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Male infertility and Vasectomy Reversal

INTRODUCTION

Until recently, society placed the burden of infertility, or “barrenness.” on women Today, we know that approximately 40 percent of infertility cases are caused by a male factor, 40 percent by a female factor, and 20 percent by a combination of male and female factors. Infertility is usually indicated when a couple fails to achieve pregnancy after at least one year of unprotected intercourse. Many different factors can cause or contribute to male infertility, and the purpose of most diagnostic testing is to identify these factors.

Regardless of the cause, infertility is always a couple problem, and both partners must work through the treatment and emotional trauma together. This section explains how the male reproductive system works, how physicians evaluate male infertility. and what can be done to improve the chances of conception when a man has a fertility problem. If a prior vasectomy is the cause of infertility, vasectomy reversal offers a good chance of regaining fertility.

CONCEPTION

There are many steps involved in the process of conceiving a child. In order for traditional conception to occur, the man must ejaculate his semen, the fluid containing the sperm, into the woman’s vagina near the time of ovulation.

Ovulation occurs about once a month when one of the woman’s ovaries releases an egg, which is then picked up by one of the fallopian tubes and begins traveling toward the uterus (Figure 1). The man’s .sperm must be capable of swimming through the vagina and cervical mucus, up the cervical canal into the uterus, and up into the fallopian tube, where it must attach to and penetrate the egg in order to fertilize it. The fertilized egg continues traveling to the uterus and implants in the uterine lining, where it grows and matures. If all goes well. a child is born approximately nine months later.

A variety of problems can prevent the sperm from making its journey to fertilize the egg. Sometimes the man does not produce enough sperm, the sperm can’t swim properly, or they can’t penetrate the egg. In order to understand the potential problems, it is first necessary to understand the process of sperm production.

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Figure :- Female reproductive tract. Arrows indicate path sperm must travel to reach the egg.
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Figure 2 : Sperm are manufactured in the seminiferous tubules that fill the two testes.

SPERM PRODUCTION

Sperm are manufactured in thread-like tubules that fill the two testes (Figure 2). These tubules, called seminiferous tubules, are lined with several layers of cells. Over a period of about three months, sperm cells in the layer closest to the tubule wall migrate to the tubule’s central passageway, called the lumen. These round. immature sperm cells gradually lengthen as they approach the lumen, developing the typical tadpole appearance of mature sperm (Figure 3). The head of the sperm contains the male genetic material, which will enter the egg and join the female genetic material during fertilization to form an embryo. The midpiece of the sperm provides the energy needed by the tail to propel the sperm forward. Results of treatment given to improve fertility may not be apparent for at least three months, the time from the beginning of sperm formation to the ejaculation of mature sperm.

Outside the seminiferous tubules in the interstitium are the Leydig, cells (Figure 2). These cells produce the male hormone testosterone, which is responsible for the development of such masculine physical characteristics as body and facial hair. large muscles, and a deep voice. Testosterone also helps stimulate the sex drive and potency, or the ability to achieve and maintain an erection. Leydig cells almost always function well even if sperm production is poor.

A variety of problems can prevent the sperm from making its journey to fertilize the egg. Sometimes the man does not produce enough sperm, the sperm can’t swim properly, or they can’t penetrate the egg. In order to understand the potential problems, it is first necessary to understand the process of sperm production.

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Figure 3 : Mature sperm as seen through the microscope

THE EFFECT OF HORMONES ON SPERM PRODUCTION

Hormones initiate sperm production. The pituitary gland, located at the base of the brain, releases follicle stimulating hormone (FSH) and luteinizing hormone (LH). The primary action of FSH is to stimulate the cells in the seminiferous tubules to produce sperm. The primary action of LH is to stimulate the Leydig cells to produce testosterone, which is necessary for sperm production and development. These and other hormones work together to ensure that adequate amounts of healthy sperm are produced.

EJACULATION

The ejaculation of sperm is an intricate process. Sperm released into the lumen of the seminiferous tubules are not fully mature until they travel through the epididymis, a tiny 10-foot-long coiled tube attached to the back of each testis (Figure 4). The efferent ducts of the testis connect the seminiferous tubules with the epididymis, which in turn leads into a large duct about 14 inches long called the vas deferens, commonly referred to as the “vas.” Behind the bladder is a pair of pouches called seminal vesicles. Each one is joined to a vas to form an ejuculatory duct. The two ducts lead into the prostate gland and direct the ejaculate (semen) into the urethra, a tube leading from the bladder to the end of the penis. The seminal vesicles contribute 90 percent of the fluid volume of semen, and the prostate contributes most of the rest. Sperm cells make up less than five percent of the total ejaculate volume.

