The Use of In Vitro Fertilization in the Management of Male Infertility: What the Urologist Needs to Know

Infertility affects approximately 10% to 20% of reproductive-age couples, many of whom may present initially to a urologist. Some couples may be treated medically to increase spontaneous conception rates; however, many will require more aggressive management with in vitro fertilization (IVF) and/or intracytoplasmic sperm injection (ICSI). IVF involves ovarian stimulation, oocyte retrieval, and fertilization outside of the body; ICSI involves injecting one sperm into the oocyte to promote fertilization. Here we provide a brief overview of IVF and ICSI along with a discussion of the risks involved to facilitate the counseling and care of the infertile couple.Key words: Intracytoplasmic sperm injection, Male infertilityInfertility, defined as the inability to conceive within 12 months of unprotected intercourse, affects approximately 10% to 20% of reproductive-age couples.¹ As couples defer childbearing until later ages and as the obesity epidemic grows, the incidence of infertility is likely to continue to rise.^2,3 Male factor infertility is estimated to contribute to two-thirds of all cases. Of men seeking care for infertility, 18.1% reported being diagnosed with male factor infertility and 13.7% with a sperm or semen problem.⁴The evaluation for male infertility includes a thorough history and physical examination, and the mainstay of diagnostic testing continues to be the semen analysis. If abnormalities are noted on semen analysis, further testing is warranted to evaluate for possible etiologies. Where applicable, treatment is initiated with the goal of improving semen quality and male fertility. Previously, in cases in which semen quality remained profoundly impaired, the successful treatment for male factor infertility was once limited to donor insemination.The development of in vitro fertilization (IVF) revolutionized the management of female infertility. As powerful a tool as this proved to be, however, IVF fertilization rates remained poor in the presence of compromised semen parameters. A significant breakthrough in the treatment of severe male infertility was the development of intracytoplasmic sperm injection (ICSI) in 1992.⁵ By allowing the injection of a single sperm into each oocyte, ICSI provides the possibility of genetic offspring to men who have very scant numbers of motile sperm on semen analysis or who require surgical harvesting.From its inception, assisted reproduction has involved a gynecologist and an embryologist. The urologist is a critical collaborator for the treatment of couples with male factor infertility. Sperm harvested by microsurgical epididymal sperm aspiration, testicular sperm aspiration, or biopsy can be used to fertilize harvested oocytes by ICSI. The urologist may be the first to evaluate a couple for infertility, and will certainly be involved if sperm harvesting is indicated. Therefore, this article reviews the process of assisted reproduction by IVF/ICSI for urologists who may be seeing patients with infertility issues.     

Profil spermiologique de l’époux dans les couples infertiles en milieu négro-africain au Sénégal

Objective

To define the role of male infertility in black African couples in Senegal and to establish the semen profile.

Material and Methods

We analysed 17,459 sperm counts and 5,563 post-coital tests from patients consulting for primary or secondary infertility between January 1982 and December 2002. Negative and deficient sperm counts of post-coital tests were studied to demonstrate the responsibility of male infertility. For sperm counts, we studied the patient’s age, the mode of semen collection, the volume of ejaculate and semen characteristics.

Results

Primary sterility (68.4%) was twice as frequent as secondary sterility (31.6%). Male infertility (31.7%) was twice as frequent as female infertility (14.7%). Twenty eight per cent of patients presented hypospermia. Isolated oligozoospermia was observed in 10% of cases and azoospermia was detected in 23% of cases. Qualitative sperm changes were observed in 44.3% of cases. A positive semen culture was reported in 21.3% of cases. Combinations (qualitative sperm changes and abnormalities of number) were observed in 43.4% of cases. Oligo-astheno-teratozoospermia (OATS) with spermatozoa with an elongated head, cytoplasmic remnants and angulation, characteristic of varicocele was significantly more frequent in patients with varicocele (97% of men with right varicocele and 98.2% of men with bilateral varicocele). Reactive epididymosemino-prostatic dystrophy was observed in 11.9% of cases

Conclusion

Male infertility plays a real role. The semen profile of the husband of a sterile couple in Senegal is characterized by the importance of polymorphic alterations such as oligo-astheno-teratospermia and secretory azoospermia.     

