swimming in straight lines) described as the progression. Labs may also report other parameters such as the pH, viscosity, agglutination, color of the semen, the viability (percentage of sperm which are alive and dead) or other parameters. Some laboratories will also analyze sperm with computer guided systems (CASA or Computer Assisted Semen Analysis). Through tracking of each individual sperm, these analyses can provide extremely detailed data such as the speed of movement, the lateral head displacement (how much “wiggling” there is) and other parameters such as these. Although these CASA have a role in research they are not necessary for routine clinical evaluations.

Another frequently performed test of the male is the post coital test (PCT) also called the Sims-Huhner test. The test consists of asking the couple to have intercourse at midcycle and 2-12 hours later have the wife come into the office for an exam. At the time of the exam, which is done in the same fashion as a routine pap smear, some of the mucus that is present is examined under the microscope. Sperm should be visible swimming normally. This test is most useful when it is normal. A normal result implies that enough sperm are available for fertilization to take place. Unfortunately an abnormal result can be misleading. Many factors such as poor timing, low-grade vaginitis etc. can make the test seem abnormal although the couple could still establish a pregnancy. Given its simplicity and safety, however, we still frequently use this test to rule out a possible male factor infertility.

Many male patients will be referred to an urologist for evaluation. The physician may
carry out not only a physical exam but may also do blood work to establish whether hormonal levels are normal. During the exam, urologists will generally try to establish whether a varicocoele, an abnormal system of veins, is present in the scrotum. There are data implying that the presence of a varicocoele may decrease sperm number and/or quality. Since this is a surgically correctable problem, most urologists will do either a physical exam or a specialized ultrasound evaluation called a Doppler exam of the scrotum to look for these. Unfortunately, in the majority of cases of abnormal sperm parameters, a “cause” is never identified.

There are many other diagnostic tests available. Some may be useful in very specific situations such as testing for Antisperm Antibodies. Others such as the Hamster Penetration Assay, Hemizona Assay, Hypoosmotic Swelling Test, and the Acrosome Reaction Test have limited roles, if any in the evaluation of the male today. Every one of these tests was designed to give insight into the ability of a sperm to fertilize an egg. Some of these tests were useful “in the old days” but have subsequently been shown to have limited ability to predict fertilization outcomes. Some of the tests have some use in research settings. As a general statement, however, most couples will not need to have any of this kind of testing done. We rarely have to ask couples to go through the expense or bother of having any of these tests performed since the results will not change how we treat the couples.

Treatment

The treatment of male factor infertility is of course dependent on the identified problem. Sexual dysfunction, for example, is often treated by counseling rather than by “medical” therapies. Most commonly, however, we will be treating male factor infertility with therapies such as inseminations or in vitro fertilization..

In order for fertilization and subsequently pregnancy to take place, a minimum number of sperm must “find” the egg. When everything is normal, fertilization will take place in the fallopian tube. Unlike the cartoon drawings of the female anatomy that we are accustomed to seeing, the fallopian tube is not just a straight tunnel-like connection; instead it is a complex organ with many “nooks and crannies”. From a sperm cell’s perspective, it is a labyrinth. The egg will be hidden in one of these areas so a huge number of sperm are necessary at the beginning of the journey in order for a few to find the egg. Once the sperm finds the egg, the effort of many is necessary to break through the layers of cells and protein coat that surround the egg before the final step of fertilization by a single sperm can take place. When it comes to working with male factor patients, then, the question boils down to one of numbers. We must determine whether there are enough sperm available at the beginning so that one can ultimately find and fertilize the egg at the end.

In normal situations at least 50 million sperm are ejaculated into the vagina during intercourse. Of these, only 5-10 million will make it out of the vagina into the uterine cavity. It has been shown that we can easily place sperm directly into the uterine cavity by means of an intrauterine insemination wherein a small flexible catheter is passed through the cervical canal into the uterus, and the sperm can then be injected through that catheter. In order for intrauterine insemination (IUI) to be successful, as a general statement we need to have 3-5 million normal, motile sperm available for insemination into the uterus. The procedure of IUI is very straightforward. The husband will produce a specimen which is then processed in the laboratory. There are many different techniques to process sperm but in all cases the purpose is to remove the sperm cells from the semen and ideally to concentrate the best, most normal sperm into the droplet of culture media which will then be placed into the uterus. Processing of a sperm specimen will typically take 1-2 hours depending on the method used. The actual IUI is done in the office and is similar to a routine pap smear. Using a speculum to see the opening of the cervical canal, a thin flexible plastic catheter can be introduced into the uterine cavity. Once in place, the sperm containing droplet is injected through the catheter. Most women do not feel this at all, some however may experience a slight cramp when the catheter enters the uterine cavity.

Although, we usually must have 3-5 million sperm available for IUI to work, there are always exceptions to this. Occasionally we will see a pregnancy from an insemination where only a few hundred thousand sperm were available, but if less that 3 million sperm are present the couple really needs to consider alternatives because IUI may be frustrating, expensive and unsuccessful. We must also keep in mind the likelihood of success of the various procedures that we recommend to our patients, so if a couple has less than this minimum number of sperm available, it is appropriate to move on to more aggressive therapies.

In the past, couples who had less than a couple million sperm available, realistically had to consider inseminations using donor sperm. Of course, this is still an option today and many couples will undergo a series of inseminations using donor sperm. The process is very straightforward. We identify the time of ovulation and on that day place a thawed sperm specimen into the cervical canal or uterus. Success rates are excellent and cost is reasonable. The obvious downside is that the child will not be genetically linked to the husband. Nonetheless, insemination using donor sperm remains a very viable alternative for many couples.

In 1992 the technique of Intracytoplasmic Sperm Injection (ICSI) was developed in Belgium. This technique involved injecting a single sperm into the egg at the time of in vitro fertilization. This technology has revolutionized the treatment of male factor
infertility. Now, as long as the husband has sperm, pregnancy is possible. ICSI has been used successfully in situations where the husband has extremely low counts, and even in situations where there are no sperm in the ejaculate although there may be sperm production in the testis. As examples, this is the case in men who had unsuccessful reversals of vasectomies, men who are born without the vas deferens (the tubular structure connecting the testis to the urethra and the “outside world”), men who have abnormal development of sperm such that they do not fully develop. Today, the factor which determines whether a couple will have babies in male factor infertility cases treated by ICSI, is actually not how abnormal the male is but rather how normal the female is. The obvious downside of ICSI is that it requires the couple to undergo in vitro fertilization, but the advantage is that the technique allows men to establish pregnancies who previously would never have been able to do so.

Summary

Male factor is one of the most common causes of infertility. We think that it is extremely important to evaluate the male early in the investigation of the infertile couple. A number of diagnostic tests are available, but generally the work-up of the male can be as simple as a semen analysis and depending on the circumstances, a Post Coital Test or other lab tests. Sometimes examination by urologists is useful but not always necessary. Sometimes an actual “cause” for the male infertility can be identified but more commonly no explanation is found. Although the lack of diagnosis can be frustrating, the success with treatment is usually very good. The type of treatment used will depend directly on how many good quality sperm are available. In situations where sperm numbers are low but close to normal, the option of intrauterine insemination of the sperm is available. In situations where sperm numbers are markedly reduced, the best option is ICSI during a cycle of in vitro fertilization. Although the option of inseminations using donor sperm is always available, its usage has decreased dramatically as ICSI has allowed many more men to establish their own genetic pregnancy. We have been very excited with the developments in the treatment of the infertile male in the last few years and look forward to many more new options in this vibrant area.