A variety of problems can prevent the sperm from making its journey to fertilize the egg. Sometimes the man does not produce enough sperm, the sperm can’t swim properly, or they can’t penetrate the egg. In order to understand the potential problems, it is first necessary to understand the process of sperm production.

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Figure :The male reproductive tract. Arrows indicate sperm’s path at ejaculation.

THE MALE FERTILITY EVALUATION

Fertility depends upon the man’s ability to deposit adequate numbers of healthy. mature, functioning sperm into the female reproductive tract near the time of ovulation. For most men, a detailed medical history, a complete physical examination, and a semen analysis will form the major part of the fertility screening. Men who feel uncomfortable about the fertility evaluation should discuss these feelings with their partner and physician. Talking about anxiety beforehand can make the actual exam much easier.

The Fertility History

The physician will need information relevant to male fertility and will determine if adequate sexual contact is taking place. Sexual history may also be discussed at this time.

Be prepared to answer questions about the following:
• general medical history
• mumps after puberty
• trauma to the testes
• an undescended testis at birth
• frequency of sexual intercourse
• infection of the reproductive organs and bladder
• a hernia in the groin
• a vasectomy or vasectomy reversal
• radiation or chemotherapy for cancer
• if your mother took certain drugs like DES while pregnant
• tobacco, drug. and alcohol use
• exposure to environmental toxins
• thyroid disease
• sexually transmitted diseases

The Physical Examination

After the medical history is completed, a physical examination is required. The physician generally concentrates on signs of testosterone production, genetic abnormalities, muscle and fat distribution, voice pitch, hair distribution, and overall well-being. The testes and prostate are examined for size. consistency, and evidence of abnormalities.

TESTING FOR FERTILITY

Evaluation is a very important part of the infertility testing process. Without a thorough evaluation, the chances of achieving pregnancy and appropriate treatment cannot be determined. The results of a good evaluation, together with physician counseling, should allow couples to make the best choices for treatment. Testing may include physical exams, blood tests, a semen analysis, and other sperm tests. There is currently no single test to determine whether a man is fertile or infertile, so several tests to examine different aspects of sperm function are usually required. The physician will evaluate the test results and determine which treatments to prescribe. The evaluation process should provide the couple with a plan for treatment and alternatives should treatment fail.

Obtaining a Semen Sample

A semen analysis is usually the first step in evaluating a man’s fertility. Since the woman often initiates medical discussion of fertility, a semen analysis is sometimes requested by her physician even before the male partner has had an examination. Most physicians request that men avoid ejaculating for a period of two or three days before collecting a semen sample. After a period of less than one day. the amount of semen may be towered, and after a period of seven days or more. the semen may contain sperm with reduced motility (movement). Because of the natural variation in sperm numbers, physicians usually request that several samples be examined over an interval of one to three months.

Because a semen sample is generally obtained by masturbation, it is not unusual for a man to have difficulty producing a specimen. Although it is best to collect it at the physician’s office, some men prefer to produce the specimen at home. All of the instructions should be explicitly followed so that the most accurate evaluation can be made. The sample must be brought to the laboratory or physician’s office in the special container supplied within an hour of collection. During transportation, it is very important to keep the semen close to body temperature. Placing the container in a shirt pocket or under the arm will ensure that the sample remains at body temperature.

Men who are unable to produce a specimen by masturbation may ask their physician about special condoms designed for specimen collection. Ordinary condoms contain toxic substances and cannot be used. but even the special condoms are frequently toxic to sperm. These special condoms should only be used as a last resort because the semen samples are often lost by the patient or transported incorrectly.

Semen Analysis

A number of variables are checked in a semen analysis. The first of these is the sperm count, or the number of sperm per milliliter of semen. Normal semen usually contains at least 20 million sperm in each milliliter.

The second variable is sperm motility, or movement of the sperm. In a normal specimen, usually more than half of the sperm are moving forward progressively.

A sperm’s swimming motion helps it travel up through the cervix into the uterus and fallopian tubes (Figure 1). Motility is also needed for the sperm to penetrate the egg’s tough outer shell-like covering for fertilization.

The third variable is sperm morphology. Morphology is the medical term for shape or form. About half the sperm in normal semen have oval heads and slightly curving tails, which is normal. Every man has some abnormally shaped sperm. Most specialists believe that these abnormal sperm will not fertilize an egg. Many patients are concerned that abnormal sperm will increase the risk of birth defects, but this is not the case. A large percentage of abnormal sperm, however, may reduce the number of normal sperm with fertilizing potential. While evaluating sperm morphology, physicians also look for a large number of white blood cells, possibly indicating inflammation, infection, or both.

