ABOUT DR TUREK
MEN'S HEALTH SERVICES
MALE INFERTILITY
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"MY BIGGEST CONCERN WHEN |
How is male infertility defined?
About one out of every six couples who desire children has an infertility problem. This means that infertility is almost as common as diabetes in America. Infertility is defined as the inability to conceive despite trying for a year. Often, couples will seek care for infertility before a year of trying to conceive has passed and Dr. Turek believes that it is reasonable to evaluate the male partner whenever the couples present for medical care. On evaluation, a male factor "issue" is found in 30% of couples, and a contributing male factor is involved in 50% of couples. Besides being the cause of the problem, another reason to evaluate men for infertility is because it may be a symptom of significant but otherwise silent disease.
How is sperm made and how does it get out?
Sperm production is hormonally driven. Brain hormones govern sperm production and are precisely controlled. The male genitalia are responsible for sperm and ejaculate production. Within the brain, the hypothalamus and anterior pituitary control sperm production. The hypothalamus secretes gonadotropin-releasing hormone (GnRH), which acts on the anterior pituitary gland, stimulating it to release follicle stimulating hormone (FSH) and leutinizing hormone (LH). FSH and LH are released into the bloodstream and act only on the testes to encourage spermatogenesis within seminiferous tubules (action of FSH) and testosterone production by neighboring Leydig cells (action of LH) between the seminiferous tubules (Figure 1). Normal hormone balance is important for normal sperm production and these hormones are often measured as part of the infertility evaluation.
FIGURE 1. THE HORMONE AXIS THAT CONTROLS SPERM PRODUCTION. T=TESTOSTERONE.
The male genitalia consist of the scrotum, which houses the testicles and associated ducts (the epididymis and vas deferens), and the penis (Figure 2). The testes are covered by a tough white fibrous layer called the tunica albuginea, which extends inward and divides the testis into many lobules. Each of the 200 to 300 lobules contains one to three very long and tightly coiled seminiferous tubules, within which sperm production occurs. Sertoli cells line the seminiferous tubules and serve as nurse cells to provide essential nutrients to sperm. In the absence of spermatogenesis, only Sertoli cells are seen on microscopic inspection of a testicular biopsy.
Another important cell type within the testis are Leydig cells, which make testosterone, the essential male hormone. Testosterone is responsible for normal male secondary sex characteristic development, libido or sex drive and normal erections. Testosterone is also important for sperm production, as levels of this hormone are 50 fold higher within the testis as in the blood.
FIGURE 2. THE MALE REPRODUCTIVE TRACT. FROM NETTER, WITH PERMISSION.
It has long been believed that sperm take 90 days (3 months) to be made and ejaculated. Dr. Turek recently discovered and published that in fact this time frame is actually much shorter. Sperm develop in the testicles for 50-60 days and are then excreted into the coiled ducts of the epididymis and complete their maturation for another 14 days. Sperm waiting to be ejaculated remain in the epididymis, near the bottom of the scrotum. At ejaculation, sperm are propelled through the vas deferens within the spermatic cord and into the abdominal cavity and join the seminal vesicles, which add alkaline fluid that helps to support sperm. The ejaculate consists of fluid from 3 sources: the vas deferens (sperm fraction), the seminal vesicles, and the prostate. The seminal vesicle fluid makes 80% of the total semen volume, the vas deferens 10% and the prostate gland another 10%. This mixture of semen then exits the penis during ejaculation.
How is male infertility evaluated?
"IT MAKES TREMENDOUS SENSE TO EVALUATE MALE INFERTILITY;
THE PROCESS IS SHORT, EFFICIENT AND INFORMATIVE AND CAN REALLY
CHANGE THE DIRECTION THAT COUPLES TAKE." DR. TUREK
Traditionally, the health care response to a couple with infertility has been for the female partner to visit the gynecologist for an evaluation. The male partner may or may not be asked to give a semen analysis. It the semen analysis is abnormal, couples are often shuttled straight to assisted reproduction and the infertility issue bypassed. In the modern era of managed care and cost-containment, this sequence of events is now inappropriate. The modern evaluation of male infertility is undertaken methodically to acquire 4 kinds of information (Figure 3). Then, a decision is made to pursue surgical or nonsurgical therapy; if neither is appropriate, assisted reproduction can be invoked to overcome even the severest forms of male infertility.
