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Treatment options

Details the treatment available for the different forms of male factor infertility.


Management options for male factor infertility

There are several treatment options available to patients with male factor infertility. In some cases the cause of infertility is correctable, while in others it is not. Treatment options may include one of the following techniques: following health advice, drugs, surgery, IUI, IVF, ICSI, donor insemination and adoption. The choice that is right for a couple is not always clear and other factors such as the age of female partner and the presence of other infertility factors such as tubal blockage need to be considered when making a decision.

Health advice

This may include e.g. cut down or stop smoking and alcohol consumption, loose weight if overweight, avoid hot baths and takes shower instead, wear loose boxer shorts, avoid exposure to chemicals and pesticides, stop taking social drugs etc. These simple measures are sometimes sufficient to improve the sperm count and quality. But, it is important to remember that it may take up to 3-12 months before any improvement in sperm is seen.

Drugs

Many drugs have been used empirically in the treatment of male infertility without firm evidence that they work e.g. clomiphene (clomid), tamoxifen, masterolone (pro-viron), steroids, and antibiotics, etc. Owing to the long duration of the sperm cycle (about 70 days), the treatment must be continued for a period of up to six months. In addition, there may be unpleasant side effects. It is not possible to predict whether or not a patient will respond to this sort of treatment. However, in a few cases some drugs have been shown to be very effective. Approximately one third of male factor infertility is considered to be due to the damaging effects of oxidative stress on sperm. Oral Antioxidant supplementation such as vitamin C and vitamin E, carinitines, selenium etc may improve sperm quality by reducing oxidative stress.

Tablets

For example bromocriptine for men with sexual dysfunction due to excess production of prolactin. Viagra for impotence.

Injection

Patient with hypothalamic pituitary failure such as those with Kallmans syndrome can be treated with gonadotropin injections. These offer a high chance of natural conception. Combination treatment is required including FSH or hMG and hCG. These drugs are also effective for men in whom the pituitary glands do not produce enough FSH and LH which are needed for the production of sperm (about 0.5% of cases). GnRH pumps can be used as an alternative treatment. The disadvantage being that the treatment has to be continued for several months and that the injections are expensive.

Surgery

Surgical management of male infertility has advanced significantly over the last decade. There are a number of surgical procedures that may be used in restoring male fertility. If surgery is successful it would allow for conception through intercourse, allows the couple to have subsequent children without additional medical treatment. Furthermore it avoids the risks associated with treating female partner such as multiple pregnancy and ovarian hyperstimulation syndrome.

Varicocele ligation

This is a simple operation where the distended veins surrounding the vas are either tied off or injected with a chemical solution to block them. It is carried out under a general anesthetic and is usually performed as a day-case surgery. Percutaneous embolization is a new technique that aims at blocking off the refluxing internal spermatic vein(s) using a coil or a balloon. It is a mini invasive surgical procedure. It is done in the X-ray department. None of the two methods has been proven to be superior to the other. Surgical treatment of varicocele may be of benefit to men who have large varicocele and low sperm count. Most studies have reported improved semen quality following varicocele repair. In the absence of a female factor infertility, pregnancy rates of up to 50% within one year following surgery are claimed.

Reversal of vasectomy

Up to 6% of vasectomised men return for reversal. This is a simple operation, which is done under a general anesthetic and involves rejoining the two ends of the vas together. The best results are achieved when microsurgery techniques are used. The operation is usually successful in about 70-90% of cases but not all of them will achieve a pregnancy. The longer the time since the vasectomy the greater the chance that sperm production may be permanently damaged. Also, the presence of high levels of antisperm antibodies may adversely affect the outcome. Pregnancy after vasectomy reversal usually occurs naturally after 6-9 months unlike surgical sperm retrieval immediate result. Vasectomy reversal is much cheeper than IVF and ICSI (Fertility and Sterility journal 1997). In the absence of a female factor for infertility, vasectomy reversal should be offered as a first option for couples seeking conception after vasectomy.

Unblocking the vas (vasovasostomy) and connecting the vas to the epididymis (vasoepididymovasostomy).

The operation involves removing the obstructed tissues and joining the ends together using a microsurgical technique. If the obstruction in the vas is near the epididymis, the vas may be rejoined to the epididymis. The operation is performed under a general anesthetic. The patient may need to stay in the hospital for 1-2 days and should be able to resume normal activities in 1-2 weeks. The result of the operation will depend on the extent and site of the obstruction. The operation may be considered as an alternative to surgical sperm recovery and IVF.

Transurethral Resection of the Ejaculatory Ducts (TURED)

This is a surgical procedure and involve the insertion of a minitelescope through the urethra and cutting both ejaculatory ducts. The procedure may be recommended to treat ejaculatory duct obstruction . It can be done under a general or a spinal anesthetic.

Intrauterine insemination

The procedure intrauterine insemination is an effective treatment in mild male subfertility (The INeS Study Group BMJ 2015).

IVF

In vitro fertilization, IVF, is the main form of treatment for men with moderate sperm quality or quantity or both.

ICSI

Intracytoplasmic sperm injection, known as ICSI, may be considered if the sperm count is very low. About 28% of men with azoospermia on general laboratory testing were found to have sufficient sperm in their centrifuged semen samples to proceed with IVF with ICSI without resorting to surgical sperm retrieval or donor sperm (Swanton and Child, Human Reproduction, 2006).

ICSI and surgical sperm retrieval

Techniques like PESA or TESA may be used to collect sperm from men with obstructive azoospermia. Cystic fibrosis is associated with azoospermia due to congenital absence of vas deferences and if the female partner is a carrier the couple would be advised to have IVF with ICSI, surgical sperm retrieval and PGD in order to avoid having a baby with cystic fibrosis. About 50 percent of men with non-obstructive azoospermia have foci of sperm, including 30 percent of men with Klinefelters syndrome(47,XXY). These men may be able to father their own children using using advanced reproductive technology including TESE (testicular sperm extraction), ICSI and PGD.

Stem cell based treatment is a possible option in the near futrue where men who suffer from non obstructive azoospermia. It may allow couple to have natural conception after autotransplantation of in sperm stem cells into the testicles.

Donor insemination

About one in 200 infertile men choose donor insemination if they have no sperm because of total germ cell aplasia, or damaged testicles, or are carrier of genetic abnormality or have refractory erection or ejaculation problem. donor insemination may be considered.


Adoption

Finally, adoption may be considered.

Accepting a childfree living.

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