PESA, or fine needle aspiration) is similar to MESA but does not involve microsurgery. A physician uses a needle to penetrate the scrotum and epididymis and draws sperm into a syringe. Testicular sperm extraction (TESE), the removal of a small amount of testicular tissue, is used to retrieve sperm from men with impaired sperm production, or when MESA fails. These procedures are done under local anesthesia, usually take about 30 minutes, and may cause pain and swelling.
Sperm washing isolates and prepares the healthiest sperm for insemination. Sperm and washing medium are combined and spun rigorously (centrifuged) and the process is repeated if necessary. The process separates sperm from white blood cells and fatty acids (prostaglandins) in the semen that may hinder sperm motility. It also concentrates sperm, which increases the chance for conception.
Sperm retrieved by MESA, PESA, or TESE may be used in in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). IVF involves combining eggs with sperm in a laboratory, providing proper fertilization conditions, and transferring the resulting embryos to the uterus. To retrieve an egg, a specialist uses ultrasound to guide a fine needle through the vaginal wall and into the ovary or makes an incision in the abdomen to get to the ovary (laparoscopy). Once the eggs are retrieved, they are combined with prepared sperm in a sterile dish for 2 to 4 days. After fertilization, the embryos are transferred to the uterus. IVF is used most commonly for infertility caused by female reproductive abnormalities.
Intracytoplasmic sperm injection (ICSI) may be used with immotile sperm during in vitro fertilization. Using a tiny glass needle, one sperm is injected directly into a retrieved mature egg. The egg is incubated and transferred to the uterus. Fertilization occurs in 50% to 80% of cases and approximately 30% result in a live birth. The egg may fail to divide or the embryo may arrest at an early stage of development. Younger patients achieve more favorable results and poor egg quality and advanced maternal age result in lower success rates.
While excess sperm from MESA or PESA can usually 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 repetition can lead to scarring.
Gamete intrafallopian transfer (GIFT): This procedure is recommended for couples with unexplained fertility problems and normal reproductive anatomy. Mature eggs and prepared sperm are combined in a syringe and injected into the fallopian tube using laparascopy. Embryos that result from this procedure naturally descend into the uterus for implantation.