Causes of infertility – male factor
Male factor is a cause of infertility in 42% of couples that visit an expert due to unsuccessful attempts to have a child. In further 23% male factor coincides with female factor which means that sperm quality problems affect up to 67% of patients at fertility clinics.
The male factor in infertility consists in decreased sperm parameters found during semen analysis. The most common abnormalities include the following disorders:
- oligospermia - sperm count below 15 million/mL (lower limit of normal results, according to the latest reference values set by the World Health Organisation in 2010);
- asthenospermia – sperm cells with reduced mobility (less than 32% of sperm cells exhibiting progressive movement desired during fertilisation);
- teratospermia – percentage of sperm cells with normal morphology is less than 4%.
The results of semen analysis below the so-called normal values do not mean that there is no chance of conceiving a child, but they indicate significantly reduced likelihood of pregnancy. Azoospermia, namely lack of sperm cells in the semen, is the absolute cause of infertility.
Sperm analysis with assessment of sperm cell morphology and the HBA test evaluating sperm cells’ capacity of binding with hyaluronan, typical of mature sperm cells, play a key role in diagnosis of male factor. Sperm analysis should be performed twice, at interval of at least four weeks. An SCD test that detects sperm chromatin (DNA) fragmentation should be performed during one analysis.
The next diagnosis stage depends on results of analyses and tests performed so far. A patient usually undergoes blood tests (concentration of FSH, testosterone, TSH, PRL, LH, estradiol; presence of antisperm antibodies) and testicular ultrasound. A patient is advised to consult an urologist and andrologist.
If semen abnormalities are severe, it is worth undergoing additional tests:
- if azoospermia is diagnosed, the following tests are performed: AZF that detects damage to the Y chromosome, karyotype (genetic test) and CFTR (CFTR gene is responsible for formation of seminal vessels. Damage to this gene results in cystic fibrosis).
- in case of severe teratozoospermia (lack of normal sperm cells in the semen) MSOME-6600 is conducted; it consists in assessing sperm cell morphology at 6600x magnification.
- oligostenozoospermia (less than 3 million sperm cells are found in 1 mL of semen) is an indication for AZF and karyotype test.
How to treat male infertility?
If hormonal disorders (e.g. FSH deficiency or hypothyroidism) are identified in diagnostic tests, a patient may expect fertility to be restored after pharmacological treatment. Very good results are also achieved by curing disorders that impair male fertility, such as epididymitis or prostate infection, and removal of some urinary tract abnormalities. In other cases pharmacological treatment clearly improves sperm quality merely in 15% of patients – and this is a short-term change.
Minor male factor, namely semen quality is only slightly deviated from normal values, is an indication for intrauterine insemination. This procedure consists in direct administration of the best isolated sperm cells into the uterus during ovulation. This procedure is painless. Efficacy of intrauterine insemination in a single cycle is 12% but the cumulative percentage of pregnancies increases to approx. 22% after four procedures.
Patients with moderate or severe male factor may benefit from the in vitro method called ICSI. It is an assisted reproduction technique that consists in selecting best possible sperm cell and injecting it to an egg cell for fertilisation. Efficacy of in vitro ICSI depends on female patient’s age.
If semen analysis showed no sperm cells with normal morphology, a couple is qualified for the in vitro method called IMSI that allows them for achieving effects comparable to in vitro ICSI despite very low parameters of patient’s semen. High treatment efficacy is achieved because sperm cells are selected at 6600x magnification before being injected into an egg cell.
Normal results of genetic and hormonal tests along with lack of sperm cells in the semen is an indication for sperm retrieval directly from the testes (TESA) or epididymides (PESA). Biopsy is performed under general anaesthesia and is effective in approx. 86% of cases. Sperm cells collected during biopsy can be used for in vitro ICSI or IMSI.
If an attempt to collect sperm cells was ineffective, a couple may decide to use donor’s semen. Gamete donation is a good idea also in case of medical disqualification before in vitro. A donor should have the same blood type as the patient and similar appearance. The efficacy of in vitro with donor’s semen in 16-19% in a single cycle.