Treatments for Male Infertility
Fertility Preservation in Cancer Patients
Division of Reproductive Endocrinology
The inability for a couple to have a baby is a source of great frustration and sadness. For couples having difficulty conceiving, the University Fertility Center offers hope. The University Fertility Center is part of The University of Texas Medical Branch at Galveston (UTMB) Division of Reproductive Endocrinology and Infertility. Endocrinology is the study of organs that produce hormones involved in fertility and reproduction. The UTMB Infertility Program has been helping couples start families for 25 years.
The problem of infertility should not be faced by the patient alone, but by three people - the husband, the wife, and their physician. When all three work together to investigate the problem, there is a better chance of finding a solution and making pregnancy a reality. Since a couple's infertility can be caused by problems in either the husband or the wife, it is best for both to be present during the first visit and initial evaluations.
When Should a Couple See a Specialist?
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If the woman has ever had a pelvic infection, and attempts to conceive have failed for six months. Pelvic infections can cause problems with the fallopian tubes that contribute to infertility.
If the woman has irregular menstrual cycles, which indicate that ovulation (release of eggs) does not occur every month, and attempts to conceive have failed for six months.
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If attempts to conceive have failed for one year.
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15-20% of couples who want to conceive have infertility problems.
Infertility problems can result from either the man or woman. In 15-20% of infertile couples, both the man and woman have problems.
University Fertility Center Services
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Tubal Reconstructive Surgery
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Microsurgical Reanastomosis
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Artificial Insemination from Donor
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Intrauterine Insemination
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Advanced Male Infertility Tests-Sperm Penetration Assay (SPA)
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Hysterosalpingogram
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Fertility Drugs
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Ultrasound Ovulation Monitoring
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Evaluation and treatment of excessive facial hair growth
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Comprehensive care of menopausal women
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Evaluation of delayed puberty
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Reconstruction of developmental anomalies of the reproductive tract
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Bone Density Studies (DEXA)
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Patients receive appointments with board-certified or board-eligible reproductive endocrinologist. These specialists are gynecologists who have had two or more years of special training in treating infertility and gynecologic endocrinology problems. They have expertise in the areas of hormone treatment, surgical reconstruction of the tubes and the reproductive tract, in vitro fertilization, GIFT, and other modern reproductive technologies. As part of an academic medical center, the physicians have access to the latest approaches in the diagnosis and treatment of infertility.
What Happens During a Basic Fertility Evaluation?
Infertility tests for a man may include:
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Semen analysis
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A test for sperm antibodies
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Sperm penetration assay (SPA), which is a test to see whether sperm are capable of penetrating the egg
A woman is tested to determine whether she is ovulating. The procedures will include:
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A basal-body temperature chart, which indicates the day of ovulation in each cycle
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Blood tests to determine progesterone level
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An endometrial biopsy, in which a small piece of the uterus lining is removed for evaluation by the pathologist. It is a simple office procedure that determines whether a hormonal deficiency is preventing the fertilized ovum from implanting itself in the uterus.
If these procedures show that there is no ovulation, then ovulation can usually be induced with fertility drugs such as Clomid®, Bravelle®, Repronex®, Follistim®, or Gonal-F®.
Hysterosalpingogram
This is an X-ray of the uterus and fallopian tubes to determine if the tubes are open and to detect defects in the uterus lining that could be preventing implantation. It is an outpatient procedure performed by the UTMB Department of Radiology.
Laparoscopy
Laparoscopy at UTMB's Day Surgery Unit is performed under anesthesia to diagnose abnormalities in the tubes, ovaries, and other pelvic organs. This procedure provides a clear visual picture of the organs and is also used to treat endometriosis and pelvic adhesions.
Information About Modern Reproductive Technologies
In Vitro Fertilization (IVF)
In vitro
fertilization is a process by which, in the laboratory, eggs and sperm
obtained from the infertile couple are combined in a culture dish in an
incubator. When fertilization takes place under these controlled conditions,
one or more eggs are transferred into the woman's uterus, where it is hoped that
the egg will implant itself, grow, and result in a normal pregnancy.
The in vitro fertilization program is a team effort involving reproductive endocrinologists, nurses, embryologists, andrologists, and anesthesiologists. Care is provided not by a single physician, but by a team of physicians and nurses.
When Should a Couple Consider IVF
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Infertility has not responed to conventional methods of treatment and one or more of hte following factors are involved:
Unsuccessful tubal surgery
Uncorrectable tubal obstruction
Low sperm count
Endometriosis
Poor cervical mucus
Sperm antibodies
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No reason for infertility has been found after thorough evaluation, and the couple has failed to conceive after the GIFT procedure
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The woman has at least one functional ovary and a functional uterus
Steps in the IVF Procedure
1) Fertility drug injections to induce multiple follicular development
Early in the menstrual cycle the woman is given injections of a fertility drug such as Bravelle®, Repronex®, Follistim®, or Gonal-F® to stimulate the ovaries to develop more than one egg. Two to four fertilized eggs are transferred to the uterus to increase the chances of successful pregnancy. Fertilization and transfer of more than one egg increases the likelihood of successful pregnancy; at the same time, it increases the chance of twinning and other multiple pregnancies. However, in most instances, only one egg implants and develops. If more than four eggs are fertilized, the rest of the eggs are frozen and preserved for transfer in subsequent cycles.
