Infertility

Treatment

This description is not intended to be a complete guide to every form of available therapy. Should any doubt exist, you should ask your doctor for advice.

Male

Probably the largest single problem facing couples with regard to male causes of infertility is that of teratozoospermia. This term implies a condition where the number of structurally (morphologically) normal sperm is below an acceptable fertility limit. Thus, although the male’s sperm count is normal, the percentage of normal (fertile) sperm is too low. This problem is further compounded by the fact that a number of laboratories do not accurately test for this situation. One often sees couples in whom the male has initially been passed as being normal, but the problem is found after proper retesting. Unfortunately the cause of this condition is as yet unknown, therefore specific treatment is difficult.

Treatments generally prescribed for male infertility are:

General

Paying attention to good health
Maintaining physical fitness but avoiding excessive exercise
Maintaining your body weight in the correct BMI range
Successfully dealing with stress
Avoiding tight underwear (it causes overheating of testes)
Avoiding regular hot baths or saunas
Stopping smoking (this includes cannabis/marijuhana)
Restricting alcohol intake (it is extremely toxic to sperm function)
Avoiding infrequent ejaculation - delays of one to two weeks can diminish sperm quality.

People often ask about the use of vitamins especially C and E, the use of Zinc and alternate forms of medicine. There is now some evidence, which suggests that for males with significant Sperm DNA Fragmentation the use if Vitamin C and E and other antioxidants can lead to an improvement.

Recently drugs such as St.John’s wort, ginkgo and Echinacea have been implicated in reducing male fertility and should be avoided! In general avoid all forms of so called “natural remedies”.

Specific Treatment

This deals with sperm problems in one of two ways.

The first is to improve sperm production and quality at the testicular level, ie where it is produced (see General & Drugs).

The second is to deliver more and possibly better quality sperm to the site of fertilisation.

a) In the female’s Fallopian tubes by physical means, e.g. AIH and GIFT together with other technologies such as sperm preparation.

b) In the laboratory via IVF and ICSI.
ICSI has made major strides in helping severely affected infertile males to achieve children.

a) Drugs

These include tamoxifen, gonadotropins (FSH) and HCG, bromocriptine for elevated prolactin levels, kallikrein and l-carnitine for poor motility but to mention a few. Results are variable and today this approach has been by passed by ART. It may well be that most of the male problems are genetic and we eagerly await advances in this area of diagnosis and treatment.

b) Physical Means

i) Intrauterine insemination (IUI)

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The mucus barrier that exists in the cervix definitely reduces the number of sperm (both normal and abnormal) that can pass into the uterus and tubes following normal sexual intercourse. Normally about 15% of ejaculated sperm succeed in passing through the cervix. Where the male already has a reduction in sperm count and or morphology, and or motility, this normal barrier reduces the yield of fertile sperm even further.

Intravaginal as opposed to intrauterine insemination is rarely performed.

In order to improve the success rate of this type of treatment, the sperm is prepared as described below and is then is artificially inseminated by gentle insertion of a small plastic tube through the cervix into the uterus. No more than 0.2ml-0.5ml of prepared sperm is placed in the uterine cavity. The technique of sperm preparation or washing involves separation of the seminal plasma from the spermatozoa and selection of the more morphological normal and motile sperm for insemination. The potential improvement in fertility that this type of treatment may yield depends upon the male problems, and should be discussed with your doctor.

When IUI is combined with induction of ovulation (IO) pregnancy rates of 20-25% per 3-4 cycles of treatment are not uncommon. This represents the most commonly used alternative to IVF where applicable.

Sperm washing may be used to help males with retrograde ejaculation.

ii) ART.

See below

c) Surgery

i) Varicocoele

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A varicocoele is a group of abnormally dilated veins which surrounds the testicle. How varicocoeles cause infertility is not known, but surgical correction of this condition may results in an improvement of sperm quality.

ii) Surgical correction of obstructions

Occasionally, surgery can be used to overcome blockages to the male reproductive tract. These blockages include reversal of vasectomy (male sterilisation).

An alternative to this type of surgery is ICSI in association with surgical sperm collection (SSC). This treatment decision requires a careful evaluation of the couple.

If antisperm antibodies are already present as well ICSI may well be the better alternative.

With regard to surgery on the male it must be pointed out that it should only be undertaken as part of a total treatment approach for the couple and not as an isolated procedure by a surgeon who is not part of a fertility team.

iii) Surgical sperm collection (SSC)

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With the development of ICSI a new approach to certain types of male problems became available. Certain males have obstructions to sperm leaving the testis. Causes include birth defects (such as congenital absence of the vas deferens), blockages due to infections or men who have had vasectomies. In addition some males produce so little sperm (often due to genetic problems) that when they are sent for a semen analysis no sperm can be found. In many of these cases sperm can be obtained directly from the epididymis or testis by a needle or testicular biopsy, often performed under local or general anaesthesia. With SSC very small numbers of sperm may be obtained and this coupled with ICSI, which only requires a single moving sperm per egg injected, is a powerful tool in the treatment of male infertility.