Other factors examined include semen viscosity (thickness) and semen volume (amount). Ejaculated as a liquid, semen almost immediately assumes a jelly-like consistency and then liquefies again within 30 to 40 minutes. Therefore, semen viscosity is examined at an interval after ejaculation when full liquefaction should have occurred. If the semen does not liquefy, sperm may have problems entering the cervix. The volume of an ejaculate varies normally from one to five milliliters: there are about five milliliters in a teaspoon. If the volume of semen is low. the sperm may not reach the cervix.

ADDITIONAL SPERM TESTS

Many functions of the sperm can be evaluated in the laboratory. The results of these tests are sometimes helpful to the physician in determining the likelihood of pregnancy or in selecting treatments. The tests are not appropriate in every case and the patient’s physician will best know which tests to perform.

Fructose Test

If no sperm are found in the semen analysis, a test for fructose may be done. Fructose is a sugar-like substance found in the seminal vesicles. The absence of fructose in the semen means either that the vas are obstructed at or before the ejaculatory ducts, or that the seminal vesicles are absent.

Postcoital Testing

The postcoital test (PCT) measures the ability of sperm to live and swim in the woman’s cervical mucus. The PCT is performed during the days just before or at the time of ovulation. when the mucus is clear, colorless, watery, abundant, and stretchable. These are prime conditions for sperm passage. About two to 12 hours after intercourse, a cervical mucus sample is taken from the woman during a pelvic examination and examined under a microscope. Because the accuracy of a PCT depends on correct timing, more than one test may be necessary. A PCT can suggest problems with the quality of sperm or cervical mucus, or suggest the presence of antisperm antibodies or allergies to the sperm in the man or woman.

Antisperm Antibody Tests

Antisperm antibody tests try to determine if a man or woman carries substances causing the sperm to clump together, lose motility. or lose the ability to fertilize an egg. These antisperm antibodies are found when a man or woman’s immune system falsely recognizes sperm as foreign material and tries to destroy them. Antisperm antibody testing may be performed on a man or woman’s blood, a man’s semen, or a woman’s cervical mucus.

The Determination of White Blood Cells in Semen

White blood cells in semen may be detrimental to sperm function. Although it may seem simple to identity a round white blood cell in comparison to a sperm cell. this is not always the case. Immature sperm also appear as round cells in the semen. Special stains are needed to differentiate white blood cells from immature sperm. Whereas immature sperm cells are only a reflection of infertility and not necessarily a cause. while blood cells can possibly cause infertility. White blood cells can sometimes indicate an infection in the urinary tract. Cultures of the semen for ordinary bacteria. Chlamydia,. or other sexually transmitted diseases may be indicated if white blood cells are found in semen.

Computer-Assisted Semen Analysis

Computer-assisted semen analysis is a computerized method of analyzing semen. Often sophisticated measures of sperm motility can be obtained, such as how fast the sperm are moving in a straight line and swinging their heads as they move. Some laboratories also employ the computer-assisted semen analysis method to determine the morphology, or number of normal-looking sperm, which provides additional information.

Sperm Enhancement Studies

Some laboratories perform sperm tests in special ways. trying to optimize sperm performance in the test. For example, tests may be performed using different protein concentrations, salt concentrations, or other substances that may improve sperm function. Sometimes chemicals such as caffeine may be added to sperm in an attempt to improve their motility. Though improved pregnancy rates are questionable, some physicians use these “enhanced” sperm in the hope that they may perform better than the patient’s untreated sperm.

Sperm Penetration Assay

In a sperm penetration assay (SPA), also known as the hamster-egg penetration test or humster test. eggs are taken from a female hamster and stripped of their zona pellucida. or outer shell-like covering. These eggs are then exposed to human sperm in the laboratory. Human sperm are able to penetrate these specially treated eggs but the eggs cannot develop into embryos. A normal test usually results in greater than 10 to 20 percent of eggs penetrated, or six penetrations per egg. A lower number of penetrations may suggest that the sperm are unable to penetrate a woman’s egg. The SPA may be useful when other studies have tailed to show a cause of infertility.

Acrosome Reaction Tests

The acrosome is an enzyme-filled cap which covers part of the sperm head. The acrosomal enzymes in the cap are used to dissolve a hole in the egg’s tough outer shell so that the sperm can penetrate the egg and fertilize it. Special stains determine if the sperm can acrosome react appropriately.

Zona Binding or Hemizona Assay

In order for a sperm to successfully penetrate an egg. it must first bind itself to the eggs outer shell (zona pellucida). The zona binding assay or hemizona assay measures the ability of the sperm to bind to this shell. Human eggs used in the test are obtained from autopsies, surgically removed ovaries, or in vitro fertilization (IVF) programs. These eggs are cut in half. One half of an egg is incubated with a known fertile donor’s sperm, while the remaining half is incubated with the male patient’s sperm. An index is then calculated by counting the number of sperm bound to each half of the egg and dividing the number of patient’s sperm bound by the number of donor’s sperm bound. This test can help determine if the sperm are capable of binding to and penetrating the egg.

