Treatment of Male Infertility
FSH (Follicle Stimulating Hormone) is
the hormone that directly stimulates the testis to produce sperm. It is secreted
by the pituitary gland present in the brain. This hormone is present in both
males and females. In the female, it stimulates the ovary to produce the
follicle that contains the ovum.
The pituitary gland is sensitive to the
activity of the testis. If activity is low, it raises the FSH level to stimulate
the testis further. Therefore, an FSH level higher than normal is an indication
of low activity of the testis, which is why the pituitary raised the FSH level.
High FSH level is the reason for infertility or low testicular activity, it is
only a result and a sign of the low activity of the testis.
If FSH level drops below the lower
normal limit, the testis stops producing sperm. This occurs in
FSH is available as injections,
that can be given is FSH level is below normal or if the testis is inactive
despite a normal or slightly high level.
b-Androgens / Testosterone
Being responsible in part for
spermatogenesis, and in full for the development of the testis and normal
masculine characters, defficiency
of testosterone may lead to infertility.
Treatment depends on the cause. If
cause is failure of the testis to produce testosterone despite high
LH level (the hormone produces by the pituitary
to stimulate the testis to secrete testosterone), the patient is treated by
testosterone preparations. If the cause is failure of the pituitary to secrete
LH, the patient is treated by LH injections.
Various forms of testosterone exist:
tablets, injections and gel. An active form is also available (dihydrotestosterone).
On the other hand, if testosterone level
rises much above the normal level (abuse by athletes...etc) if leads to fall of
FSH level and arrest of sperm production.
Both males and females have the same
set of hormones (FSH, LH, testosterone, estrogen and prolactin), though in
A rise in estrogen level may lead to
infertility. Even in the presence of a normal estrogen level, it is the opinion
of some physicians that neutralizing the normal estrogen will promote fertility
in infertile patients. Anti-estrogens neutralize the excess estrogen by
competing with it to its receptors at the cell surface.
d-Prolactin Lowering Drugs
As for estrogen,
increased prolactin level can cause
infertility. Some drugs can decrease prolactin level. However,
it must be noted that a very high prolactin level may issue from a brain tumor
(benign). It is therefore that brain CT
is needed to exclude this possibility.
2-Medical Treatment for Varicocele
There is no medical treatment for
varicocele. However, some drugs are claimed to increase the tone of veins and
may temporarily and paritally neutralize the effect of varicocele, if the
varicocele is of a minor grade.
3-Drugs that Enhance Sperm
This is a compound that is concentrated
in the epididymis where sperm acquires motility.
Increases the energy source (ATP) in
the neck and tail of the sperm
Reactive oxygen species (ROS) are
generated by pus cells (in case of infection) and by aging and dying cells. They
damage the sperm external membrane leading to decreased motility and vitality.
Anti-oxidants fight ROS and decrease their level.
The are general tonics that enhance
general body functions. In particular, vitamin E acts as an anti-oxidant, and
vitamin B12 enhances cell division and therefore sperm production.
4-Medical Treatment of Infection
Infection and inflammation can result in infertility by damaging the testis,
vas deferens or by decreasing sperm quality and motility.
Antibiotics are necessary to treat
infections. In many instances, they should be given to both the man and woman,
since infection is delivered from one partner to another at sexual intercourse.
Antibiotic treatment is preferably
prescribed according to culture and
sensitivity which determines the best antibiotic for the specific mibrobe an
Anti-inflammatories also help decrease
pain, testicular damage and vas occlusion during inflammation.
5-Medical Treatment for High Semen
If semen is
too viscous, sperm motility is hindered.
Some medications can dissolve semen and decrease its viscosity. They are also
prescribed in inflammation and obstruction of nasal sinuses. If these fail,
assisted reproduction (specifically
IUI) can bypass the problem.