THE PATIENT HISTORY
The history reviews medical problems including recent fevers, illnesses, cancer and infections. Prior surgery, including orchidopexy, herniorraphy, trauma, open retroperitoneal, pelvic or bladder procedures and prostate surgeries should be elucidated. A family history of cryptorchidism, midline defects or hypogonadism is important. A developmental history of hypospadias, congenital anomalies and DES exposure may also be found. The use of medications including nitrofurantoin, sulfasalazine (and possibly other sulfa drugs), cimetidine, alpha-blockers, calcium channel blockers, allopurinol and many other medications may also impact on fertility.
FIGURE 3. DR. TUREK'S PATHWAY FOR MALE INFERTILITY EVALUATION.
A social history may elucidate the habitual use of alcohol, tobacco use, recreational drugs and anabolic steroids, all of which can hurt sperm production. The use of spermicidal lubricants, and incorrect patterns and timing of intercourse may be noted from a sexual history. Dr. Turek recently published the first real research study that convincingly shows that hot tubs and baths can have a major impact on semen quality. Lastly, an occupational history is important to determine exposure to ionizing radiation, chronic heat, dyes, pesticides, herbicides and heavy minerals (lead, cadmium, mercury). The vast majority of exposures discovered on the patient history are reversible and so are valuable to find and discontinue.
KEY POINTS FOR PATIENTS
THE PHYSICAL EXAMINATION
This will assess blood pressure, height, weight and body mass as well a body habitus including obesity, gynecomastia and secondary sex characteristics. The penis may show hypospadias, chordee, plaques or venereal lesions. The testes are evaluated for size, consistency and irregularities. The epididymides should not be swollen or tender, indicative of infection or obstruction. Careful palpation of each vas deferens can show that they are missing, abnormal or inflamed. The spermatic cords above the testes should be felt for asymmetry suggestive of a lipoma or varicocele. Lastly, a rectal examination is important in evaluating the prostate (if age appropriate) and identifying large cysts, infections or dilated seminal vesicles all of which may be associated with infertility.
THE SEMEN ANALYSIS
Although not a true measure of fertility, the semen analysis, if abnormal, may suggest that the probability of achieving fertility is statistically low. Among the numbers on the test, the sperm concentration and motility appear to correlate best with fertility. Two well-performed semen analyses can often suggest a diagnosis or direction. Normal values for the semen analysis are found in Table 1.
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| Ejaculate volume | 1.5-5.5mL |
| Sperm concentration | >20 x 106 sperm/mL |
| Motility | >50% |
| Forward progression | 2 (scale 1-4) |
| Morphology | >30% WHO (>14% Kruger) |
| Also: No agglutination (clumping), white cells, or increased viscosity | |
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| TABLE 1. SEMEN ANALYSIS-WHO MINIMAL STANDARDS OF ADEQUACY | |
The evaluation of the various shapes of sperm is termed morphology. Several descriptive systems exist to evaluate morphology, and within each classification system, sperm are designated normal or abnormal based on a list of criteria. It is believed that sperm morphology may correlate with a man's fertility potential, but in actuality, it has only been shown in studies to correlate with the ability of sperm to penetrate and fertilize eggs in the setting of in vitro fertilization (IVF) (Figure 4).
FIGURE 4. RELATIONSHIP BETWEEN KRUGER (STRICT) MORPHOLOGY AND EGG FERTILIZATION RATES WITH IVF.
It is not been convincingly demonstrated that sperm morphology correlates with the ability of couples to conceive with either sexual intercourse or intrauterine insemination (IUI). Sperm morphology may also be a sensitive indicator of testicular health because sperm morphology is largely determined during sperm production in the testis. The main role of morphology in the male evaluation is to complement the semen analysis data and better estimate the chances of fertility.
KEY POINTS FOR PATIENTS
HORMONE TESTS
Testing pituitary-gonadal hormones can provide valuable information on the state of sperm production. In turn, there are abnormalities of these hormones that can cause infertility. The standard hormone evaluation includes an FSH, testosterone, LH, and prolactin. These hormones should be considered in infertile men with sperm concentration less than 10 x 106 sperm/mL and soft testicles. The more common patterns of hormonal disorders seen with infertility are in Table 2.