The relationship between body mass index, semen and sex hormones in adult male

This study was aimed at evaluating the relationship between body mass index, sex hormones and semen characteristics in male adults. 120 male adults aged 20 to 50 years who consented to participate in the study were used. Serum samples collected from each subject were analyzed for Luteinizing hormone (LH), Follicle stimulating hormone (FSH), Prolactin (PRL), Progesterone, Estradiol and testosterone by classical ELISA method. Semen samples obtained by masturbation after 72 hours of abstinence were analyzed for sperm count and motility. The results showed statistically significant correlations at 99% confidence level between body mass index and serum concentrations of progesterone and oestradiol and sperm count. No significant correlations were observed between body mass index and sperm motility, serum concentrations of prolactin, testosterone and luteinizing hormone. In conclusion, this study has shown that statistically significant correlations exist between body mass index, semen characteristics and male sex hormones and may broaden our understanding of the physiology of male fertility/infertility. Keywords: Body mass index, Semen quality, Male sex hormones, Fertility/infertility.     

Stratégies biologiques à l’heure de l’Assistance Médicale à la Procréation chez le blessé médullaire

Most men with spinal cord injury (SCI) men have fertility problems caused by anejaculation and decreased fertility of the ejaculate. There are two main causes for the impaired reproductive potential in SCI men: ejaculatory dysfunction and poor quality semen. However, current treatment techniques allow a large number of SCI males to achieve ejaculation (rectal electro-stimulation, penile vibrator stimulation). Firstly, masturbation and/or penile vibrator are used at home allowing the couple to perform insemination themselves. The semen of men with spinal cord injuries has commonly been characterised by small volume, abnormal count (low or high), decreased sperm mobility, increased formation of reactive oxygen species, sperm autoimmunity, necrospermia. This impairment is thought to be due to insufficient drainage, genitourinary infections and raised scrotal temperature. Testicular biopsy reveals varying degrees of tubule degeneration and decreased spermatogenetic activity. Semen could be used for various assisted reproductive technologies such as intrauterine insemination,in vitro fertilisation (IVF) and microinsemination (ICSI). The literature reports pregnancy rates by intrauterine insemination of about 15 to 20% per couple. Clinical pregnancy rates after IVF and ICSI techniques are 30% per cycle and these results are comparable to the clinical pregnancy rates when these techniques are performed for female infertility. However, semen must be frozen as soon as possible after the injury and the patient must be informed about the various available assisted reproductive technologies.     

Importance of a semen analysis report for determining the relationship between SCSA sperm DNA fragmentation index and assisted reproductive technology pregnancy rate

In the past, semen parameters have been the primary diagnostic criteria used to establish male infertility. However, with the exception of sperm motility, which is known to be linked to rates of in vitro fertilization success, these parameters are generally unreliable at accurately predicting the potential fertility of a couple. More recent research has suggested that sperm DNA fragmentation index (DFI) may be a more robust and reliable means of predicting assisted reproductive outcomes.The present study aimed to assess the relationship between sperm motility, sperm DFI, and rates of clinical pregnancy by analyzing data from 3000 couples dealing with infertility. Using the most recent semen analysis reports available from male partners in these couples, we assessed these parameters and found that the lower the sperm DFI value, the higher the rate of clinical pregnancy. When we assessed the correlation between sperm DFI, sperm motility, and clinical pregnancy, we observed a strong negative correlation between DFI and motility, but observed no significant relationship between sperm motility and pregnancy rates. These results thus indicate that the measurement of DFI via a sperm chromatin structure assay (SCSA) may be a valuable tool for analyzing semen in order to better predict and improve pregnancy rates in infertile couples.     

Interpretation of semen analysis among infertile couples.