Hypo-osmotic Swelling Test

Each sperm is surrounded by a cell membrane that functions somewhat like its skin. This “skin” protects the sperm and keeps it intact. The hypo-osmotic swelling test (HOS) is used to examine the function of the sperm’s cell membrane. Sperm are placed in a special salt and sugar solution and examined for swelling of the sperm tail. Abnormal or decreased swelling may suggest a problem with sperm function that could result in infertility.

Medications Associated with Infertility.

Certain medications and chemicals have been associated with affecting sperm function, including spironolactone for high blood pressure, colchicine for gout. caffeine, nicotine, alcohol, marijuana, other street drugs, and anabolic steroids. Refer to Table I for a more complete listing of medications associated with male infertility.

Affecting Hormonal Activity
• Antiandrogens: cimetidine, cyclosporine, spironolactone
• Steroids: anabolic, androgenic
• Prolactin-inducing agents: cimetidine (peptic ulcer treatment), methyldopa.
phenothlazines, tricyclic antidepressants
• Abused substances: alcohol, marijuana

Toxic to Sperm Cells
• Chemotherapeutic agents (cancer treatment): alkylating agents, cisplatinum
• Antibiotics: nifrofurantoin. sulfa drugs
• Pesticides: dibromochloropropane

Affecting Ejaculation
• Alpha Blockers: phenoxybenzamine, phentolamine. prazosin. terazosin
• Ganglionic blockers: guanethldine. methyldopa, teserpine

Miscellaneous
• Tobacco (by cigarette smoking)
• Cocaine
• Beta Blockers

Table I. Medications associated with male infertility.

CAUSES AND TREATMENTS OF MALE INFERTILITY

Environment

Sperm production may be affected by a man’s environment. Nicotine from cigarette smoke may directly affect testosterone-producing cells in the testes. leading to abnormal sperm morphology and decreased sperm motility. Excessive marijuana usage has also been associated with a decline in fertility. Chronic alcoholism not only affects male potency but has also been associated with decreased sperm production. Men whose occupations require long hours of sitting or those who frequent hot tub baths may experience decreased sperm production due to excess heat in the scrotal area. A recent illness associated with fever may also temporarily affect sperm count and motility.

Testicular Disease

Testicular disease can result in the complete absence of sperm in the semen (azoospermia). This condition is found in a small fraction of infertile men and is generally not associated with a reduction in testosterone or sexual function. In most cases, the cause of the disease is unknown, although it sometimes results from an infection in the seminiferous tubules. For example, the mumps virus, if contracted after puberty, can affect both testes and destroy the cells in the seminiferous tubules that make sperm. If these cells are destroyed, the testes will be unable to produce any more sperm. Treatment options such as donor insemination, where the female partner is inseminated with a donor’s sperm, or adoption may be appropriate treatments when the male partner is unable to produce sperm. If the tubules are not severely damaged, testicular disease may simply reduce the sperm count or motility. Intrauterine insemination (IUI) or IVF may be appropriate treatments in these cases. More information about insemination techniques is provided later.

Hormone Deficiencies

Hormones are chemical messengers produced by organs called the endocrine glands. Deficiencies or overproduction of hormones involved in sperm production are infrequent and may be treatable with medication. To check for hormonal problems, the physician may order blood levels of male hormones (testosterone). pituitary hormones (FSH, LH, and prolactin). thyroid hormones, and/or adrenal hormones. Hormone levels are particularly important if the man experienced a delay reaching puberty or other signs of altered growth and development in childhood. If FSH is elevated in the blood, it might indicate that few or no sperm are produced in the testes. If pituitary hormones are low as a result of pituitary disease or other hormone levels are low, they may be supplemented with hormonal medication, and sperm production may be at least partially restored.

Physicians may also prescribe hormones for low sperm count or low motility. This is called “empirical” treatment, because no specific abnormality is being treated. Some of these medications include drugs such as clomiphene citrate and tamoxifen. It is very important that patients who receive these medications understand that this treatment is somewhat controversial, and appropriate follow-up is necessary to determine if the therapy has resulted in any improvement. Couples should not put all their hope into empirical therapy and subsequently delay thinking about alternative treatment plans.

Varicoceles

A frequent condition that may contribute to male infertility is the varicocele. A varicose vein around the testes which has enlarged and produces too much heat to the area. These enlarged veins are present in approximately 15 percent of all men. Varicoceles pose no threat to a man’s health and usually cause no discomfort or other problems. Fertility potential is reduced in about 30 to 50 percent of men who have a varicocele. Though Varicoceles are associated with infertility (approximately one-third of men with infertility will have a varicocele), the majority of men with a varicocele do not have significant fertility problems.

