UCSF Male Reproductive Health offers a full range of diagnostic tests, and medical and surgical treatments to diagnose and treat the spectrum of male infertility problems. The team (Drs. Ira Sharlip and James Smith) specializes in the full range of microsurgical procedures and medical treatments currently available for male infertility. Once the diagnostic evaluation is complete, one or more options are chosen to treat the infertile male. Problems with the male anatomy can often be treated effectively with surgery while medical conditions and the need to enhance sperm production can sometimes be treated using medical therapy. Any treatment may be expected to have an effect on semen quality roughly 3 months after it is started, as this is the length of time required for a single cycle of spermatogenesis (sperm production). If neither surgical nor medical therapy is appropriate, assisted reproductive technologies are available.
In choosing a treatment plan, consideration should be given to the couple's long term goals and financial constraints and the results of the female partner's evaluation in addition to male factor findings.
The decision to pursue medical therapy as an option is based on the specific diagnosis and treatment plan developed for each individual patient. The most successful medical therapy for male infertility involves the reversal of chemical, infectious or endocrine imbalances. This is termed specific therapy and is usually successful because treatment is based upon the correction of well-defined pathophysiologic states. Examples of this include acute prostatitis, epididymitis or varicocele, the replacement of the pituitary hormones (FSH and LH) in radiation or surgically induced pituitary disease, and the treatment of men with low levels of testosterone.
Another kind of treatment is termed empiric therapy and is an attempt to correct rather ill-defined pathologic states. The use of clomiphene citrate, tamoxifen or antioxidants for low sperm density or motility are examples of this form of therapy. These treatments often have limited efficacy, because the generally intact homeostatic mechanisms within the body tend to counteract the intended effect. In other words, hormonal treatments based on the principle that "if some hormone is good, then more is better" are destined to failure and should be avoided.
There are a variety of surgical options for male factor infertility based on the exact diagnosis:
Ejaculatory failure is the inability to ejaculate. It has a variety of causes that include pelvic nerve damage from diabetes mellitus, multiple sclerosis or abdominal-pelvic surgery and spinal cord injury. It is important to distinguish ejaculatory failure from impotence (the inability to achieve an erection), premature ejaculation (ejaculating before one desires) and retrograde ejaculation (ejaculating into the bladder and not into the penis). Rectal probe electroejaculation is a commonly performed technique that may enable anejaculatory patients to produce an ejaculate capable of achieving a pregnancy. With rectal probe electroejaculation, the pelvic sympathetic nerves undergo controlled stimulation such that a reflex ejaculation is induced and the semen collected.
The varicocele is defined as dilated and twisted veins within the scrotum, and is basically a consequence of our upright posture. A varicocele can be found in 42% of infertile men and has an unquestioned statistical association with infertility. Interestingly, 15% of normal, fertile men also have a varicocele, a fact which complicates the relationship between infertility and varicoceles. An improvement in semen quality can be expected in roughly 67% of patients who have varicocele ligation, with improvement most likely to be an increase in sperm motility rather than sperm count. The pregnancy rate following varicocele repair is approximately 40%, with pregnancy occurring an average of 9 months after surgery.
The varicocele remains the most correctable factor when poor semen quality is discovered, but since it is very common, the operation should only be considered if other infertility risk factors are absent. Varicoceles can be corrected by venous embolization, laparoscopy or through a small inguinal or subinguinal incision.
The male reproductive tract is basically one long tube of varying dimensions. Infection or traumatic injury to the genital tract can result in scarring and blockage within this tube. A classic example of a surgically correctable blockage is a vasectomy. Approximately 5% of men who have a vasectomy undergo a vasectomy reversal. The success of a vasectomy reversal depends on many factors, the most important of which are the skill of the surgeon and the findings at the time of surgery. In the best of circumstances, 85-99% of patients can be expected to have a return of sperm after vasovasostomy (vas to vas connection). With a healthy female partner, this is associated with a pregnancy rate of 60-65%. The surgery is performed as an outpatient and the patient is generally able to return to work in 3-4 days. When congenital absence of the vas deferens is diagnosed, microsurgical reconstruction is generally not possible; however, sperm extraction techniques can be offered to patients.
Ejaculatory duct obstruction is diagnosed in approximately 10% of men without sperm in the ejaculate. The underlying pathology is usually blockage of the ducts within the prostate by stones, cysts, or scar tissue. The condition is effectively treated with a simple, outpatient procedure that involves resectioning the ducts within the prostate. Significant improvements in semen quality occur in 70% of patients so treated, and this is associated with 20-30% pregnancy rates.
Intracytoplasmic sperm injection (ICSI) has revolutionized the treatment of male infertility. The sperm requirement for egg fertilization has dropped from hundreds of thousands for in vitro fertilization (IVF), to one viable sperm required for ICSI when combined with IVF. This has led to the recent development of aggressive new surgical techniques to provide viable sperm for egg fertilization from men with low or no sperm count. This has also pushed urologists beyond the ejaculate and into the male reproductive tract to find sperm for biologic pregnancies. Presently, sources of sperm in otherwise azoospermic (no ejaculated sperm) patients include the vas deferens, epididymis and testicle using sperm aspiration techniques.
Sperm aspiration techniques involve the use of minor surgical procedures to collect sperm from organs within the genital tract. These techniques are indicated for men in whom the transport of sperm is not possible because the ductal system that normally carries sperm to the ejaculate is absent (i.e. congenital absence of the vas deferens) or unable to be reconstructed. Most recently, sperm has been fairly reliably extracted (60-70% of the time) from the testes of men with sperm production problems of such severity that no sperm is found in the ejaculatory ducts.
It is important to realize, however, that in vitro fertilization (IVF) technology is required to achieve a pregnancy with the vast majority of these extraction procedures, and thus success rates are intimately tied to a complex and complementary program of assisted reproduction for both partners.
Sperm extraction procedures include:
|The UCSF Center for Reproductive Health, located in Northern California's San Francisco Bay Area offers a comprehensive array of infertility evaluation and treatment options for both men and women. Our services include: Infertility Evaluation, Male Reproductive Health, Fertility Preservation, Reproductive Surgery, Tubal Reversal Surgery, In Vitro Fertilization (IVF), Intracytoplasmic Sperm Injection (ICSI), Pre-implantation Genetic Diagnosis (PGD), Intrauterine Insemination (IUI), Ovulation Induction, Donor Sperm Insemination, Egg Donor Program for Donors, Egg Donor Program for Recipients, Polycystic Ovarian Syndrome (PCOS), Recurrent Pregnancy Loss, Gestational Surrogacy, Genetic Screening and Counseling Psychological Support.|