Among the male partners of 1074 infertile couples the mean results of semen analysis were sperm count 78 X 10(6)/ml, seminal volume 4.0 ml, proportion of progressively motile sperm 54%, proportion of sperm with normal morphologic features 81.4% and total motile sperm count 152.3 X 10(6) per ejaculate. After excluding 65 couples who chose donor insemination and 300 with known female causes of infertility, the cumulative pregnancy rates in the remaining 709 couples were higher with increasing sperm density and motility and seminal volume, but the higher rates were significant only when these variables were combined into total motile sperm count per ejaculate. The cumulative pregnancy rates were 20% with a total motile sperm count of 9 X 10(6) or less, 37% with a count of 10 to 19 X 10(6) and 52% with a count of 20 X 10(6) or more (p = 0.001). Counts higher than 20 X 10(6) were not associated with a further improvement in pregnancy rates, but variability in the results was high, which suggests that the test should be repeated as necessary to determine the true range. Although standards for these and other seminal variables are ill defined, the total motile sperm count incorporates the most useful prognostic information from semen analysis, and the associated pregnancy rates can help guide clinical decisions.     

Diurnal and seasonal changes in semen quality of men in subfertile partnerships

ABSTRACT

Circadian and circannual rhythms influence not only the environment, but also human physiology. In times of increasing numbers of couples struggling with infertility, and thus increasing demand for successful assisted reproduction, the aim of our study was to evaluate circadian and circannual rhythms and their association with semen quality. A total of 12 245 semen samples from 7068 men, collected at the andrology laboratory of the Department of Reproductive Endocrinology, University Hospital Zurich, between 1994 and 2015, were uniformly analysed in terms of sperm concentration, total sperm count, progressive motility and normal morphology. On the basis of these four parameters, we retrospectively examined the circadian and circannual changes of semen quality. The Mann–Whitney U test and multiple linear regression analysis were used for the statistical evaluation. The semen samples collected in the early morning before 7:30 a.m. showed the highest levels in sperm concentration, total sperm count and normal morphology, all with statistical significance. Progressive motility did not show any significant alterations based on circadian rhythm. Furthermore, a significant increase in sperm concentration and total sperm count was found in spring, with significant decreases in the summer. The highest percentage of normal morphology was found in summer. For progressive motility, no significant seasonal variation could be demonstrated. Male semen quality varies with both circadian and circannual rhythms. Collection of semen in the early morning, where semen quality was highest, can be used to improve natural fertility as well as fertility resulting from assisted reproduction.     

A massive ovarian mucinous cystadenoma: a case report

Background  

Infertility is defined as inability of a couple to conceive naturally after one year of regular unprotected sexual intercourse. It remains a major clinical and social problem, affecting perhaps one couple in six. Evaluation usually starts after 12 months; however it may be indicated earlier. The most common causes of infertility are: male factor such as sperm abnormalities, female factor such as ovulation dysfunction and tubal pathology, combined male and female factors and unexplained infertility.     

Effect of Uremia on Semen Quality and Reproductive Function in Humans

In this study, we sought to evaluate the effect of uremia on semen quality and reproductive function in humans. For this purpose, 53 end-stage uremic patients were randomly selected. The semen samples were produced by masturbation. Fertility index (FI) was calculated according to the following formula: sperm density (×10⁶/ml) × sperm motility (%) × normal sperm morphology rate (% per 10,000). The semen samples of uremic patients were compared with those of fertile and infertile males. The results show that three patients failed to produce semen. There were no sperm found in four semen samples. The sperm motility, survival rate, sperm density, and normal sperm morphology rate of the remaining 46 patients were found to be significantly lower than those of controls. The uremic patients had the FI of 0.68(2.08) which was obviously lower than that of fertile 7.7(13.51) and infertile 4.13(5.77) males. It was, therefore, concluded that uremia caused a significant decline in sperm quality and reproductive function which resulted in consequential infertility in humans.     

The development of a qualitative assay for male infertility from a study of enzymes in human semen.

Various enzymes in the semen of men were examined to see if any could be related to measures of fertility. Fumarase activity was highly correlated with sperm number and percentage motility. Diamine oxidase activity was higher in samples with sperm counts of less than 20 X 10(6)/ml and aperm motility of less than 20%. Monoamine oxidase, adenine deaminase and prostaglandin dehydrogenase were undetectable in significant amounts in all samples, while peroxidase and adenosine deaminase were not correlated with sperm count and motility. It is suggested that the simple spectrophotometric assays for fumarase and diamine oxidase could form the basis of a routine assessment of human semen samples for estimation of male infertility.     

