Assisted Reproduction
Some of the ART procedures described as treatment for female infertility are relevant to certain types of male infertility. These include Intracytoplasmic sperm injection (ICSI) and In Vitro Fertilization (IVF).
ART (Assisted Reproduction Technology)
| Procedure | Description | Indication | Remarks |
| Artificial insemination | Large numbers of healthy sperm are injected at the entrance of the cervix or high in the uterus, bypassing the cervix and giving direct access to the fallopian tubes. Prior to injection, sperm is specially prepared in the laboratory to maximize its fertilizing ability. |
Existence of sperm antibodies in a woman’s cervical mucus. Male infertility due to low sperm count or low number of healthy sperm (see also ICSI). Other sperm abnormalities which prevent fertilization (see also ICSI). |
A minimum of viable sperm needs to be available – chances of success decrease if sperm count is low or if only a few spermatozoa are motile. |
| IVF (In Vitro Fertilization) | Hormone therapy with gonadotropins is given to stimulate the ovaries to produce several mature eggs. Eggs are retrieved and fertilized in vitro with either the partner’s or donor sperm. If fertilization occurs within 24 to 28 hours, one or more embryo(s) are placed in the uterus. |
Treatment of infertility due to fallopian tube occlusion and endometriosis. Male infertility due to sperm abnormalities which prevent fertilization. Some cases of unexplained infertility. |
As fertilization occurs in vitro, IVF used in male infertility can serve to detect specific sperm abnormalities, such as the inability of seemingly good quality sperm to fertilize. |
| GIFT (Gamete Intra – Fallopian Transfer) |
Follows same procedures as IVF except that fertilization occurs in the body (in vivo). Spermatozoa and eggs are placed directly into the fallopian tubes where fertilization can occur. |
Infertility due to endometriosis and cervical mucus disorders. Unexplained infertility. Some cases of male infertility. |
Can only be practiced if fallopian tubes are healthy. There is no way to verify that fertilization has taken place, since it occurs in vivo. |
| ZIFT (Zygote Intra – Fallopian Transfer) |
Same procedures as IVF except that fertilized eggs are placed in the fallopian tubes at a certain stage of embryo development (zygote). | Same as for GIFT. | Can only be practiced if fallopian tubes are healthy. |
|
ICSI |
An in vitro microsurgical fertilization technique in which a single sperm is selected and injected into an egg. Performed with eggs obtained after ovulation stimulation, as per IVF. |
Male infertility when very few normal sperm are available and/or Fertilizing ability of sperm is dramatically reduced. | Has become an alternative to artificial insemination with donor sperm |
| MESA (Microsurgical Epididymal Sperm Aspiration) |
Spermatozoa are retrieved directly from the epididymis (area in the testes where spermatozoa mature and are stored). Fertilization is then attempted with ICSI. |
Severe male infertility. Absence of sperm in the ejaculate (azoospermia). Congenital abnormalities (e.g. absence of vas deferens). | Usually enough sperm can be retrieved from one procedure to be frozen for later use if required. |
|
TESE |
Biopsy of the testes is performed in order to obtain spermatozoa directly from testicular tissue. Fertilization is then attempted with ICSI. |
Severe male infertility. Absence of sperm in epididymis. Absence of epididymis. |
Option if MESA is not possible. |
In Vitro Fertilization (IVF) was the first ART procedure and is still the most commonly used.
During an IVF cycle, eggs and sperms are collected and placed together in a laboratory dish (in tubes historically and hence the name “Test-Tube baby treatment”) to fertilize. Hormonal medications are usually used to help stimulate development of as many eggs as possible. If the eggs are successfully fertilized in the lab, they are transferred into the woman’s uterus. Ideally, one of the fertilized eggs will implant and develop, just as in a routine pregnancy.
Stage 1: Ovarian stimulation, monitoring, and ovulation triggering
Having a greater number of mature eggs available for fertilization increases the chances for achieving pregnancy. Since a woman’s body normally releases only one mature egg every month, hormonal medications are used to stimulate the ovaries to develop more ovarian follicles. Follicles are fluid-filled sacs in which eggs mature. The medications also control the timing of ovulation to make it easier to retrieve the eggs.
Monitoring Ovarian Stimulation:
Your doctor may use ultrasound to obtain images of your ovaries and monitor the number and size of maturing follicles. Since developing follicles secrete increasing amounts of oestrogen, blood tests are used to monitor hormone levels, which help determine the best time to administer medication and time egg retrieval.
Stage 2: Egg Retrieval
Once ovarian stimulation is complete and follicles have matured, your doctor will try to retrieve as many eggs as possible, although all the eggs may not be used in the current IVF cycle.
Egg retrieval is performed under local anaesthesia. The mature follicles are identified using ultrasound, and then a needle is passed through the vagina to withdraw the fluid from the mature follicle with gentle suction. The fluid is immediately examined under a microscope to see if an egg has been retrieved. The process is repeated for each mature follicle in both ovaries. All retrieved eggs are removed from the follicular fluid and placed in an incubator.
Vaginal progesterone treatment may be started the evening after retrieval to help prepare the uterine lining to receive a fertilized egg.
Stage 3: Fertilization
About two hours before the eggs are retrieved, a semen sample is collected from the male partner and processed to select the strongest, most active sperm. The sperm are then placed with the eggs in an incubator set to the same temperature as a woman’s body. The next day, the eggs are examined under a microscope to determine whether fertilization has occurred. If it has, the resulting embryos will be ready to transfer to the uterus in about 72 hours.
Stage 4: Embryo Transfer
Embryo transfer is not a complicated procedure and can be performed without anaesthesia. The embryos are placed in a tube and transferred to the uterus. The number of embryos transferred depends on a woman’s age, cause of infertility, pregnancy history, and other factors. If there are additional embryos that are of exceptional quality, they may meet the guidelines for freezing (cryopreservation) for later use.
Intracytoplasmic sperm injection (ICSI) is a micromanipulation technique in which fertilization is brought about by the injection of a single sperm into an unfertilized egg (or oocyte, – see illustration 2). ICSI is performed with eggs obtained after ovulation stimulation as for IVF, and has greatly improved the treatment of male infertility occurring as a result of severe oligozoospermia.
ICSI requires only one sperm for each egg and because of this, its indications have been expanded to include nearly all men with serious infertility, including many who would previously have been considered hopeless/impossible cases. Provided the spermatozoa are viable, even sperm dysfunction may be overcome, since more than 50% of eggs fertilize normally regardless of the sperm quality. Obstructive azoospermia can also be treated by retrieval of spermatozoa directly from the testes and even immature spermatozoa have been used to produce embryos.
Intracytoplasmic Sperm Injection (ICSI)
The success rates in ICSI are greatly influenced by the quality of sperm preparation and by the skill of micromanipulation. ICSI, combined with IVF, is the most effective treatment for male infertility with a success rate of 20-25% of treatments resulting in a live birth.
When infertility is caused by anatomical problems or abnormalities found in the male reproductive system, all but the most severe cases can usually be corrected using a variety of surgical procedures.
Sometimes, the cause of infertility can be traced to past infections or inflammation that left scarring or adhesions. This condition can often be surgically corrected to improve fertility.
In many cases, surgery may be all that is needed to restore a man’s fertility. However, these procedures are frequently part of a more comprehensive approach and may be utilized in conjunction with other therapies.