In about 40 percent of infertile couples, the male partner is either the sole cause or a contributing cause of infertility. Therefore, a semen analysis should be done very early in the evaluation of a couple seeking infertility treatment, preferably as one of the very first tests and clearly before any invasive or uncomfortable tests are performed on the woman.
About 90 percent of male infertility cases are due to low sperm counts, poor sperm quality (movement/shape) or both. More than 70 percent of male infertility cases are treatable thanks to scientific advancements such as intracytoplasmic sperm injection and hamster zona sperm cryopreservation, which address sperm quality and sperm count issues.
Visit our common causes of infertility page to learn about other less common causes of male infertility.
Approximately 40 percent of couples having difficulty conceiving experience some degree of male infertility. Most men produce millions of sperm each day; however, many of these may be abnormal either in count, shape (morphology), movement (motility) and function. The semen analysis is a primary diagnostic tool for determining both urological and infertility issues. Included in the semen analysis report are semen volume and viscosity, liquefaction time, sperm count, viability, motility and grade, white cell count, pH, and morphological assessment with classification of abnormal forms present.
When and Where Should a Man Have a Semen Analysis?
A semen analysis should be done very early in the evaluation of a couple seeking fertility treatment, preferably as one of the very first tests and clearly before any invasive or uncomfortable tests are performed on the woman (HSG or surgery). The best place to have a semen analysis performed is at a laboratory associated with reproductive endocrinologists who perform sophisticated, high-tech procedures. These laboratories are board certified and report their results in a manner that is understood by anyone who works with infertility patients. Insurance coverage also will direct you to a service on your provider list.
Separation of sperm from seminal plasma is important for intrauterine insemination (IUI) or other advanced procedures since the process identifies and isolates the most highly motile (higher mobility) sperm. A two-step washing procedure separates the sperm from the seminal plasma while maintaining high sperm recovery. For infertility patients with an increased number of abnormal sperm, white blood cells or ejaculate debris, the two-step wash often results in a higher quality sperm sample that offers a higher degree of fertilization potential.
Included in the sperm washing report are ejaculate volume, sperm count, motility and grade, post-wash (post-swim-up if applicable) and final re-suspension volume.
IVF with ICSI (Intracytoplasmic Sperm Injection)
Since the mid-90s, fertility centers around the world have scrambled to master the technique of intracytoplasmic sperm injection (ICSI), a breakthrough procedure that has revolutionized treatment for male factor infertility and boosted national IVF success rates significantly. Our Center was the first in the Tristate to achieve fertilization with this technique and the first in Greater Cincinnati to achieve pregnancy, just one year after the first international pregnancy was announced.
ICSI’s innovation lies in the ability of specialists to inject a single sperm directly into an egg. Until ICSI, low sperm counts and sperm with poor movement or shape posed barriers to fertility since the sperm possessed a significantly reduced potential to fertilize eggs. Today, ICSI, coupled with IVF, offers couples significantly higher chances at fertilization. Live birth rates for couples requiring ICSI are similar to rates for couples not requiring ICSI, assuming the woman is of similar age.
Which Couples Need IVF with ICSI?
Indications for IVF and ICSI are:
- Severely low sperm count (usually less than 5 million sperm/ml)
- Severely low motility (usually less than 20 percent even with normal sperm counts)
- Normal percent motility but with a poor motility grade (grade is how well the sperm swim)
- Severely abnormal morphology (sperm shape)
- Failed or poor fertilization in a previous IVF attempt
Does the Man’s Age Affect the Couple’s Chances of a Live Birth?
The man’s age is not nearly as important as the woman's age. Even if there are problems with a man’s sperm, with ICSI, fertilization can still be achieved independent of the man’s age. Men over age 50 do have a small but significant reduction in live birth rates compared to younger men. There’s also a slight increase in the incidence of genetic abnormalities in the child (i.e. Down's syndrome) as the man ages, but the increased risk with advancing age is not nearly as high for men as for women.
Fertilization rates using ICSI typically are equal to or greater than 75 percent, with damage to the embryo approaching zero.
IVF with IMSI (intracytoplasmic morphologically-selected sperm injection)
Intracytoplasmic morphologically-selected sperm injection (IMSI) vastly improves the selection of normally-shaped sperm (normal morphology) for higher pregnancy rates and reduced miscarriage rates and is most appropriate for couples with severe male infertility. Our Center was the first in the Tristate and one of only a few in the country to offer this advanced technology.