Evidence for decreasing quality of semen during past 50 years.

OBJECTIVE--To investigate whether semen quality has changed during the past 50 years. DESIGN--Review of publications on semen quality in men without a history of infertility selected by means of Cumulated Index Medicus and Current List (1930-1965) and MEDLINE Silver Platter database (1966-August 1991). SUBJECTS--14,947 men included in a total of 61 papers published between 1938 and 1991. MAIN OUTCOME MEASURES--Mean sperm density and mean seminal volume. RESULTS--Linear regression of data weighted by number of men in each study showed a significant decrease in mean sperm count from 113 x 10(6)/ml in 1940 to 66 x 10(6)/ml in 1990 (p < 0.0001) and in seminal volume from 3.40 ml to 2.75 ml (p = 0.027), indicating an even more pronounced decrease in sperm production than expressed by the decline in sperm density. CONCLUSIONS--There has been a genuine decline in semen quality over the past 50 years. As male fertility is to some extent correlated with sperm count the results may reflect an overall reduction in male fertility. The biological significance of these changes is emphasised by a concomitant increase in the incidence of genitourinary abnormalities such as testicular cancer and possibly also cryptorchidism and hypospadias, suggesting a growing impact of factors with serious effects on male gonadal function.     

Characterization of semen collected from beagles and captive Japanese black bears (Ursus thibetanus japonicus)

This study characterized semen collected from the Japanese black bear, Ursus thibetanus aponicus, to provide information on semen cryopreservation for artificial breeding. Preliminary studies using a beagle dog as the model species showed that sperm concentration and total sperm count were lower in semen collected by electroejaculation than in semen collected by digital manipulation, but that sperm motility, viability and morphology were similar. Characterization of semen obtained from Japanese black bears by electroejaculation under general anesthesia revealed that semen volume and total number of spermatozoa collected were lower; but that sperm concentration, motility, viability and morphology were equivalent to those reported in other ursids. When semen was collected via a catheter inserted into the urethra during the stimulation for ejaculation, the sperm concentration, total sperm count and motility were relatively higher than when semen was collected directly in a test tube. Specific normal semen characteristics (mean +/- SEM) were pH, 7.6 +/- 0.0; volume, 0.212 +/- 0.038 mL; sperm concentration, 361 +/- 100 x 10(6)/mL; total sperm count, 84.0 +/- 32.2 x 106; +++ motility, 30 +/- 5%; motility, 77 +/- 3%; viability 77 +/- 2%; and abnormal morphology, 11+/- 2%. These results suggest that semen can be collected from Japanese black bears by electroejaculation.     

The breeding management affects fresh and cryopreserved semen characteristics in Melopsittacus undulatus

Melopsittacus undulatus is a companion parrot worldwide diffused. Many parrots are considered endangered or vulnerable. The preservation of semen is crucial in endangered species, thus, M. undulatus could be a good model to study sperm characteristics and semen cryopreservation in these other endangered parrots. In this study the effect of the breeding management (males bred in promiscuous aviary or in couple) on sperm characteristics (motility, membrane integrity and morphometry) of fresh and cryopreserved semen was evaluated. The computer-assisted sperm analysis (CASA) revealed a significant effect of the husbandry method on semen characteristics in budgerigars: male housed in couple with the female in individual cages allowed the higher results in term of both semen quantity and sperm quality. Total and progressive motility were significantly higher in males bred in couple (68.7 ± 8.9% and 54 ± 15.9%, respectively) than in promiscuous aviary (48.3 ± 15.1% and 24.4 ± 12.4%, respectively), such as sperm velocity (average path velocity, straight line velocity, and curvilinear velocity). The type of sperm movement (amplitude of lateral head displacement, beat cross frequency, straightness, and linearity), sperm membrane integrity and morphometry parameters seemed not affected by the husbandry method. The standardization of a CASA procedure for the semen analysis in M. undulatus allow further studies on parrot semen manipulation and cryopreservation, but the method used for the breeding of the male could have a significant effect on the semen quality.     