6-Medical Treatment for
If obstruction is partial , it may
still be treated medically, by treating the causative infection and inflammation
(see before) and by medications that decrease formation of fibrous tissue
(tissues that accumulate in the vas deferens and
7-Medical Treatment for Antisperm
Steroids (cortisone) can be used in
small doses to inhibit body immunity to a mild extent
that may be enough to decrease Antisperm
antibody formation. However, steroids have many side effects and can be
dangerous. Above all, their dose must be gradually tapered rather than stopped
suddenly, and must be taken under strict medical supervision. A safer
alternative is assisted reproduction.
Treatment for Male Infertility
The decision for surgery is taken when
other measures fail, or if there is a situation that will damage the testis if
left untreated such as varicocele or rupture of the testis.
In case sperm concentration is too
little or if there is no sperm at all, it is necessary to determine whether this
is due to weak activity of the testis, or whether activity is normal but there
is obstruction of the vas deferens that segregates the sperm despite normal
activity of the testis. Accordingly, treatment modality is decided.
Determination of testicular activity is
done by taking a very small sample of the testicular tissue through a small
incision and examining it for its activity.
This is performed under local
anesthesia (or general if required). A 3-5 mm incision is cut in the scrotum
down to the testis. A 2mm incision is cut in the testis and a 1mm biopsy of
tissue is extracted. The testis is closed by one suture, and the scrotum is
closed by 1 or 2 sutures. The procedure takes about 10 minutes and the patient
can get off the operating table and walk out of the operating room on his own
since it is neither painful nor uncomfortable. Patient can return to daily
activities at the same day. It is a minor procedure.
Tissues are examined in the pathology
laboratory and the report comes out in 1-2 days. The result is determined
according to the number of sperm in each tubule (unit of testicular tissue),
the architecture of cell arrangement (regular or disorganized), and the
thickness of the basement membrane (outer wall of each tubule).
It is possible to examine part of the
biopsy for sperm content immediately following extraction and to
freeze the sperm for future use in
Testicular Sperm Extraction (TESE)
In some cases, a biopsy is taken from
the testis and it shows no sperm. This biopsy is taken from one pole of the
testis as shown in the picture, and only represents this pole, meaning that
there may be sperm in other parts of the testis.
Absence of sperm in one pole means that
this is a case of weak activity of the testis. If all modalities of
treatment fail and ICSI is decided, it is
necessary to find a couple of sperm with which to perform ICSI. In this case,
TESE is performed. This is when we search for sperm in all poles of the testis,
and wherever they are found, they are extracted and ised for ICSI whether
immediately or later, in which case they are
These biopsies are usually four in
number, and do not affect masculinity or sexual performance or even testicular
size. They are small.
Sperm extraction can be performed with
local or general anesthesia, through a 1-2cm incision in the scrotim through
which both testes can be accessed. Alternatively, sperm can be aspirated by a
needle without opening the skin. This is easier for both the physician and the
patient, but the sperm yield is less than in classic open biopsy. In both cases,
patients are leave the hospital in 1-2 hours and can return to their daily
activities the next day.
Varicocele is abnormal dilatation and tortuosity of veins exiting the
testis. It can hinder sperm production both in quality and quantity.
Regardless its size, all grades of
varicocele (mild, moderate or sever) can cause infertility, though to different
extents. Treatment of varicocele is ONLY by surgery (varicocelectomy).
There is a debate between physicians
about the value of surgical treatment for varicocele. However, when it comes to
large grades of varicocele (Grade 3), there is no debate. There is a consensus
that it should be treated surgically, otherwise it will result in total death of
the testis (atrophy). Mild and moderate varicocele (grade 1 and 2) may not cause
atrophy of the testis but do cause infertility that increases by time as long as
the varicocele is left untreated, which is why it should be surgically
eliminated. This is the opinion of Andrologists (such as myself) and Urologists.
It is the opinion of Gynecologists that surgery should be restricted to larger
grades of varicocele.