Tying off (occluding) these veins will improve sperm quality in some men and possibly improve their chances for conception. Occlusion may be performed surgically via a small incision in the lower abdomen or upper scrotum, often under general or local anesthesia. Alternatively, a radiologist can use x-ray guidance to go through a vein in the upper leg or a vein in the neck to occlude or block off the varicocele. Success rates in eliminating varicoceles are approximately 95 percent, and semen quality may be improved in some men. Unfortunately, it is difficult to predict which men with varicoceles will experience an improvement in semen quality after varicocele occlusion.

Antisperm Antibodies

Antisperm antibodies may be formed when sperm are exposed to the male immune system. Since no sperm are produced until puberty, the immune system is not accustomed to sperm and therefore may respond by producing antibodies to reject the sperm. Antisperm antibodies commonly form after vasectomy in about 70 percent of men. Other causes that break down the barriers in the testes, such as infection or trauma, also lead to production of antisperm antibodies. The antibodies can attach to different parts of the sperm and either prevent their passage to the egg or prevent fertilization. Treatments for antisperm antibodies may include steroids such as prednisone and cortisone, sperm washing, intrauterine insemination, or in vitro fertilization. However, high doses of cortisone steroids can cause severe complications. Sperm washing may damage the sperm and often does not remove the antibodies. IVF may assist couples who have antisperm antibodies which prevent the sperm from reaching the egg. but only if the sperm can still fertilize the egg once it comes in contact. These antibodies usually cause few problems except when attempting to produce a pregnancy.

Duct System Obstruction

An obstruction of the duct system, such as in the epididymis or vas. may block the outflow of sperm. Infection, including sexually transmitted disease, injury, or surgery can scar the delicate tubules of the epididymis or obstruct the vas. The vas may be absent (a birth defect) or severed in a vasectomy. If the obstruction is complete on both sides for any of these reasons, the semen will contain no sperm even though the seminiferous tubules are in perfect working order. If no sperm are seen during a semen analysis, a chemical fructose test can be performed to determine if blockage in the duct system is present. Very frequently, a patient with no sperm will require measurement of the FSH blood level, a biopsy of the testes to determine if sperm are being produced, and x-rays of the ejaculatory ducts to determine whether surgery could correct a blockage. A high blood FSH level in a man with no sperm suggests that the testes cannot produce sperm, and attempts to repair an obstruction should not be performed.

Surgical techniques are available to restore the free flow of sperm from the testes through the duct systems. The likelihood of success depends to a great extent upon the cause of the obstruction and the length of time it has been present. More information on surgical procedures to repair duct system obstruction is provided in this section on vasectomy reversal.

Infection

Many physicians will try to clear an infection and/or semen white blood cells with antibiotics or other treatments in the hope of providing improved fertility potential Infections in the epididymis, seminal vesicles, or prostate gland may cause few or no symptoms, but can cause infertility.

Premature or Delayed Ejaculation

Premature ejaculation, which causes the semen to be involuntarily deposited outside of the vagina, clearly prohibits healthy sperm from reaching the egg Insemination may be used to achieve pregnancy if premature ejaculation is a persistent problem. Some men also experience an extreme delay in ejaculating into the vagina, especially during the “on demand” pressure that infertility treatment may require. While some neurological or psychological problems may cause premature or delayed ejaculation the possibility that these problems are caused by the stress of infertility treatment should not be overlooked. Men often develop ejaculatory problems during , infertility treatment that they never experienced before beginning treatment.

Hypospadias

A congenital condition, hypospadias. causes the opening of the urethra through which semen passes during ejaculation, to be located on the underside of the penis instead of the end. In severe cases, the semen is not correctly deposited into the vagina. Insemination may help to achieve pregnancy, especially if the sperm are otherwise healthy. Surgery can provide permanent correction in some cases.

Retrograde Ejaculation

Retrograde ejaculation is a disorder that causes the semen to be released backward into the bladder during ejaculation. Sometimes little or no semen comes out of the urethra during ejaculation. This condition may be congenital and may be found in men with diabetes, multiple sclerosis, or previous trauma to the bladder neck. including prior prostate surgery. It may also be a side effect of certain medications, such as anti-depressants and drugs prescribed to treat high blood pressure. The urine, containing the retrograde ejaculate, may be collected and the sperm removed for insemination. In some cases, treatment with oral medication such as pseudoephedrine can improve the condition of retrograde ejaculation by encouraging the bladder neck to close during ejaculation.

Medications or Drugs

Certain medications or drugs may interfere with sperm production (Table 1) It is important that men inform their physician of all medications and drugs used over the last six to 12 months. Men who have received chemotherapy or radiation treatment, which can cause infertility or reduced fertility, should obtain their past medical records for their current physician.