精子端粒长度与特发性男性不育相关

端粒是真核生物染色体末端的多功能特异性DNA-蛋白结构,覆盖在染色体末端,保护基因组的稳定性。端粒在减数分裂过程中起到了十分重要的作用,协助染色体配对、联会、同源重组和分离。精子中的端粒可能在精子的受精能力和胚胎发育中起到重要作用。近年来,端粒与生殖的相关性研究成为一个新的热点,但精子端粒与男性不育间的相关性并不明确。本文采用实时荧光定量PCR方法检测中国特发性男性不育人群(126例)和正常可育男性人群(138例)的精子相对端粒长度,结果发现,特发性男性不育病例的精子平均相对端粒长度(2.894±0.115)低于正常对照组(4.016±0.603),差异具有统计学意义(P=5.097×10^-5);并且精子相对端粒长度与精子密度、精子总数和精子活力都有显著的相关性：精子数量较多和/或精子活力较高,精子相对端粒长度较长。研究结果提示,在中国人群中,精子端粒长度与特发性男性不育具有相关性,精子的端粒长度可能影响精子发生和精子的功能,精子端粒的缩短导致精子数目及活力的降低从而导致男性不育。     

Variants of the CLOCK gene affect the risk of idiopathic male infertility in the Han-Chinese population

Recent experimental animal studies suggested that the circadian locomotor output cycles kaput protein gene (CLOCK) has been reported to play a critical role in sperm function and male fertility. The aim of this study was to determine whether variants of the CLOCK gene are involved in idiopathic male infertility. The study included 478 idiopathic infertile men and 194 fertile controls who completed physical examinations. Each subject donated 5?ml of peripheral blood and a sample of semen in the ejaculate. An aliquot of each blood sample was used to separate the serum for the measurement of testosterone as well as follicular stimulating hormone (FSH) using the standard radioimmunoassay. The rest of the blood samples was used to extract the DNA for the assay of three tagging single-nucleotide polymorphisms of CLOCK gene, viz., rs1801260, rs3817444 and rs3749474, using the real-time fluorescence quantitative PCR. The ejaculate of each subject was used for semen analysis by computer-assisted semen analysis system. The results indicated: (a) the variant rs1801260 associated with normal semen parameters was linked to a significant increase in the risk of idiopathic infertility, (b) the variant rs3817444 associated with both normal and abnormal semen parameters also indicated an increased risk of idiopathic infertility, and (c) the variants rs3749474 associated with both normal and abnormal semen parameters, on the other hand, conferred no significant risk for male infertility. Furthermore, elevated serum testosterone and FSH levels were correlated with the three variants of CLOCK gene in idiopathic infertility. The findings demonstrate that the human subjects with variants of the CLOCK gene are associated with idiopathic male infertility and therefore may be applied as a risk factor of male infertility.     

Facteurs de stress psychologique et qualité du sperme dans une population de 450 hommes infertiles slovènes

