Infertility in Men

Description

Other Treatments

Hormone therapy has been effective for women with infertility problems, but has been disappointing in men except in a few specific cases:

• Gonadotropin-releasing hormone (GnRH) is often very helpful in restoring fertility in men with gonadotropin deficiency and hypogonadism.
• GnRH may be useful for restoring sperm production after chemotherapy treatments.
• Sperm production occasionally responds to low doses of estrogen and testosterone or testosterone alone, menotropins (Pergonal, Repronal), clomiphene citrate (Clomid), human chorionic gonadotropin (hCG), or human follicle-stimulating hormone (r-hFSH, Gonal-F).
• Prolonged treatment with follicle-stimulating hormone (FSH) prior to ICSI may improve implantation rates.
• Aromatase inhibitors block aromatase, an enzyme that is a major source of estrogen in many major body tissues. These agents include anastrozole (Arimidex) and letrozole. (Femara). They may be helpful for specific men whose infertility is associated with an abnormal testosterone-to-estrogen ratios.

Nonhormonal Agents

Bromocriptine. Bromocriptine (Parlodel) is used in men whose infertility is related to excess prolactin manufactured by the pituitary.

Antibiotics. Infections interfering with fertility may be successfully treated with antibiotics.

Mast Cell Blocking Antihistamines. Studies report that certain antihistamines that block mast cells may be beneficial for some men with low sperm counts. Mast cells are inflammatory immune factors that may play a role in lower sperm quality. Studies have reported that two such agents used overseas, ebastine and tranilast, improved pregnancy rates. Similar antihistamines in the US are fexofenadine (Allegra), loratidine (Claritin), and cetirizine (Zyrtec).

Varicocele Repair

Repair of a varicocele (varicocelectomy) in men with infertility problems is a common surgical practice. Nevertheless, although many urologists favor varicocele repair, the few well-conducted studies on this procedure suggest that it does not improve the chances for a successful pregnancy. Some experts argue that such studies were not using the most advanced techniques, which may be more effective. Some studies report that repair may improve the success rate of assisted reproductive technologies, such as intrauterine insemination (IUI). Still, the overall benefits remain uncertain, and additional rigorous trials are needed. In any case, the procedure does not appear to be at all beneficial for improving fertility in men whose varicoceles are very small.

Varicocele repair for fertility is sometimes considered when the following conditions are met:

• When the varicocele can be felt during a physical examination.
• Surgical treatment of varicoceles may be important in boys and adolescents to prevent later testicular damage.
• When the male partner with varicoceles has abnormal semen quality or abnormal sperm function test results.
• When the couple has known infertility and the man has varicoceles but the woman is either fertile or can be treated for her infertility.

Varicocelectomy. Varicocelectomy, the standard repair procedure, involves tying off the swollen and twisted veins. Recovery takes six days and most men cannot resume full activity for about three weeks. This technique eliminates 90% of varicoceles.

Recent techniques called microsurgeries use laparoscopy, which employs tiny incisions (less than an inch). This approach allows for quicker recovery, although the procedure itself takes longer. It also has a higher rate of complications than the standard approach.

Varicocele Embolization.A nonsurgical technique called varicocele embolization may eventually prove to be an effective and less painful treatment for varicoceles, including in young boys. It involves inserting a narrow tube (catheter) through a small incision in the neck or leg. Tiny steel plugs are passed through the catheter to block off the affected veins. It takes 15 to 45 minutes under local anesthetic. Recurrence occurs in more than 10% of cases, often requiring conventional surgery. This procedure is not yet widely available and it may not be appropriate in some men.

Treatment for Retrograde Ejaculation and Failure of Emission

Men with retrograde ejaculation and failure of emission caused by surgery, severe disease, or spinal cord injury are treated with various methods.