Stress

Psychological stress may occasionally interfere with male sexual drive, erection, and ejaculatory functions. This is particularly true during the course of a couple’s infertility evaluation. Sexual problems such as premature or delayed ejaculation or impotence sometimes arise several months into fertility therapy. Fortunately, these problems are generally temporary and can be resolved in a supportive environment. Men should discuss these matters openly with their partner and physician. Sometimes discussion alone will relieve much of the tension. A therapist trained to help infertility patients cope with the stress of treatment may also be helpful.

INSEMINATION

There are two types of insemination procedures: intracervical insemination (ICI) and intrauterine insemination (IUI). Inseminations are timed to occur in conjunction with ovulation. The semen sample used for insemination may be obtained from the male partner, or from a donor if the male partner is unable to produce an adequate sample. Some conditions benefiting from insemination with the male partner’s sperm include retrograde ejaculation, premature or delayed ejaculation, hypospadias. reduced sperm quality, poor sperm/cervical mucus interaction, and unexplained infertility. Insemination is relatively simple and takes only a few minutes to perform.

Intracervical Insemination (ICI)

ICI involves depositing the semen sample directly into the cervix. The physician places the semen into the cervix with a syringe or cannula. A plastic-coated sponge or cap may be placed into the vagina to keep the semen near the cervix. The sponge or cap is removed four to six hours after the insemination.

Intrauterine Insemination (IUI)

IUI involves depositing washed sperm directly into the uterine cavity, thus bypassing the cervix. The sperm must be first separated from the semen because the seminal fluid can irritate the uterus and cause severe contractions and pain. Washing the sperm also harvests the most motile sperm. By bypassing the cervix, the sperm is placed nearer to the fallopian tube where fertilization usually takes place, to increase the chance of pregnancy.

Donor Insemination (DI)

In cases where the male partner’s semen quality is inadequate to produce a pregnancy, the couple may wish to use sperm from an anonymous donor. Donor insemination (DI) may be performed using IC1 or IUI depending on the recommendation of the patient’s physician. DI allows the woman to carry a pregnancy and permits the couple to experience the pregnancy together. This method of conception is a very personal decision, since the child will not be genetically related to the male partner. It is important that both partners have grieved the loss of their fertility and are aware of and comfortable with the issues involved in raising a child conceived by DI.

Many infertile couples express concern about the safety of donated sperm. The clinic should have a thorough medical history of the donor and his family. The donor should also be required to undergo testing or genetic screening for common diseases, hepatitis B

and C. sexually transmitted diseases, and AIDS. Most clinics use frozen sperm so that the donor can be re-evaluated before his sperm is used. Donor sperm clinics can often provide information regarding a donor’s physical traits, although there is no guarantee that a donor’s traits will be passed on.

ASSISTED REPRODUCTIVE TECHNOLOGIES

In Vitro Fertilization (IVF)

Since the birth of the world’s first in vitro fertilization baby in 1978. IVF has become an integral part of infertility therapy. During IVF, the woman receives ovulation-inducing medications which cause her ovaries to produce multiple eggs. These eggs are retrieved from the ovaries by an outpatient ultrasound-guided procedure and mixed with the man’s sperm in a laboratory dish. When fertilization occurs, the resulting embryos are transferred into the woman’s uterus. IVF may be used by couples who failed to conceive with other methods and is especially helpful in cases of low sperm count because fewer sperm are needed to achieve fertilization. If the sperm are defective or abnormal however, fertilization may still fail to occur. Pregnancy rates from IVF vary widely from program to program. Nationally, success rates are about 20-25% percent per egg retrieval attempt for couples with a male factor. Pregnancy rates are affected by the woman’s age, her hormonal status and uterine environment, and the man’s sperm quality.

Zygote Intrafallopian Transfer (ZIFT)

Zygote intrafallopian transfer is a variant of IVF in which the eggs are retrieved and fertilized in a manner identical to IVF. After fertilization however, the resulting zygotes are placed into the woman’s fallopian tubes instead of the uterus. Pregnancy rates with ZIFT are about the same as with IVF.

Gamete Intrafallopian Transfer (GIFT)

Gamete intrafallopian transfer is another variant of IVF in which a mixture of the gametes (sperm and eggs) is placed into the fallopian tubes, where fertilization hopefully occurs. A major disadvantage of GIFT is the inability to confirm fertilization if the woman does not conceive. Therefore, GIFT is typically not used when male factor infertility is present.

Micromanipulation

Recent technical advances have progressed in assisting fertilization of the egg by the sperm. Patients who have undergone IVF and had poor egg fertilizations may benefit from micromanipulation techniques such as intracytoplasmic sperm injection (ICSI).

