In part 2 of our review of the new Male Infertility guidelines from the American Urological Association (AUA) and American Society of Reproductive Medicine (ASRM), we address the medical and surgical treatment of male factor infertility.
One of the most important new guidelines addresses the use of testosterone in men of reproductive age. Testosterone use has been found to shut off sperm production, and is NOT indicated in the treatment of male factor infertility. Patients with low testosterone may be treated with “off label” use medications such as clomiphene citrate or “clomid,” which is a selective estrogen receptor modulator, or human chorionic gonadotropin (hCG), or a combination of these medicines. These medications will increase testosterone but do not have a negative effect on sperm production.
Another new guideline addresses the use of follicle-stimulating hormone (FSH) analogues with the aim of improving sperm count, pregnancy rate, and live birth rates in partnerships where men possess unexplained infertility. Although these studies are old, there is data to show that FSH can be a benefit to men. Unfortunately, FSH medications can be expensive and may not be covered by insurance plans.
Men who have a clinical varicocele, which are dilated veins around the testicle that are identified in a physical exam by a reproductive urologist, should consider surgical repair to help improve abnormal sperm parameters. In this patient population, with healthy, fertile female partners, a significant number of men see an improvement in semen quality. In patients who have non-palpable varicoceles, which are dilated veins detected only by imaging, these should not be repaired as they do not typically result in improved semen quality. A specialized reproductive urologist can be helpful in determining the difference.
For men with obstructive azoospermia there are two options to achieve a pregnancy: reconstruction or surgical sperm retrieval with in-vitro fertilization (IVF), or a combination of the two. This patient population should be counseled regarding both of these options. The most common cases of azoospermia are the result of a prior vasectomy or blockages in the epididymis. In the patients who choose surgical sperm retrieval, this procedure can be performed in conjunction with their female partner’s IVF cycle or performed prior to an egg retrieval and then frozen.
In patients who have no sperm in their ejaculate as a result of low sperm production (non-obstructive azoospermia), a procedure called microsurgical testicular sperm extraction or “microTESE” should be performed to give the best results in finding sperm. 50% of the time, sperm can be identified and combined with oocytes in vitro to achieve a pregnancy.
At Yale Urology, our experienced urologists offer our patients medical and surgical treatment of male factor infertility and have specific expertise in micro surgical skills. We would be happy to discuss any of these options with you and your partner so you can make an informed personal decision. We welcome your call at 203-785-2815.