Treatment Options For Male Infertility

Treatment Options for Male Infertility

ABSTRACT: Infertility affects 15% of couples; male factors are involved in 50% of cases, with half of these having a correctable cause.

CME OBJECTIVE: The reader will be aware of the latest methods for evaluating men for infertility and of the available therapeutic options.
Peter N. Kolettis, MD, no conflicts of interest

Defined as the inability to conceive after 1 year of unprotected intercourse, infertility affects an estimated 6.1 million Americans. "Infertile couples deserve a thorough, cost-effective, and minimally invasive evaluation by a team specializing in reproduction," says Peter N. Kolettis, MD, who is the only urologist in Alabama and Mississippi to complete a fellowship in male infertility and microsurgery.

Assessing Male Fertility

Infertility should not be confused with sterility, says Kolettis, noting that approximately one third of infertile couples can conceive at some point without treatment. The evaluation, however, should begin earlier than 1 year if there are risk factors, such as prior infertility, advanced female age, exposure to gonadotoxic drugs, or if the couple requests it.

The initial work up for men begins with a comprehensive medical history, a physical examination with emphasis on the genitourinary system, and two semen analyses performed in a specialized laboratory. Both hormonal and genetic testing may be indicated, depending on the results of the initial evaluation.

Kolettis emphasizes that a semen analysis is not a fertility test but rather a test of a man's fertility potential. "Men with an abnormal semen analysis can still establish a pregnancy, as long as viable sperm are present in the semen, with the chance of a possible pregnancy increasing with rising numbers of motile sperm in the semen."

Microsurgical Treatment

A varicocele (dilated veins of the pampiniform plexus) is the most common abnormality identified in a male infertility evaluation, found in as many as 40% of men with primary infertility (those who have never established a pregnancy). A varicocele is detected even more frequently in men with secondary infertility (those who have previously established a pregnancy but currently cannot).

"Minimally invasive subinguinal microsurgical varicocele ligation allows for a faster recovery and less postoperative pain than the traditional inguinal approach," says Kolettis. "Angiographic embolization is another option with minimal morbidity and equivalent success rates, when performed by experienced interventional radiologists."

Vasectomy Reversal

An estimated 500,000 vasectomies are performed in the United States annually; 2% to 6% of men who undergo a vasectomy seek to have it reversed, says Kolettis. Patency (sperm returning to the semen) after vasectomy reversal depends on the time since the vasectomy, the quality of the fluid noted from the vas deferens during surgery, the presence or absence of epididymal obstruction, and surgical technique. The chance for pregnancy depends on the above factors, plus any female fertility factors that may be present, he says.

"When performed within 3 years of vasectomy, the chance of sperm returning to the semen is >95%, with a pregnancy rate of about 75%. Between 3 and 8 years postvasectomy, there is a better than 85% chance of seeing sperm after reversal, with a pregnancy rate >50%," says Kolettis. "Even in patients whose vasectomy was performed 15 years ago, a pregnancy rate of 30% is possible."

About 80% of men who pursue vasectomy reversal are attempting conception with a new partner, he discloses. "The chance for pregnancy is greater for couples who attempt conception with the same partner, because typically the time since vasectomy tends to be shorter and they have proven fertility as a couple," he says. Kolettis served as lead author of a recent study upon which these results are based (Urol. 2003;61:1221-1223).

Findings from another study with Kolettis as lead author (J Urol. 2003;169:2250-2252) suggests a vasectomy reversal also offers a reasonable chance for pregnancy, even when the woman is aged 35 and older. In these couples, the male partner had undergone vasectomy reversal; female partners were older than 35 years. The average time between vasectomy and reversal was 10 years.

Of the 40 couples with adequate follow up, pregnancy occurred in 35%, and the ongoing/live delivery rate was 33%. Nearly half (46%) of women aged 35 to 39 years became pregnant after their partner had a vasectomy reversal. However, women in their 40s were much less likely to conceive, with just 14% becoming pregnant.

"In this scenario, the chance for success is, at the very least, comparable to one cycle of in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI)," says Kolettis. "Therefore, men should not be eliminated from consideration for vasectomy reversal simply because their female partner is older than age 35. If the female partner is age 40 or older, the chances for pregnancy decreases significantly, and couples should be counseled about their realistic chances of conceiving."

Kolettis also points out that vasectomy reversal is less expensive than ICSI and does not expose the female partner to risks associated with superovulation. "By making it possible for couples to conceive naturally, vasectomy reversal avoids the increased risk of multiple births that comes with IVF," he says.

Patients with congenital or inflammatory epididymal obstruction also have a potentially correctable condition. For men with ejaculatory duct obstruction, transurethral resection of the ejaculatory ducts is possible.

Assisted Reproduction

For patients with unreconstructable obstructive lesions, or for those who do not desire surgical correction, sperm retrieval with ICSI can result in pregnancy. "With ICSI, a single sperm is injected directly into the egg, thereby bypassing many forms of sperm dysfunction or other barriers to fertilization," he says. "To date, this procedure has proved successful for many types of male-factor infertility."

Kolettis performs microsurgical sperm retrieval "because it offers the potential to retrieve the greatest number of sperm, which can be cryopreserved and used at a later date. This approach minimizes the need for repeat sperm retrieval procedures and allows sperm retrieval to be performed prior to the ICSI cycle."

One of the most exciting developments in the treatment of severe male-factor infertility due to nonobstructive azoospermia is the use of testicular sperm with ICSI. According to Kolettis, these men, who do not have ductal obstruction, lack sperm in their semen because of severely decreased sperm production. He points out that the etiology is unclear, although the underlying cause may be genetic.

Some men, however, produce small amounts of sperm, which can be retrieved from the testis and used with ICSI. "Because of the extremely low level of sperm production, an open biopsy provides a better chance for successful sperm recovery than percutaneous aspiration," he says. "If sperm are obtained, they can be cryopreserved for future ICSI cycles." Kolettis advises these men undergo genetic testing prior to ICSI. If sperm are not available, or if the couple does not wish to undergo ICSI, they may pursue adoption or therapeutic insemination with donor sperm.

Kolettis, who has performed more than 200 microsurgery procedures for infertility, collaborates closely with a specialized team of nurses, laboratory personnel, and gynecologists who specialize in female infertility. "Using a combination of established corrective treatments and new technologies, we can provide the most cost-effective, least invasive treatment for the infertile couple," he concludes.

For more information
Dr. Peter Kolettis
1.800.UAB.MIST
mist@uabmc.edu