This procedure requires precise microscopic instruments to make a small hole in the egg’s outer covering so that the sperm can be injected directly into the egg. Micromanipulation of eggs and sperm requires great expertise and is not always a readily available procedure. As more experience is obtained, potentially more patients will be candidates for this form of assisted reproductive technology.

VASECTOMY REVERSAL

About one percent of men who have a vasectomy decide to have vasectomy reversal. The most common reasons for requesting vasectomy reversal are divorce and remarriage, death of a child, and the desire to have more children after initially electing sterilization.

Vasovasostomy and Vasoepididymostomy

The most common cause of obstruction in the vas is vasectomy for birth control although birth defects or prior hernia surgery can also result in blockage. Vasovasostomy is a surgical procedure designed to restore continuity and repair blockage in the vas and is the main procedure used for vasectomy reversal.

Vasovasostomy is performed by stitching the inner and outer layers of the vas back together (Figure 5).

Vasoepididymostomy is a surgical procedure designed to bypass an obstruction in the epididymal tubule, the inner tube of the epididymis which carries sperm from the testes to the vas. Obstructions may be caused by pressure of testicular fluids after a vasectomy. from infections, trauma, or congenital causes. Vasoepididymostomy is performed by stitching the inner and outer layers of the vas directly to the epididymis and its inner tubule above the level of obstruction, thus bypassing the blockage (Figure 6). This “bypass” procedure is sometimes used for vasectomy reversal if no sperm are present in the vas fluid at the time of surgery, which may indicate a blockage in the epididymal tubule. As the time from vasectomy until vasectomy reversal lengthens, an increasing percentage of patients will have no sperm in the fluid obtained from the vas during vasectomy reversal.

Vasectomy reversal is usually performed on an outpatient basis under local or general anesthesia. The procedure usually lasts from two to three hours, after which the patient stays in the recovery room for observation for approximately three additional hours. He is then free to go home. He should stay in bed for the first day or two after the procedure and not resume strenuous activity or sexual intercourse for approximately three weeks.

scarred
Figure : Vasopvasostomy for vasectomy reversal. The inner and outer layers of the vas are sutured back together.

Evaluation Prior to a Vasectomy Reversal

If a man has had a vasectomy for less than 10 years and has no other problems, history of surgery, or physical illness, often no further evaluation is necessary prior to vasectomy reversal. If the vasectomy was performed over 10 years ago, additional evaluation is needed because success rates of repair decrease after 10 years or longer of obstruction. Evaluation usually consists of a physical examination to examine the size and consistency of the testes. an FSH blood level test, a semen fructose determination, and possibly a testicular biopsy. As noted before. FSH is a hormone from the pituitary which stimulates the testes to produce sperm. If the level of FSH is very high in the blood, the testes are probably not producing any sperm. If this hormone is normal or low. it does not necessarily mean that testicular production is normal and the ejaculatory ducts are open from the seminal vesicles outward, so it helps to locate a blockage. Fructose in the semen usually means the seminal vesicles are normal. If the testes are producing sperm but there is no sperm in the semen. there must be an obstruction somewhere between the testes and the urethra.

About 70 percent of men develop antisperm antibodies after vasectomy. Some physicians suggest that antisperm antibody testing should be performed prior to surgery. However, the high birth rate after reversal and the questionable correlation of antibodies with pregnancy after reversal make antibody testing an unreliable predictor of pregnancy after surgery. Therefore, there is probably little benefit in looking for antisperm antibodies before surgery for vasectomy reversal.

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Figure 6 : Vasoepidymostomy for vasectomy reversal. The inner and outer layers of the
vas are stitched to the epididymis and its inner tubule.

How is it Done?

A vasovasostomy for vasectomy reversal is usually performed through incisions in each side of the scrotum. If the vasectomy was performed at a very high scrotal level or if a long segment of the vas was removed, it may be necessary to extend the scrotal incisions up into the lower inguinal (groin) region. It may or may not be necessary to bring the testes and epididymis out of the scrotum. If vasoepididymostomy is required, the surgeon must bring the testes and epididymis out of the scrotum.

The vas is a very small structure. It is approximately two millimeters in outer diameter, about the size of a thick spaghetti noodle. The actual lumen or inner passageway where the sperm flow through is less than one half of a millimeter in diameter. The outer layer is thick and muscular in order to propel the sperm. Since vasovasostomy is performed on such a small structure, any scarring can cause the lumen of the vas to close and the procedure to fail. The epididymal tubule is even smaller than the vas lumen. Repairs involving obstruction of the epididymis are therefore even more fragile. Fortunately, modern microsurgery has enabled surgeons to perform repairs with reasonable success. The main reason for improved success is the advent and skilled use of the operating microscope. At 10 to 40 times magnification, the tiny sutures (which can barely be seen with the naked eye) can be placed accurately in the muscular layer and the inner layer of the vas.

