There is a common path that many couples follow on their way to fertility treatment. It starts with the woman talking to her OB/GYN about the fact that it is taking longer than she expected to get pregnant. Often the doctor will order some tests for her and start a simple oral medication as a first line treatment.
The problem is that 40-50% of couples with infertility have a male factor contributing to their difficulty conceiving. So, many times, treatments that only help the female side of the equation are unsuccessful. This can increase the frustration and anxiety of couples, as they spend several more months trying with no success.
Shady Grove Fertility’s physicians always suggest including the male partner right from the start. “I always recommend a semen analysis at the first appointment,” says Dr. Howard McClamrock of Shady Grove Fertility’s Baltimore Harbor Office. “Patients shouldn’t start any kind of treatment without knowing the result of a semen analysis.”
Men are sometimes wary of being tested. They might be uncomfortable with the process or afraid to see the results, but the semen analysis is a fast, simple test that is crucial to getting on the right treatment path.
Plus, men can be reassured that whatever the results are, there is help for them. “We can help the vast majority of men,” says Dr. McClamrock, “nearly all of them.”
TESTING FOR MALE FACTOR INFERTILITY
All that is required for a semen analysis is for the male to provide a semen sample. While many SGFC offices have collection rooms, samples are encouraged to be collected at home. Results are available within 3 to 5 business days and can be obtained from either your Shady Grove Fertility doctor or a referring physician. The majority of Shady Grove Fertility’s full-service locations provide semen analysis services Monday through Friday by appointment.
Once a patient has provided a sample, several factors are examined:
- Volume – Besides sperm, semen contains amino acids, enzymes and several other secretions made by the male reproductive system. If the volume of ejaculate is low, that can mean the sample may be lacking in these important secretions that aid in the fertilization process. It could also signal a blockage or other issue in the semen’s pathway.
- Concentration – This is what people commonly refer to as the “sperm count.” A low concentration can signal a problem with the testicles or male hormones that is preventing the testicles from making enough sperm.
- Motility – The movement of the sperm is another important factor. If it is low, it can affect the ability of the sperm to reach the female reproductive tract and find the egg.
- Morphology – This item refers to the shape of the sperm in the sample. The head of the sperm is the part that penetrates and fertilizes the egg. If these are misshapen, it may mean they do not contain the proper enzymes or other materials that are necessary to complete fertilization.
NO SPERM OR NO SEMEN
Sometimes, the semen sample looks normal but under the microscope, it is revealed that there are no sperm present. This can be the result of a blockage of the ducts that carry the sperm from the testes to the penis and is called obstructive azoospermia.
“Some men with obstructive azoospermia are missing the tube that carries the sperm to the urethra, called the vas deferens,” says McClamrock. “This can be confirmed by a physical examination.” More than half of these men are carriers of Cystic Fibrosis (CF), so their doctors will order genetic testing to determine whether that is the cause.
Shady Grove Fertility suggests genetic testing to all couples undergoing fertility treatment, so they will know if they are carriers of some of the more common genetic conditions like CF. If both partners are carriers of a genetic disease, their embryos can be screened for the condition before transfer so that their children do not inherit the disease.
In more rare cases, a man may not be able to produce a sample because he cannot ejaculate. This can be caused by a medical problem called retrograde ejaculation, in which the semen is discharged backwards into the urinary bladder, rather than forwards.
In about 5% or less of the cases, additional procedures have to be performed to enable examination and use of a man’s sperm. Whatever the cause, an inability to produce a sperm sample during the routine semen analysis is no cause for panic. “There are usually healthy sperm in the testes, we just have to get them,” says Dr. McClamrock. “We have several procedures that can recover the sperm so they can be used for fertilization.”
One such procedure is called Percutaneous Epidydimal Sperm Aspiration or Testicular Sperm Extraction (PESA and TESE). In this procedure, a needle is inserted into the testicle and fluid or tissue are withdrawn. The fluid is then inspected under a microscope and healthy sperm are extracted from it.
