Male Infertility

A semen analysis is the primary test in a man's infertility work-up.  This laboratory test measures the number and activity of the sperm, as well as the shape and form.  The sample is also tested for the presence of white or red blood cells, which could indicate inflammation or infection.  Typically, the specimen is incubated briefly prior to inspection.  The volume and pH are measured and the specimen is examined for its consistency.  Ejaculates are normally very viscous at first, but liquefy after 15 to 20 minutes at body temperature.  Normal pH is basic and normal volume is from 2 to 5 ml.  A low volume has obvious implications for difficulties with conception, but the significance of a higher than normal volume is unclear.

A microscopic analysis of the semen specimen is performed next, focusing on three main areas: the count, the motility (activity), and the morphology (shape).  Using the count most men have as the definition of normal, 60 million sperm/ml is considered to be normal for the New York City area, although average sperm counts vary a lot from region to region and a lower sperm count is considered normal elsewhere.  Motility refers to two characteristics of sperm: the percentage that are moving and the quality of the sperm that are moving.  A percent motility of greater than 50 percent is generally considered normal.  Morphology of the sperm has been found to be predictive of fertility potential.  The most commonly used system of reference of semen analysis is the World Health Organization (WHO) manual.  In this system, 30 percent or more normal morphology is considered normal.

For a complete evaluation, you may need to give several specimens several weeks apart.  You should note that many lifestyle factors can affect a man's sperm count and quality.  Cigarette smoking, alcohol consumption, and recreational drug use are all known to diminish both the quality and quantity of the sperm produced.  Also, many prescription drugs can affect a man's sperm count and quality and/or his ejaculatory function.  These drugs include many of the medications prescribed for high blood pressure or gout, as well as sulphasalazine (used to treat irritable bowel), nitrofurantoin, tetracyclines, cimetidine, ketoconazole, tricyclic antidepressants, monoamine oxidase inhibitors, and propranol.

For best results you should abstain from sexual intercourse for three days before producing the specimen.  If you wish, you may produce your semen sample at home.  If you collect the semen sample at home, you must bring it to the office within one hour.  Keep the sample out of direct sunlight and do not allow it to get cold or hot.  If it is a cold day, carry the semen sample container against your body to keep it as close to body temperature as possible.  Do not refrigerate the semen sample.

If the results of your semen analysis are unclear or sub-optimal, your doctor may perform other urological and hormone-level tests to determine the cause, or refer you to a urologist.

Testicular Biopsy

Testicular biopsy involves taking a small piece of tissue from the testis while the man is under light anesthesia (conscious sedation).  In a testicular biopsy, the tissue is carefully prepared and assessed under a microscope to determine the presence of sperm and whether the sperm production process is normal.  For men with a zero sperm count (azoospermia), this procedure is done to determine if a blockage is present or if poor sperm production is the cause.  For men with severe sperm production problems, this test can also determine whether small areas of sperm production are present in the testis, in which case sperm from the biopsy tissue may be used in infertility treatment.  Even just a few normal sperm found in the biopsy tissue can be used in the assisted reproductive technique called intracytoplasmic sperm injection (ICSI) where a single sperm is injected into the egg by piercing the shell of the egg.

Testicular biopsy involves passing a small needle into the testis to obtain a sample of tissue about half the size of a match head. The procedure takes roughly 30 minutes. Following this procedure, the area may be somewhat sore for the next 2 to 3 days. The scrotum may also swell slightly and/or become discolored. This should resolve within a few days.

Intracytoplasmic Sperm Injection (ICSI)

ICSI is performed primarily for:

•Severe male infertility (which includes very low sperm counts, low motility, morphology, or other sperm abnormalities), causing a low chance for success with conventional IVF

•Those with a history of low or absent fertilization in previous IVF attempts

ICSI allows many infertile men to become the biological fathers of their children.  The ICSI technique involves the injection, using a tiny needle, of a single sperm through both the zona pellucida and the wall of the egg directly into the center of the egg.  The procedure requires a great deal of technical skill in the picking up of individual sperm and its injection into the egg without damaging it.  All procedures are performed under a microscope using a sophisticated micromanipulation system.

In order to undergo ICSI, a couple must follow the same steps as for in vitro fertilization.  All treatments and procedures are the same as those for standard IVF, with the addition of the ICSI procedure itself.  Fertilization rates following ICSI are similar to those of conventional IVF with normal sperm.

Testicular Sperm Aspiration (TESA)

When sperm are only present in the testis and not in the collecting tubules, they can be obtained directly from the testicle in a technique known as testicular sperm aspiration or TESA.

In TESA, the sperm are collected while the patient is under light anesthesia (conscious sedation).  A fine needle is inserted into the testis to extract sperm from the tubules.  The technique takes about 30 minutes to perform.

This technique is usually used in combination with ICSI (intracytoplasmic sperm injection). 

 


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