The technique is an improvement of ICSI (see above). But instead of magnifying an individual sperm by 400 times to select the best sperm for egg injection, IMSI features a specially-configured, high-powered microscope that achieves magnification of greater than 6000 times. This allows the embryologist to look at sperm in greater detail to detect subtle structural damage/alterations that a normal ICSI procedure microscope cannot detect.
The advanced IMSI technique is significant for couples with severe male infertility and repeated unsuccessful IVF attempts since studies have shown increased genetic abnormalities (DNA fragmentation) in the sperm and embryos of this population.
Patient criteria best suited for IMSI include:
- Failed fertilization cycle
- At least 2 failed IVF or ICSI cycles
- History of miscarriages
- Male partner of advanced age
- High DNA fragmentation index
- High incidence of genetically abnormal embryos
Few experiences can be as emotional for couples as discovering the male partner has no sperm or has very few sperm. While as many as 25 percent of couples seeking infertility assistance have a male or male-associated factor, the shock and guilt the man and the couple feel can be devastating. When a male factor to infertility is confirmed, the couple still has options: testicular sperm extraction (TESE), or the use of donor sperm.
Finding a Sperm Donor
The choice of a sperm donor is one made by the couple. The donor phenotype (hair and eye color, for example), age, ethnicity, background and education are just some of the concerns encountered when choosing a sperm donor.
So where do couples go to find a donor? Some search Google. Our center also can make recommendations. All sperm banks are licensed by the federal government, and donor screening is mandated by the government. Each sperm bank should clearly outline its screening process. A medical, genetic, family and social history are available as well as phenotypic characteristics. Some donor programs have pictures of their donors, and some donors are willing to have contact with the couple at a designated time. These options are variable with each donor sperm bank.
The Insemination Process
Once a couple selects a sperm donor, we provide a full fertility workup of the female partner to ensure the sperm factor is the only infertility issue. We then perform insemination either in a natural cycle, where the female tracks ovulation with ovulation predictor kits, or through ovulation induction oral medications. With well-timed insemination and all female fertility factors addressed, the chances of a live birth following donor sperm insemination are excellent and mostly dependent on the age of the woman.
If you have concerns about the use of donor sperm or whether you may need donor sperm, please contact us. We offer the expertise to help you with the emotional, social and medical issues surrounding the use of donor sperm.
Hamster Zona/Low Sperm Count Cryopreservation
(Freezing Single Sperm Cells)
Previously, men with exceptionally low sperm counts could only benefit from infertility techniques such as intracytoplasmic sperm injection if sperm could be harvested at exactly the same time as a woman’s egg was being retrieved. This typically involved a surgical procedure known as testicular sperm extraction. Harvested sperm could not be frozen using traditional methods because the low volume of sperm cells are nearly impossible to find in the solution used to protect sperm during freezing.
Today, thanks to breakthrough technology, even one sperm cell can be safely stored for as long as needed in the empty shell of a hamster egg. The process pushes the treatment of male-factor infertility nearly to the point of nonexistence.
The Bethesda Fertility Center was the first in Ohio, and only one of two centers nationally, to achieve success with this technology.
Testicular Sperm Extraction (TESE)
Not all sperm are easy to access for fertilization procedures, especially when intracytoplasmic sperm injection (ICSI) is recommended. Some men are unable to provide sperm samples on their own with high enough sperm counts. To make fertilization possible for these men, the Bethesda Fertility Center, with assistance from urology specialists, uses sperm aspirated from the testicle or epididymis.
Testicular sperm extraction is a procedure that removes a small amount of testicular tissue by biopsy under local anesthesia. It is performed on an outpatient basis with minimal discomfort. Testicular sperm extraction is indicated for patients with:
- History of vasectomy
- Non-obstructive azoospermia (absence of sperm in the semen due to absence or marked reduction of sperm produced by the testicles)
- Congenital absence of bilateral vas deferens
- Testicular cancer
Our center was the first in the Tristate to achieve pregnancy with sperm aspirated from the epididymis and the first in Greater Cincinnati to achieve pregnancy with sperm aspirated from the testicle. We can recommend urologists who coordinate with our Reproductive Studies Lab when performing testicular sperm extraction.