If PESA or TESE is unsuccessful in retrieving sperm, a second option may be to do a Testicular Biopsy. In this procedure, a needle is used to remove a small sample of tissue from the testes. The tissue is then inspected under a microscope and any healthy sperm found are extracted from it.
These procedures sound painful, but they are done under local or general anesthesia and shouldn’t be uncomfortable for the patient. The procedures are performed by urologists in one of Shady Grove Fertility’s Ambulatory Surgery Centers and most patients return to work the following day. Shady Grove also has Urologists on staff for consultation or treatment if needed.
TREATMENT FOR MILD CASES
Once a semen sample is collected and analyzed, a treatment plan can be created. If the semen analysis reveals a slight problem with one of the factors listed above, the couple may be diagnosed with a mild form of male factor infertility. “In the case of mild forms of male factor infertility, we usually suggest that the couple start treatment with IUI,” says Dr. McClamrock. IUI or Intrauterine insemination is a much simpler, lower-tech form of treatment than In Vitro Fertilization (IVF).
IUI is helpful in cases of male factor infertility because the sperm sample is specially prepared before it is placed in the uterus. In a process called “washing,” the semen sample is transferred into a tube and placed in a centrifuge where it is spun so that the sperm with the best shape and motility are concentrated at the bottom. These sperm, which are the healthiest in the sample, are separated out and prepared for placement in the uterus. This allows for more motile sperm to get closer to the egg for fertilization.
The female partner often prepares for the insemination by taking fertility medications that cause ovulation and prepare the uterine lining for pregnancy. At a time near ovulation, a speculum is inserted into the vagina, and a soft, thin catheter is then placed through the cervix and into the uterus. The washed sperm is introduced into the uterus through the catheter. This procedure takes only a few minutes, is not painful and does not require anesthesia, IUIs are provided at your local office.
“If a couple does 3 cycles of IUI and doesn’t get pregnant,” says Dr. McClamrock, “then we would usually suggest they move onto IVF, often with ICSI, even if the male factor infertility is mild.”
ICSI, which is short for Intracytoplasmic Sperm Injection, is a process in which an embryologist injects a single, healthy sperm into the cytoplasm, or center, of each egg. This process of fertilization only requires one healthy sperm per egg. ICSI is one of the most incredible advances in fertility treatment because it allows for fertilization even in cases of severe male factor infertility.
“For several decades physicians have tried to help men with male factor infertility. Treatment for male factor infertility was revolutionized some years ago with the introduction of ICSI,” says Dr. McClamrock. “ICSI is the answer for almost every male factor problem.”
To use ICSI, the couple must undergo In Vitro Fertilization (IVF). For IVF, the female has daily injections of fertility medications, for several days, which result in the maturation of many eggs inside her ovaries and prepare her uterine lining for pregnancy. Once the follicles containing the eggs have grown to a sufficient size, an egg retrieval procedure is performed. When the mature eggs are taken to the laboratory, the embryologist will perform ICSI and fertilize each egg individually. After 5-6 days of development, the best embryo will be transferred into the woman’s uterus where it has the chance to implant and develop into a pregnancy.
YOUR CHANCES ARE GOOD
Guys aren’t jumping at the chance to get their semen analyzed, but it’s a painless, simple test that is critical to fertility treatment – and the earlier you know the results, the better your chances of success.
“If you wait too long, the aging process can start to create difficulties on the female side, even where there were none before. Then, treatment becomes more complicated,” says Dr. McClamrock. “If all you have is male factor infertility, then we’re going to be able to help you, and the treatment most likely will be fairly easy.”
No man wants to find out that he has male factor infertility. The good news is that there are so many effective ways to treat it that it shouldn’t prevent him from becoming a dad.
Editor’s note: This blog was originally published in October 2014, and updated for accuracy and comprehensiveness as of November 2020.
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