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| Condition | T | FSH | LH | PRL |
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| Normal | NL | NL | NL | NL |
| Primary Testis Failure | Low | High | NL/High | NL |
| Hypogonadotropic Hypogonadism | Low | Low | Low | NL |
| Hyperprolactinemia | Low | Low/NL | Low | High |
| Androgen Resistance | High | High | High | NL |
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| TABLE 2. CHARACTERISTIC HORMONE PROFILES IN INFERTILE MEN. | ||||
KEY POINTS FOR PATIENTS
FURTHER TESTING
Many other tests are available to help evaluate male factor infertility if the 4-point evaluation fails to find a diagnosis. One guiding principle that Dr. Turek uses when it comes to such tests is to only order these tests if it will change the way the patient is managed. They include:
1. Seminal Fructose and Post Ejaculate Urinalysis
Fructose is normally present in the ejaculate. If absent, or the pH in the ejaculate is low, then the seminal vesicles may be missing or obstructed. A post ejaculate urinalysis (PEU) is a microscopic inspection of the first voided urine after ejaculation for sperm. Retrograde ejaculation is diagnosed in this manner.
2. Semen Leukocyte Analysis
On a routine semen analysis, "round" cells are often found in addition to sperm with tails. These "round" cells are either immature sperm forms (spermatocytes) or white blood cells (leukocytes). It is important to distinguish between these two cell types because the treatments differ. Dr. Turek offers specific stains of the ejaculate to look for leukocytes (CD45 monoclonal antibody).
3. Anti-Sperm Antibody Test
The presence of IgA and IgG antibodies on sperm has been implicated as a cause of infertility in 5-10 % of men. Certain risk factors may predispose to the presence of sperm antibodies and include obstruction (vasectomy), trauma or torsion, infection (prostatitis) and chronic heat exposure. Dr. Turek offers a specific sperm test to detect these antibodies.
4. Sperm DNA Fragmentation Assay
Evidence suggests that the quality of sperm DNA packaging is important for fertility. High levels of reactive oxygen species and oxidative stress are known to cause sperm DNA to fragment. The structure of sperm chromatin (the DNA-associated proteins) can be measured by several methods, including the COMET and TUNEL assays as well as by flow cytometry after acid exposure and staining. These tests measure the degree of DNA fragmentation after chemically stressing the sperm DNA-chromatin complex, and can indirectly reflect the quality of sperm DNA integrity.
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FIGURE 5. EXAMPLE OF SPERM WITH NORMAL (YELLOW-GREEN) AND FRAG- MENTED (RED) DNA BY FLOW CYTOMETRY. |
Abnormally fragmented sperm DNA rarely occurs in fertile men, but can be found in 5% of infertile men with normal semen analyses and 25% of infertile men with abnormal semen analyses. This testing can detect infertility that is missed on a conventional semen analysis. Often reversible, causes of DNA fragmentation include tobacco use, medical disease, hyperthermia, air pollution, infections (leukocytospermia), chemotherapy, irradiation, sperm processing and varicocele.
5. Scrotal Doppler Ultrasound
High frequency (10mHz) non-invasive ultrasound of the scrotum has become a mainstay in the evaluation testicular and scrotal lesions. Most commonly, Dr Turek will order this to look for clinically suspicious varicoceles.
6. Transrectal Ultrasound (TRUS)
High frequency (5-7mHz) transrectal ultrasound offers superb imaging of the prostate,
seminal vesicles and ejaculatory ducts. This is a first-line method of diagnosing
ejaculatory duct obstruction.
7. CT Scan/MRI Pelvis
Since the advent of TRUS, these studies are only rarely indicated. One reason to order
this study is to further evaluate a patient with an isolated right varicocele.
8. Karyotyping
Also infrequently indicated, chromosomal analysis is performed in men with low (less than 5
million) or no sperm in the ejaculate.
9. Y Chromosome Analysis
It has become apparent that up to 8% of men with low sperm counts and 15% of men
with no sperm counts may be missing small portions of the Y chromosome, termed Ymicrodeletions.
KEY POINTS FOR PATIENTS
Are there nonsurgical treatments for male infertility?
"GOOD REPRODUCTIVE HEALTH IS BASED ON GOOD OVERALL HEALTH. THIS IS WHY
I TELL MY PATIENTS TO TREAT THEIR BODIES LIKE A TEMPLE." - DR. TUREK
Currently, in 75% of cases of male infertility, underlying problems can be identified and in many cases treated. Here we review in a general way the non-surgical and surgical male infertility treatments that continue to withstand the test of time either because they make good medical sense or have been shown to be cost-effective in the era of assisted reproduction.