2) Ultrasound monitoring
Success with in vitro fertilization is closed related to harvesting the eggs at the right time. Hormone levels in the blood are monitored daily after the first four or five days of fertility-drug injections; as the follicles grow, they are monitored through a series of ultrasound examinations. Ultrasonography is a procedure that uses high-frequency sound waves to provide a picture of the ovaries and the growing follicles.
Just before ovulation, when the size of the follicles and the level of the hormone estradiol are optimal, an injection of another hormone (Human Chorionic Gonadotropin) is given. This hormone will cause the eggs to be released 36 hours after it is injected, and retrieval is scheduled for that time.
3) Egg retrieval
Eggs can be taken from the ovaries either by transvaginal ultrasound-guided retrieval or laparoscopic techniques. The technique used depends on the accessibility of the ovaries.
Transvaginal ultrasound-guided retrieval is usually performed under conscious sedation. The ultrasound probe is introduced into the vagina and the follicles are located. Then, the aspiration needle is passed through a guide into the pelvic and the follicular fluid is aspirated.
In laparoscopy, a laparoscope is introduced through a small incision just below the navel to visualize the ovaries. Another instrument, which is used to position the ovaries and hold them steady, is introduced through a second, smaller incision made in the lower abdomen. A needle, passed through the laparoscope, aspirates (draws out) the follicular fluid, which contains the eggs.
The fluid aspirated from the follicles containing the eggs is transferred to a special laboratory where the eggs are identified under a microscope, transferred to a special culture medium, and placed in an incubator.
A sperm specimen is obtained from the husband at the time of egg retrieval. Another sperm specimen, obtained and frozen one week earlier, will be used if the sperm sample obtained on the day of laparoscopy is not optimal.
The egg and the sperm are combined in a culture dish, and the dish is placed in an incubator for 48 hours. This process of fertilization outside the human body is referred to as in vitro fertilization.
Even under normal physiological conditions, fertilization does not always occur when a sperm and egg meet, and sometimes an egg is fertilized but does not develop further. When fertilization and development do occur, the eggs are transferred to the uterus three to five days after egg retrieval.
4) Egg transfer
The fertilized egg is transferred to the uterus by way of a small plastic catheter; the procedure requires no anesthesia. Progesterone, a hormone that prepares the lining of the uterus for implantation, will be administered daily (after transfer) either by injection, vaginal suppositories, or as a gel (Crinone gel®).
Obstetrical Care
A test for pregnancy is performed about two weeks after the fertilized eggs are transferred to the uterus. If the test is positive, progesterone treatment is continued for another eight weeks. Prenatal care after in vitro fertilization is the same as for any other pregnancy and may be provided by your obstetrician.
IVF Time Commitment
1) Consultation visit
2) Brief visits for five days or more for ovulationinducing injections (injections may be administered by your regular physician, or your husband could
be trained to give these injections)
3) Visit for blood samples and ultrasound examination every morning for three to seven days before egg retrieval
4) One day for transvaginal ultrasound aspiration
5) One day in the clinic for egg transfer
It is important for couples to understand that IVF is attempted only when all conventional methods of treatment have failed. The probability of pregnancy in any attempt of IVF is approximately 40 percent. This average may be higher in women under 30 years of age, and lower in women over 40. The average number of attempts is three. Couples who achieve pregnancy without medical intervention do so only after an average of three months. In vitro fertilization is a time-consuming, expensive process, but it is the only option for women with damaged tubes and for those who have exhausted all other treatments.
Cryopreservation-Frozen Embryo Transfer (FET)
In the majority of IVF or GIFT cycles, stimulation of the ovaries by fertility drugs results in development of several follicles and retrieval of multiple eggs. Usually, only three to four eggs are transferred immediately in that cycle. The rest of the fertilized eggs are frozen and stored in a special freezer. With the current programmable freezing method, 60 to 80 percent of embryos are viable after thawing. One of the advantages of Frozen Embryo Transfer (FET) is that the transfer will occur in a natural ovulatory cycle. When stimulating drugs are not used, endometrial receptivity is improved and implantation is more likely.
Additional Modern Reproductive Technologies Available
Oocyte Donation Program
Most donor eggs are obtained from anonymous donors. IVF with donor eggs has the highest pregnancy rate since the egg donors are always less than 35 years old. The alternate source of eggs is close friends or relatives who are willing to undergo ovarian stimulation and egg retrieval for the sole purpose of donating eggs. Oocyte donation presents many medical and ethical questions which should be considered before the oocyte donation procedure is initiated.
Few Treatments for Male Infertility
Microsurgical Epididymal Sperm Aspiration (MESA)
Possible indications for this procedure include congenital absences of the vas deferens or failed vasectomy reversal. Sperm aspirated from the most proximal regions of epididymis are the most recently produced and have the best motility. This sperm is then used for ICSI and IVF or GIFT procedures.
Intracytoplasmic Sperm Injection (ICSI)
This technique facilitates laboratory fertilization via the microinjection of one sperm inside the egg. Sperm with a low motility can thus be helped to penetrate the shell around the egg (zona pellucida) and achieve sperm-egg fusion. A single living sperm, even with poor motility, can fertilize the egg. Only the microinjection aspect of this technique, done in the laboratory, differs from conventional IVF.
In ICSI, the woman must follow the same procedure as for IVF with ovarion stimulation and ovum pick up, followed by laboratory fertilization and embryo transfer after 48 hours.