Diagnosis: Male Factor
What Male Factor Infertility Means and Its Impact on Fertility
Male factor infertility (MFI) means, simply put, that a man has a lower than normal chance of fertilising an egg without assistance. "Lower than normal" may mean anything from slightly reduced to zero chance.
MFI is common. Statistics show 30-40% of infertile couples suffer exclusively from male factor infertility, 30-40% exclusively from female factor infertility, and the rest from unexplained or combination factors involving both partners. This serves to highlight the fact that infertility is far from being a female-only problem--in fact, the problem is equally likely to rest with the male. The reason behind a man's infertility is mostly elusive and unlikely to change the options for treatment.
Happily, MFI carries a generally good prognosis as long as some sperm are being produced. Amongst IVF patients, only those with tubal infertility are more likely to conceive. On the downside, if MFI is severe enough there is no hope of a "surprise pregnancy".
Sperm may lack the ability to fertilise an egg for one of a number of reasons:
- Count: Contrary to what you were told at school, it actually takes a minimum of between half and one million healthy, rapidly-motile sperm to fertilise a single egg. This equates roughly to a post-wash count of five to seven million sperm per ml. This is because sperm work together to navigate their way through the inhospitable environment of the female reproductive tract. It's physcially impossible for a single sperm to make a successful journey all by itself. So much for "it only takes one". Count may be reduced because of lack of production in the testicles, or failure of sperm to get from the testicles into the ejaculate (for example blockage/previous vasectomy).
- Motility: Only rapidly motile sperm can reach and penetrate an egg. Even if fertilisation happens in vitro, motility is required to get through the "shell" of the egg.
- Morphology: This is much less important than you might think, especially if you are using ICSI. The DNA contained in the head of abnormally-shaped sperm is just fine.
- Anti-sperm Antibodies: Antibodies can cause a loss of motility, the clumping together of sperm, and the inability for the sperm to fertilise an egg. This is much more common in men who have had vasectomies.
- Sperm DNA Fragility: This means the DNA carried in the head of the sperm is damaged. The somewhat controversial belief is that higher levels of DNA damage will lead to greater numbers of genetically abnormal embryos being formed, resulting in implantation failure and early pregnancy loss.
Standard Semen Analysis: This will give an indication of count, motility and morphology. It will also give details of any other cells - for example white blood cells - which may indicate infection.
Post-wash Semen Analysis: Some specialists like to analyse the sample after washing, as if for an IUI. This will give a more accurate indication of whether the sample is good enough for IUI or whether IVF will be needed.
Antibody Tests: This is most reliably done on a semen sample. Tests include the immunobead assay and the mixed agglutination reaction. Results are given as a % of sperm with antibodies attached.
Sperm Chromatin Structure Assay: This is the test for DNA fragility. It's performed on a semen sample. Results are given as a DNA Fragmentation Index which aims to indicate what % of the DNA is damaged.
TESA/MESA/testicular biopsy: If no sperm at all are found in the ejaculate, an aspirate or biopsy may be taken to hunt for sperm in the epididymus or testicle. There's a big difference between a few sperm and no sperm at all.
Hormone assays: This is a blood test. FSH means much the same thing in men and women. High FSH indicates poor response by the testicles (or ovaries). Testosterone is usually also measured, and sometimes other hormones such as LH and prolactin.
Karyotyping: Some males have abnormal genes which affect fertility, such as the XXY karyotype which is known as Klinefelter's Syndrome, or the cystic fibrosis gene which can cause anatomical defects in the sperm transport system. Balanced translocations can also occur in males as well as females.
Physical examination and ultrasounds: You may be referred to a urologist for physical examination and ultrasound of the testicles and prostate. Two of the most common things to look for are varicocoeles and prostatic disease.
Treatment of MFI is centred on IUI, IVF, and ICSI. IUI can be used to give a marginally poor ejaculate a "head start". IVF is used for more severe male inferility, and ICSI is used where the severity is such that sperm are no longer able to penetrate the egg by themselves at all. TESA/MESA or testicular biopsy are sometimes used to retrieve sperm, especially if none are present in the ejaculate. Some couples use donor sperm with IUI or IVF.
Many other options have been suggested. It's important to note that because it takes a while for sperm to be produced, any treatment which aims to improve semen quality will take three to six months to produce results.
Lifestyle factors such as overheated testicles (sauna/hot baths), smoking, or drug use can affect semen quality. These must be eliminated. In a few cases, this might be enough to resolve the problem.
Many dietary supplements, naturopathic remedies, and alternative therapies have been suggested over the years, including arginine, B vitamins, coenzyme Q10, SAMe, ginseng, vitamin C, zinc, L-carnitine, co-enzyme Q10, vitamin E and selenium, omega 3 fatty acid supplementation, and acupuncture. Sadly, studies fail to consistently support any benefit. However, when used as recommended there seems to be no harm, either.
Hormonal supplements are used by some specialists. Supplementing directly with testosterone seems to actually reduce male fertility, but clomid and FSH have been used to stimulate testicles into production. A limited number of studies show a marginal benefit, but not enough to replace the use of IVF/ICSI.
Sperm DNA fragility is treated using ICSI, which seems to produce a higher pregnancy rate than plain IVF in this group, and also TESA/MESA, the aim of which is to use the freshest sperm possible, based on the theory that most DNA damage happens whilst the sperm is being stored in the body. Men may also be advised to ejaculate frequently (ie daily) to reduce storage time.
IVF is the most successful treatment for antisperm antibodies, with ICSI used if fertilisation fails to occur. IUI is also an option in some cases.
Variocoelectomy remains controversial. Some studies show benefits and others show no benefit at all. Some specialists believe there are select groups of patients in which the surgery is worthwhile. Be sure to discuss the pros and cons fully with your doctor.
Vasectomy reversal is most successful in cases where modern techniques have been used, and where the vasectomy was fairly recent (less than a couple of years). A successful reversal produces sperm in the ejaculate but count, motility and antibodies may still warrant assisted conception. Discuss the pros, cons, costs and chances of success carefully with your doctor prior to surgery.
Infections, prostatic disease or other conditions should be treated as indicated. If there has been prolonged or severe insult to the testicles, assistance may still be needed to achieve pregnancy.
It's pretty clear from our semen analysis that IVF/ICSI is the only way we're going to be able to achieve a pregnancy using our own gametes. Obviously this is not good news, but at least we have the chance to try. Our other options are sperm/embryo donation or adoption. No good reason has been found for our diagnosis, but the chicken pox Mr Bea contracted for the first time at sixteen years old is a possible culprit.
The biggest thing that strikes me about male factor infertility is the stigma. There are few men who are confident enough to talk about their diagnosis openly, and I find myself restricted from talking about our problems with friends and family at the express request of my husband, who wants his diagnosis to remain private. If I do tell someone we're doing IVF, it's automatically assumed we have a female factor problem.