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There is not a more confusing type of medical care in the field of fertility than what is delivered by many urologists to the couple that suffers from "male infertility." In fact, many couples are told to delay the IVF treatment they should have had sooner (because of the wife's/partner’s advancing age). The result is that the couple just waits for some dubious treatment to increase the male partner’s sperm count. Numerous control studies have demonstrated that administering clomid or nutritional supplements to the male does nothing to improve sperm count. Often, the suggested testosterone supplements just lowers rather than raises his sperm count, and may even render him totally sterile.
In most communities, many infertile men are sent to a urologist who almost always recommends a "varicocoelectomy." This procedure ties off a varicose vein from the testicle. More than 15% of all men have a varicose vein in their left testicle, and most of these men are quite fertile. It is a completely benign and normal variant of testicular anatomy. Yet often the man is subjected to this completely meddlesome surgery, despite the absence of a varicocoele, and despite its ineffectiveness in improving his sperm count. Varicocoelectomies are ironically quite effective in delaying the treatment the couple really needs, and all the while the wife's/partner’s eggs just keep getting older. Furthermore, if done clumsily, a bilateral varicocoelectomy can reduce the male partner’s/husband’s merely low sperm count down to a zero sperm count.
So what is appropriate treatment for male infertility in an infertile couple? For most men with low sperm counts, there is no treatment which will raise the sperm count. Sperm counts are genetically determined. In cases of low sperm count, it is best to go directly to IVF and ICSI (which is injecting sperm into the egg) before the wife’s/partner’s eggs become so old that the process becomes a compounding problem.
Azoospermia
There are many infertile couples in whom the male is completely azoospermic (that is, no sperm at all in the ejaculate). For these cases, the urologist is actually needed, but again often their treatment is poorly performed. If the azoospermia is not caused by a previous vasectomy, it is usually not correctable with reconstruction, and then sperm retrieval with IVF and ICSI is necessary. In fact our male specialist, Dr. Sherman Silber’s center was the first to invent sperm retrieval with ICSI for azoospermic men in the 1990s. Dr. Silber has the greatest expertise and experience with this process.
There are two entirely different situations and causes for no sperm in the ejaculate (azoospermia): obstructive and non-obstructive. For obstructive azoospermia, (aside from a vasectomy, which is reversible with reconstructive microsurgery) there are men who were born with absence of the vas. Most of these men have a mutation on their CF (cystic fibrosis) gene or chromosome 7, but do not have cystic fibrosis. They just never developed a vas deferens in fetal life. The man does not discover this problem of no sperm in the ejaculate until they actually try and have children. In this case, there is no vas to reconstruct, and so the only way they can have children is to microsurgically retrieve sperm from their epididymis and inject this sperm into the wife's/partner’s eggs via IVF. This procedure is virtually 100% successful.
The second type of azoospermia is "non-obstructive." This means there is no obstruction, but the patient "appears" to have no sperm production at all in his testes. Usually this is partly just an illusion. The majority of such patients do have a tiny amount of sperm production in their testes, however it is not quantitatively enough sperm production to "spill over" into the ejaculate. These cases should usually, but not always, be successful in retrieving enough sperm for successful IVF and ICSI.
In both types of sperm retrieval, obstructive and non-obstructive, it is important to use precise microsurgical techniques rather than just "needle sticks" to have the highest percentage of success and also the least amount of pain or complications. Unfortunately, this is not always the case, and some male partners/husbands have fairly horrible experiences. In summary, male infertility treatment, short of IVF and ICSI, should be limited to microsurgery for azoospermia, with careful thought about making your choice of where to go for such treatment.
If you have any questions, you may call us at (212) 400-9624.
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