INTERCOURSE-RELATED ISSUES
Only about 20% of young men actually know the exact time to have sex during the female cycle to achieve a pregnancy. The critical period can be assessed by either basal body temperature charting or home kits that detect the LH surge in the urine immediately (24 hours) prior to ovulation. Since sperm reside in the cervical mucus for 48 hours and are released continuously, it is not necessary that coitus and ovulation occur at the exact same time. Another issue is how often to have sex to conceive. Ejaculation has to occur frequently enough to bracket the ovulatory period. Sex every other day around this period is recommended. Recent evidence also suggests that most couples become pregnant from intercourse before ovulation rather than after ovulation. The level of sexual stimulation prior to ejaculation is important to the quality of ejaculation.
MEDICATIONS AND TOXINS
Medications are usually extensively tested for their potential as reproductive hazards before marketing. Despite this, it is wise to discontinue any unnecessary medications that can be safely stopped during attempts to conceive. A list of gonadotoxic medications is found in Table 3.
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| Calcium channel blockers | Allopurinol |
| Cimetidine | Alpha blockers |
| Sulfasalazine | Nitrofurantoin |
| Valproic acid | Lithium |
| Spironolactone | Tricyclic antidepressants |
| Colchicine | Antipyschotics |
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| TABLE 3. MEDICATIONS TO AVOID WHILE TRYING TO CONCEIVE | |
Lubricants should also be avoided if possible; Surgilube, K-Y jelly and saliva should definitely not be used as they may contain antiseptics that hurt sperm. If necessary, vegetable oils such as olive oil appear to be the safest. Other toxins include heat exposure from regular saunas, hot tubs or jet tubs or baths, cigarettes, cocaine and alcohol. Marijuana can also lead to reversible depression of spermatogenesis.
HORMONAL TREATMENTS-SPECIFIC
Effective hormonal therapy can be offered to patients with diseases that also predispose to infertility. This is called specific treatment. Other therapies are offered to men with less well-defined reasons for infertility. These are called empirical treatments. The following list has examples of conditions that cause infertility and that are amenable to specific treatment:
Hyperprolactinemia
The normal role of prolactin in men is not clear, but it may keep testosterone levels
high in the testis and help the growth and secretions of the sex glands. Normal
prolactin levels are important for normal sex drive and fertility as well. Hyperprolactinemia occurs when prolactin levels rise above normal and this is a
medical condition that is routinely treated. Other reasons for elevated prolactin include
stress during the blood draw, obtaining the blood test too soon after awakening
(prolactin levels rise during sleep), illness in the body and medications.
Hypothyroidism
Both high and low levels of thyroid hormone can affect sperm production. Thyroid
issues account for < 0.5% of infertility but are very treatable. Because of their rarity,
routine thyroid screening is not recommended for infertility patients.
Congenital Adrenal Hyperplasia
Most commonly, the 21-hydroxylase enzyme is deficient and there is low cortisol
production. The testes fail to mature because of this. The diagnosis is rare and
classically presents as early puberty; careful laboratory evaluation is essential. The
condition and the infertility associated with it are both treated with corticosteriods.
Testosterone Problems
There are conditions in which no or low testosterone is present due to abnormal
hormone signaling in the brain (Kallman Syndrome). Infertility associated with these
conditions can be effectively treated by replacing pituitary hormones. On the contrary,
anabolic steroid use, commonly taken by college and professional athletes, impairs
sperm production and leads to zero sperm counts in most men. In this case, the
steroids should be discontinued to reverse the problem.
OTHER SPECIFIC TREATMENT
Leukocytospermia
Elevated white blood cells in semen (>1 million/mL) is termed pyospermia or leukocytospermia and is associated with (a) silent genital tract infection, (b) elevated reactive oxygen species, and (c) poor sperm function and infertility. Sperm can be damaged by oxidative stress from leukocytes because the sperm have little inherent protective antioxidant activity. The treatment of leukocytospermia is controversial without an obvious bacterial infection. When appropriate, the use of broad-spectrum antibiotics such as doxycycline and trimethoprim-sulfamethoxazole in combination with frequent ejaculation has been shown to durably reduce seminal leukocyte concentrations. Generally, the female partner is also treated.