• Drugs known as alpha-adrenergic agonists, including pseudoephedrine (Sudafed, Actifed), stimulate muscle contraction and help ejaculation. The tricyclic antidepressant imipramine (Tofranil) has similar effects, and in one analysis of 35 studies was more effective than pseudoephedrine. Pseudoephedrine is available over the counter, however, and can help many men. Promising investigative agents include amezinium, which increases blood pressure.
• If drugs are not effective, a technique called electrovibration (or electrical stimulation) is often beneficial. (Drugs in any case are not helpful for men with complete failure of emission.)

With any of these methods, the sperm can be collected for intrauterine insemination or assisted reproductive techniques. Spontaneous conception is possible, but not common, even with these treatments.

To prepare sperm for IVF, men with retrograde ejaculation typically sodium bicarbonate four times a day to reduce the acidity of the urine. After ejaculation, the man urinates or has a catheter (a tube) inserted to withdraw urine, which is then submitted for washing techniques to separate out the sperm.

Techniques for Men with Spinal Cord Injury

Procedures that assist ejaculation are helping men with spinal cord injury conceive children. Vibratory or electronic stimulation is proving to be very beneficial for many of these men. The sperm retrieved using these methods are inserted into the women using self-insemination, IUI, IVI, or ICSI. Nearly a third of couples achieve pregnancy, a success rate that approaches natural conception.

Vasectomy Reversal (Vasovasostomy)

Vasovasostomy. For men who wish to conceive after vasectomy, reversal surgery (vasovasostomy) may restore fertility. In vasovasostomy the severed ends of the vas deferens (which were cut during vasectomy) are reconnected to reestablish the flow of sperm. The reversal procedure is difficult; it involves sewing together the two ends of both tubes, each with pinhead sized openings.

Pregnancy Rates After Vasovasostomy. An Australian study reported that the pregnancy rates in the late 1990s after reversal surgery were nearly four times higher than they were in the early 1980s. Pregnancy rates of over 50% are now being reported after a vasovasostomy. One study indicated that when successful conception occurs, it does at an average of one year after the surgery.

A successful reversal is more likely if the following conditions are present:

• The section removed during vasectomy was not long.
• The original procedure was performed on straight sections of the vas deferens.
• The pieces joined during the vasovasostomy are of equal size.

The closer in time the vasovasostomy is to the original vasectomy the better. In one large study, the pregnancy rates were 76% for those who had vasectomy less than three years before reversal surgery, decreasing to 30% for those who had vasectomy more than 15 years prior. The lower rates as time goes by are probably due to increasing chance for obstruction of the epididymis and the development of anti-sperm antibodies. Success rates, according to a 2003 study, are slightly better if the male partner does not change female partners after the procedure. The procedure may offer some chance for successful pregnancies even in women over 35 (who are, in any case, at higher risk for failure).

Reversal versus ART. Even though newer techniques such as ICSI are improving pregnancy rates after vasectomy, vasovasostomy is still a better choice than assisted reproductive technologies (ART) for most men who want children.

Success rates with reversal surgeries are improving and the costs are lower than with ART. In addition, a vasovasostomy does not pose a risk for multiple births. In one study, the pregnancy rate for vasovasostomy was 52%, whereas success after intracytoplasmic sperm injection (ICSI) was between 25% and 30% (ICSI is the ART treatment of choice for men who have had vasectomy). Even for men who have failed vasovasostomy, a repeat procedure appears to be less expensive than embarking on fertility treatments at that time.

ART may, however, be a better approach than reversal for men with evidence of anti-sperm autoantibodies due to vasectomy. ICSI may also be more effective than reversal surgeries in men whose vasectomy was conducted at least 15 years or more beforehand.

Miscellaneous Surgical Procedures

Surgical Treatment of Obstructions. Obstructions in the area of the ejaculatory ducts have been successfully treated by excising or scraping the area where the prostate gland surrounds the urethra and by reconstructing the ducts.

Correcting Undescended Testicles. Undescended testicles of young boys may be repositioned surgically to prevent later infertility. It is important to perform the operation before 15 to 18 months of age to prevent the destruction of most of the sperm-producing cells, which occurs if the testicles remain in the abdomen.