The purpose of this prospective study was to examine the relationship between psychological stress and male reproductive function. The study population consisted of 450 men attending the infertility outpatient clinic and 45 men participating in an IVF-ICSI programme. Psychological stress was measured in four ways. Firstly, the “WHO (five) Well-Being Index” (1995 version) assessed the risk of depression in the previous two-week period. Secondly, Zung’s Anxiety Scale Inventory was used to assess the features and severity of anxiety. Thirdly, the global reaction to various types of chronic life stress events related to family, partner, sexual behaviour, job strain and stress related to infertility treatment, with a more intense reaction corresponding to a higher score. Fourthly, the participant indicated by no (=1) or yes (=2) whether he had been exposed to the following acute stress situations: unemployment, moving house, personal illness or illness of a close relative, road accident. All questionnaires were completed after collection of the semen sample. The incidence of depression and anxiety symptoms in the two study populations (6.5% and 5.3%, and 20.3% and 30.8%, respectively) was twice as high as that observed in the general population. Anxiety was more pronounced (50%) in ICSI patients than in conventional IVF patients. To assess a relationship between psychological stress factors and male reproductive function, we used multiple regression analysis after adjustment of sperm parameters for age, sexual abstinence, type of infertility (primary or secondary), elevated body temperature, varicocele, and history of cryptorchidism and genital infection. Depression scoring was associated with increased sperm concentration (a 7.3% increase by score unit), an intense reaction to chronic stress was associated with a decreased sperm count (3.1% by score unit), and decreased motility “a”, motility “a+b”, and vitality (0.5, 0.5, and 0.6% by score unit, respectively). Exposure to acute stress was associated with increased motility “a+b” (3.5% when the man was exposed to acute stress). Analysis using dichotomous division of fertile and infertile men did not reveal any significant correlation between any stress factor and infertility. These findings indicate that depression and anxiety are frequent in a population of infertile men attending the outpatient clinic or during IVF-ICSI attempts, while significant changes of sperm characteristics are related to depression (decreased sperm concentration), intense reaction to chronic stress (decreased sperm count, motility “a” and “a+b”, and vitality) and exposure to acute stress (better motility “a+b”). This study confirms that stress factors must be taken into account in the management of infertile couples with particular attention to depression and reaction to stress.     

Impact of Cu and Fe concentrations on oxidative damage in male infertility

Oxidative stress in the reproductive system is thought to have an effect on the fertilizing ability of sperm. The purpose of this study was to assess the interaction of iron (Fe) and copper (Cu) ions in suspected subfertile and fertile male groups and to find out the relationships of the semen parameters (sperm count, motility, and abnormal morphology), glutathione, malondialdehyde, and reactive oxygen species with these variables. Semen and blood obtained from 60 subfertile men and from 40 fertile volunteers were examined. The sperm count and motility in the subfertile male group were found lower than those in fertile male group (p<0.001). Cu levels in serum and seminal plasma in the subfertile male group were significantly higher than those in the fertile male group (p<0.001 and p<0.05, respectively). There was also a significant increase in the Fe level of seminal plasma in the subfertile male group (p<0.001). However, there was no significant difference in the Fe level of serum in the subfertile male group. In conclusion, these findings suggest that Cu and Fe might be mediators of the effects of oxidative damage and play an essential role in spermatogenesis and male infertility; the determination of Fe and Cu levels in serum and seminal plasma during infertility investigation is recommended.     

Sperm DNA fragmentation and oxidation are independent of malondialdheyde

Background  

There is clinical evidence to show that sperm DNA damage could be a marker of sperm quality and extensive data exist on the relationship between DNA damage and male fertility status. Detecting such damage in sperm could provide new elements besides semen parameters in diagnosing male infertility. We aimed to assess sperm DNA fragmentation and oxidation and to study the association between these two markers, routine semen parameters and malondialdehyde formation.     

Genetic screening in couples experiencing recurrent assisted procreation failure

Infertility is a major health problem affecting about 10-20% of couples in the reproductive age group. Male factor is assumed to be responsible in about 50% cases of infertility. The origin of reduced testicular sperm function is unknown in about 50-70% of cases and for such couples assisted reproduction techniques (ART) are a boon. Male infertility is often due to poor semen quality and may be associated with genetic defects. ART has revolutionized management of infertility and intracytoplasmic sperm injection (ICSI) is the ART procedure of choice in 60-80% cases. Despite major technological advancements and professional expertise in ART, the success rate and carry-home live birth rate of ICSI is low (18-25%). This study was aimed to understand the genetic etiopathology of recurrent ART failure. For this, 110 couples with 3 or more failed ART cycles were recruited. A detailed history was taken and only idiopathic ART failure cases were enrolled for this study. They were subjected to cytogenetic and Yq microdeletion analysis. Genetic abnormalities were detected in 19 couples. Since a large number (18.2%) cases harboured genetic abnormalities, it is important for all couples opting for ART to undergo a thorough genetic analysis to prevent recurrent emotional, physical and financial stress.