Vascctomy reversal is usually performed by reconnecting the severed ends of the vas by first placing several sutures in the muscular layer along one side to hold it together. A smaller suture is then used to place six to 10 tiny stitches to pull together the inner layer. The outer layer is then finished with a slightly larger suture (Figure 5). In vasoepididymostomy, a similar procedure is performed except that the epididymis essentially has no muscular layer and only a small, delicate inner layer. The outer muscular layer of the vas is connected directly to the epididymis. and the vas lumen is connected to the tiny epididymal tubule (Figure 6).

At the time of surgery, the surgeon checks to see if sperm are found in the testicular end of the vas. If sperm are found, the surgeon can be assured that the tubing (vas and epididymis) is open and unobstructed. If no sperm are found, the surgeon may decide to examine the vas and epididymis closer to the testis. If an obstruction is found, the vas will be sewn to the epididymis to bypass the obstruction.

Possible Complications

Complications from vasectomy reversal are rare. The most common complication is bleeding after the surgery, but less than five percent of patients experience any bleeding. Bleeding usually stops by itself hut causes some swelling and results in a longer recovery. A repeat surgery is rarely necessary to stop the bleeding. Only rarely does an infection develop which requires treatment.

Results

Pregnancy rates after vasectomy reversal are directly correlated with the length of time since vasectomy. the woman’s fertility status, and previous pregnancies. If a man has had a vasectomy for less than three years, the sperm return rate and pregnancy rate are approximately 95 percent and 75 percent respectively. The more time that has passed since the vasectomy. the lower the rates for sperm return and pregnancy. If more than 15 years has passed, rates are approximately 70 percent and 30 percent respectively. The pregnancy rate after reversal can further be predicted by the appearance of fluid in the vas at the time of surgery. If the surgeon sees many intact motile sperm in the vas fluid, the sperm return rate and pregnancy rates are approximately 94 percent and 63 percent respectively. The fewer normal sperm are seen. the lower the rates for sperm return and pregnancy. If no sperm are seen. rates are approximately 60 percent and 30 percent respectively. Female infertility factors may also affect pregnancy rates, and in some cases an evaluation of the woman is warranted.

Postoperative Care

The patient is usually restricted to bed rest for the first day or two after vasectomy reversal. He should not lift heavy objects, strain, or have sexual intercourse for approximately three weeks. A semen analysis will be obtained at six to 12 weeks and every three to four months after the procedure until pregnancy occurs. Such monitoring will reveal late vasal obstruction, defined as scar tissue that forms following the reversal. This scar tissue occurs in three to six percent of patients. If sperm have not appeared by six months after vasovasostomy or 18 months after vasoepididymostomy, the reversal has failed. If an adequate semen analysis occurs after surgery but no pregnancy occurs, sperm antibody testing and female fertility evaluation may be advised. The average time for a pregnancy to occur is 12 months. and most pregnancies occur during 24 months following the procedure.

If the first reversal fails, a repeat vasovasostomy may be successful, although the success rate for repeat vasoepididymostomy is unfortunately not very high. Sixty percent of men have sperm return to the semen after a repeat vasectomy reversal. and pregnancy occurs in 25 to 35 percent of female partners.

Future Treatments

Several investigators have tried to use lasers under the microscope to “weld” the vas together. Although this seems to be a neat. high-tech idea. results have not been improved and have actually been worse than with microsurgical suture techniques.

Often couples wonder if sperm can be retrieved from the vas or epididymis and used for fertilization, thus sparing the man an operation. Unfortunately, this is not as easy as it sounds. The sperm in the vas and epididymis have been backed up and are often somewhat old, degenerated, and lacking in good fertilizing potential.

Furthermore, the process of retrieving sperm also involves careful microsurgical techniques and is probably as big an operation as the vasectomy reversal. If sperm are retrieved, fertilization would probably better occur if IVF techniques were employed. The success rate with IVF is about 10 to 20 percent per attempt, although success rates of up to 35 percent have been reported. When compared to vasovasostomy with an overall success rate of 50 to 70 percent, sperm retrieval is not the preferred alternative.

CONCLUSION

The study of infertility has come a long way over the last few decades. Gone are the days when physicians assumed that all infertility problems involved only women. A variety of factors can limit a man’s fertility: infection, hormonal imbalance, injury, varicoceles. even psychological and emotional problems. If a man is infertile due to a prior vasectomy, he has a good chance of regaining fertility after a vasectomy reversal. A couple faced with infertility should investigate all aspects of the problem with the guidance of a qualified physician. With the help of today’s advanced diagnostic and reproductive technologies, many infertile couples can achieve their goal of becoming parents.