Treatment approaches for male infertility varies greatly, depending on the severity of the sperm problem. In mild cases, artificial insemination (or intrauterine insemination, IUI) may be enough. In an IUI cycle to address male infertility, semen sample is prepared and concentrated in the laboratory before it is injected directly into the uterus. Higher concentration and direct injection alone can sometimes overcome male infertility.
In more severe cases, in vitro fertilization (IVF) may be the best option. IVF for male infertility allows performance of intracytoplasmic sperm injection (ICSI), which virtually guarantees fertilization, even with very poor sperm (for further details on ICSI, see below).
In most severe cases of male infertility in which sperm is completely absent (azoospermia), we are successful in retrieving very small amounts of sperm directly from the man's testicles, in approximately 85% of cases. At CHR, this procedure is performed by highly specialized urology colleagues with special expertise in these procedures. The small amounts of sperm, obtained either by testicular sperm extraction (TESE) or testicular biopsy, can then be used in ICSI to fertilize the woman's eggs in an IVF cycle.
ICSI for Male Infertility
ICSI is a microsurgical procedure, in which an embryologist selects the best sperm from a prepared sample and injects it directly into an egg. This micromanipulation of eggs and sperm ensures the mechanical fertilization of one egg by one
sperm. ICSI has revolutionized the treatment of male infertility, making it possible for a vast majority of males, even with very severe male factor infertility, to become genetic fathers of their children.
In the picture on the left, the egg is held in place with a micropipette while an embryologist inserts a tiny needle containing a sperm into the egg. The sperm is released into the egg for fertilization. ICSI is a way to “visualize” the fertilization process and make sure that fertilization actually occurs. Since with ICSI we can now achieve fertilization for practically almost any male as long as he has even only a handful of sperm, there is really no longer any reason to try mostly ineffective treatment options for male infertility.
Surgery: Not Recommended to Treat Male Infertility
Some of our urology colleagues at times recommend (micro-)surgery to treat male infertility deriving from structural problems. The two most common indications for surgical treatments are the presence of the so-called varicoceles and obstruction of semen outflow due to an earlier vasectomy.
Varicoceles are dilated veins in the scrotum, which may raise the temperature inside the scrotum, which negatively affects sperm production. In varicocelectomy, a surgical approach to varicoceles, these dilated veins are ligated in order to lower the temperature within the scrotum and restore normal sperm production.
In a vasectomy reversal, a surgical approach to reverse past vasectomy, the surgeon tries to reconnect the interrupted duct (vas deferens) that carries sperm from the testes. The aim of vasectomy reversal is to restore the passageway for sperm out of the testes so the sperm can make their way into the ejaculate.
Our urology colleagues sometimes disagree with us, the fertility specialists, about when these surgeries may be the best option. Vasectomy reversals, in our opinion, are effective in only lf 50% of cases at best. While some urology colleagues claim higher success rates, we actually have doubts about even this 50% number. We are even more skeptical about varicocelectomies. At our fertility center, we very rarely see a varicocelectomy turning an infertile male into a fertile male, who can father a child “the natural way.” A vast majority of men, even after a varicocelectomy, still need IVF+ICSI to father a child.
And that is the principal reason why we, on occasion, disagree with our urology colleagues on when to perform surgery for male infertility. For our urology colleagues, the question is whether surgeries improve the sperm parameters of the male. If they do achieve a better sperm analysis by surgery, they consider this a success. However, for us, the fertility specialists, improvement in semen analysis parameters is not enough. For us, a successful male infertility surgery is one that converts a couple from needing IVF+ICSI to being able to conceive spontaneously, on their own. Unfortunately, the number of surgeries that do this in cases of male infertility is rather small.
Given the proportion of infertile couples with issues on both male and female, the ability to treat female and male infertility in parallel is essential for modern infertility care.
Whatever the severity of male infertility, CHR has the knowledge and experience to help at least 90% of affected males to become the genetic fathers of their children. Furthermore, with our special expertise in complex cases of female infertility, including premature ovarian aging and diminished ovarian reserve, CHR is a one-stop infertility center for female as well as male infertility.
Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.