MMI is strongly dependent on female fertility therefore management of male also requires information about the female partner. Male factor is compensated by high female fecundity. Factor that influence treatments success are women age, sperms’ morphology & motility.
Men’s fertility status usually remains the same as achieved at adulthood unless there is trauma, disease or surgery of the testes or the genitals around. Slight decline with age is due to reduced potency and libido.
Husbandis assessed with tests of ejaculated semen. Postcoital test is useful to be used as the first procedure to be followed by semen analysis if necessary. Testicular biopsy is not a routine procedure. Its main indication is Testicular Sperm Extraction (TESE) for ICSI.
Management: Problems of spermatogenesis and weak sperms are difficult to treat medically. The basic fertilizing power is achieved within testes. Accessory male reproductive organs are not essential to mature the sperms. They add to motility and protection from the environment.
The aim should be to improve the fertilizing power of the sperms and not just their number and motility in semen analysis. Medical and surgical treatments of male have not produced the desired results. Even when number and percentage of motile sperms is increased benefits in terms of conception in women are not been seen because it does not alter the fertilizing capacity of sperms.
Clomiphene Citrate for its action at the levels of hypothalamus and pituitary is given. LH injections have also been tried. Bromocriptine can be useful in hyperprolactinemia.
Vitamins & hormones have been tried. Testosterone, if used, should be with caution. Its use for longer periods is risky because it then further reduces testicular function. Herbal, homeopathic and ayurvedic treatments are given to men to improve the semen. Mostly they fail to improve the semen & in some cases even worsen.
The reasons of lack of effect of these medications are obvious. The sperms in ejaculation pass through two phases. First the spermatogenesis shedding of sperms from testes which happens upto 70 days prior to ejaculation. Second storage in epididymis to achieve motility and maturation.
If drugs are effective at level a, their effect will be lost during storage. If those are effective at level b, the sperms of poor state from the original phase of level a will not improve.
The men with poor semen values should straight away be referred to ART centers because ART procedures are the only hope for such men. All other managements are of doubtful value.
Male are equally responsible for infertility. They are more difficult to treat. They, therefore, need to be more careful and should seek proper medical care at the ART Centers .
In case of normal female factors, simple procedure of intrauterine insemination (IUI) can help.
Where the active sperms are extremely low, or in azoospermia if some good spermatid can be obtained the problem can be managed by Intracytoplasmic Sperm Injection (ICSI). In it one sperm is enough even if obtained by Micro epididymis Sperm aspiration ( MESA ). Suggested treatments are:
- If sperms <1million in swim up IVF/ICSI.
- If Post wash < 500,000 sperms/ml –ICSI.
- ICSI in normospermic male not recommended. There is no difference in IVF and ICSI results.
It is important to remember that the germ cells remain the same as they were generated in fetus. There is no way to alter the potentials of germ cells. In management we are compelled to use whatever is available.
Super ovulation in women enhances the chances of successful fertility in male factor.
If IUI is selected as therapy Clomiphene induced ovulation does not improve results, gonadotrophic controlled ovarian hyperstimulation does.
In the absence of testicular function, Sperm donation is done in Western countries.