HORMONAL TREATMENTS-EMPIRICAL
"REGARDING EMPIRICAL TREATMENTS FOR MALE INFERTILITY, SINCE THEY MAY NOT WORK, I ALWAYS PROPOSE A SPECIFIC TIMELINE FOR SUCH THERAPY, AND DECIDE EXACTLY WHEN TREATMENT SHOULD BE STOPPED AND OTHER AVENUES PURSUED." - DR. PAUL TUREK
Empirical therapy can also be offered to men with infertility. These treatments are not necessarily disease-based, but tend to push the hormone axis harder than normal to make more sperm or add something that infertile men may be missing to improve fertility. As a rule, empirical therapy does not work as well as specific therapy in the treatment of infertility. Several examples of empirical therapy include:
Clomiphene citrate
This is a synthetic, nonsteroidal drug that acts as an antiestrogen and binds to
estrogen receptors in the brain. This blocks the action of the normally low levels of
estrogen on the male hormone axis and causes increased output of reproductive
hormones that increases testosterone production and (hopefully) sperm production.
Clomiphene is given for low sperm counts and is much less effective as a treatment for
low motility. After starting, testosterone and FSH levels should be monitored at 2-4
weeks and the dose adjusted to keep the testosterone level within the normal range.
Higher than normal testosterone levels may result in a decrease in semen quality. A
semen analysis is obtained at 3 months and at regular intervals thereafter. Therapy
should be discontinued if no semen quality response is observed in 6 months.
Clomiphene therapy is relatively safe with the following side effects occurring in less than 5%
of patients: breast tenderness, upset stomach, weight gain, dizziness, visual
complaints, change in sex drive (more) and skin reactions.
Gonadotropins (hCG, FSH)
This treatment concept is simply the idea that "if some is good, more is better." Human chorionic gonadotropin (hCG), human menopausal gonadotropin (hMG) or pure forms of FSH are most commonly used. Serum testosterone levels and semen analyses are monitored and drug doses adjusted accordingly. These medications are safe, but can be very expensive and are all taken as injections. Therefore, there is a risk of scarring and infection at injection sites. Mood and libido changes and acne can occur. There is evidence to suggest that sperm concentration may rise with treatment. From an evidence-based viewpoint, this therapy is useful in limited situations.
Antioxidant therapy
There is evidence that up to 40% of infertile men have increased levels of reactive oxygen species ("oxidants") in the reproductive tract. These are reactive molecules (OH, 02 radicals and hydrogen peroxide) that are thought to cause damage to sperm membranes and hurt fertility. Treatment with scavengers of these radicals may protect sperm from oxidative damage. This kind of treatment may be useful for cases of unexplained low motility on the semen analysis. They are also used to reduce levels of fragmented DNA in sperm. Generally, antioxidants are found in vitamin and other nutritional supplements, which, although expensive, have minimal side effects. The best-studied fertility supplements are vitamins E and C, acetylcysteine and glutathione.
Folic acid is an important micronutrient well studied for its effects on preventing
neurologic problems in the embryo. It is involved with RNA and DNA synthesis during
spermatogenesis and has antioxidant properties. Folic acid supplementation may
benefit certain groups of infertile men, especially tobacco users. The trace element
zinc plays an important role in testicular development, sperm production, and sperm
motility. In fact, the zinc level in male genital organs is considerably higher than that in
other tissues. It is made by the prostate and is also found in maturing sperm. Zinc
deficiency has been linked to low sperm counts in men, but large randomized studies
of zinc supplementation in infertile men are lacking.
L-Carnitine and acetyl-L-carnitine are highly concentrated in the epididymis and are important for sperm maturation. In studies of infertile men, there have been significant improvements in sperm quality (sperm concentration and forward motility) in men taking this supplement relative to men taking sugar pills. What has not been significant are improvements in pregnancy rates.
Herbal Therapy
Chinese and Japanese herbal therapy has been used for centuries for a variety of maladies, including infertility. There have been recent attempts to study these medications more scientifically to demonstrate exactly how they might improve male fertility. In China, infertility is recognized as Kidney Yin Deficiency-Hyperactivity of Fire Syndrome, or too little Yin per unit of Yang. Herbs that have been used to treat infertility are listed in Table 4. Dose regimens are not standardized, but are tradition-dependent.
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| Herb Name | Application |
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| Zhibai Dihuang pills | Immunological Infertility |
| Astragalus membranaceus | Low motility |
| Hachimi-jio-gan | Unexplained infertility |
| Gosha-jinki-gan | Unexplained infertility |
| Hochu-ekki-to | Unexplained infertility |
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| TABLE 4. ESTABLISHED TRADITIONAL HERBS FOR MALE INFERTILITY. | |
What surgical treatments are used to treat male infertility?
"WHAT IS NICE ABOUT SURGICAL TREATMENTS FOR MALE INFERTILITY IS THAT THEY CAN 'CURE' THE PROBLEM AND ALLOW FOR CONCEPTION AT HOME AND NOT IN THE LABORATORY."
- DR. PAUL TUREK
The following are accepted surgical treatments for male infertility.
When man assumed an upright posture during evolution, he also gained the
varicocele. Although the majority of men with varicoceles are fertile, the association of
varicoceles with infertility is well recognized. It is currently the most common
correctable cause of male infertility. READ MORE
Ejaculatory Duct Obstruction
Dr. Turek is one of the world's thought leaders on this diagnosis, having written and published extensively about this problem in the past 12 years. Presenting as a semen analysis with a low volume, ejaculatory duct obstruction is the cause of male infertility in 1-5% of men. It is suspect with low ejaculate volume and abnormal semen quality with normal FSH and testosterone as well as normal testis size (20cc). The diagnosis is confirmed by transrectal ultrasound (TRUS) showing large seminal vesicles or dilated ejaculatory ducts in association with a cyst, calcification or stones along the duct. Once diagnosed, it is treated surgically in 1 hour by a procedure performed through the penile urethra near the prostate (transurethral resection of the ejaculatory ducts, TURED). According to Dr Turek's studies, roughly 65-70% of men who undergo the procedure will achieve a significant improvement in semen quality and 20-30% pregnancy rate can be expected. Complications include temporary blood in the ejaculate, blood in the urine requiring another catheter to clear and urinary tract infection. Less frequently, epididymitis and a "watery" ejaculate can result.
Roughly 600,000 men will undergo a vasectomy annually in the US, and 5% will change their minds and decide to have their vasectomies reversed later on. The same surgical procedure used to reverse vasectomies can also be used to "unblock" infertile men with no sperm counts due to past infections, trauma, or unexplained reproductive tract blockages. Dr. Turek is internationally renown for his expertise in these highly specialized microsurgical techniques. READ MORE
How is assisted reproduction used to treat male infertility?
If neither surgery nor medical therapy is appropriate for male infertility treatment, assisted reproduction is available to help.
Intrauterine insemination (IUI)
This is the simplest form of assisted technology and involves the placement of a
washed pellet of ejaculated sperm within the female uterus, beyond the cervical
barrier. This technique is performed in the office and is indicated for low sperm quality,
immunologic infertility and for men with mechanical problems of sperm delivery (e.g.
erectile dysfunction). The success rates vary widely and are directly related to female
reproductive potential; given this, pregnancy rates of 8-16%/cycle have been reported
with the use of IUI as a treatment for male infertility.
In vitro Fertilization and ICSI
It has been possible to fertilize human eggs in a culture dish since 1978. IVF involves
ovarian stimulation and egg retrieval from the ovaries prior to normal ovulation. Eggs
are fertilized in petri dishes with 500,000 to 5 million motile sperm. Fertilized eggs or
embyros are then transferred to the uterus through a simple vaginal procedure. IVF
can bypass moderate to severe forms of male infertility in which low numbers of motile
sperm are present. In 1992, an addition to IVF was described in which the sperm are
directly injected into the egg cytoplasm with a microscopic needle in the laboratory
phase of IVF. This has been referred to as sperm "micromanipulation" or
intracytoplasmic sperm injection (ICSI) and has helped with the treatment of male
infertility. The sperm requirement for egg fertilization has gone from hundreds of
thousands for in vitro fertilization (IVF), to one viable sperm required for ICSI. This has
led Dr. Turek and others to develop aggressive new techniques to find sperm for eggs from men with no sperm in the ejaculate. Presently, sources of sperm in that are usable for conceiving include all reproductive tract organs. READ MORE
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