Varicocelectomy (surgical treatment of
varicocele) is performed by interrupting the abnormal veins in which blood
pools, leaving behind the normal veins through which blood flows normally, while
not touching the artery, the vas deferens, the
nerves and the lymphatics. It is very important to avoid the latter
structures otherwise infertility will be worse. Interrupting the continuity of
abnormal veins is performed by closing the vein at two close points by sutures,
and cutting the vein in-between the two points.
There are various incisions to do this:
As shown in the illustration, one of
three incisions can be used, each having its pros and cons. For example, the
lowest incision is the point of meeting of all possible vein systems, while the
highest incision provides access to only one system of veins (three are three
systems). On the other hand, the highest incision provides access to the veins
and not the arteries which keeps the arteries safe, while the lowest incision
provides access to all vessels which necessitates avoiding the arteries. The two
high incision involve opening the abdominal muscles, while the lowest does not,
leading to easier recovery and less pain.
However, varicocelectomy should NEVER
be done in the scrotum.
The use of optical magnification (surgical
microscope or surgical loupe) helps to avoid injuring the important structures:
the artery and the vas deferens.
The incisions range in length from 2-5
cm. Operative time is usually 30-45 minutes, and the patient leaves the hospital
5 hours later and can return to daily activities in one day.
This is endoscopy of the abdomen, that
is performed through three separate incision, 1 cm each. The virtue of endoscopy
is that it provides access to the right and left varicocele through the same
small incisions. However, it provides access to only one system of veins, and
the other two systems cannot be accessed. It is therefore that laparoscopic
varicocelectomy is reserved for lower grades of varicocele when present on both
Orchiopexy (Treatment of Undescended
of the testis inside the abdomen leads to ooverheating of the testis,
resulting in infertility and possibly tumor formation. It is therefore that the
testis MUST be taken out of the abdomen whether by bringing it down to its
normal place if possible (orchiopexy) or
by total removal of the testis (orchiectomy)
to avoid the formation of tumors (if descent is not possible). Heat affects the
sensitive sperm-producing cells and not the sturdy hormone-producing cells.
Therefore infertility occurs but impotence and low virility do not occur.
Even if both testes have to be removes, impotence and
decreased masculinity will not occur (provided testosterone injections
every 4 months)
Ususally the undescended testis
produces absolutely no sperm. Bringing down the testis to its normal place
(orchiopexy) in early childhood may help resuming sperm production. Orchiopexy
at adulthood is absolutely necessary for avoiding tumors, and may rarely help
with sperm production.
Diagnosis: the position of the testis
can sometimes be determined by
ultrasonography, CT or MRI. If they fail to demonstrate the testis,
laparoscopy is necessary to confirm its presence or absence.
Laparoscopy is also the way by which the
testis is brought down or removed.
Bringing down the testis or its removal
is best performed by laparoscopy because it involves only three small incisions,
1 cm each, contrary to open surgery which usually involves a long incision 10cm
long at least.
Upon laparoscopy, the whole abdomen is
explored until the testis is found. The bands of
tissue that trap the testis are cut. This allows the
testis to move downwards. If this is not enough for the testis to reach the
exterior of the abdomen, its main blood vessels (that go upwards) are cut
to allow it to descend further. The testis takes blood from alternative blood
vessels. If this still is not enough and the testis is still in the abdomen, it
has to excised and totally removed as mentioned before.
If the testis is removed, it can be
analyzed and if sperm are found, they can be freezed for future conception by
The ideal result is bringing the testis
down to the scrotum. If this is not possible, the second best result is to bring
the testis out underneath the skin of the abdomen. If this is achieved, a biopsy
is usually taken from the testis to check for activity and for tumors, and it is
followed up thereafter every 6 months.
Commonly, a hernia accompanies the
undescended testis. This must be treated in the same operation.
Hormonal treatment for undescended
testis can only be used in young age, in mild grades of testicular undescent
where the testis is already out of the abdominal wall but not in the scrotum,
and if there is no hernia alongside the testicular undescent.
Is a condition where the testis is
trapped in a position higher than normal, but can occasionally settle down to
its normal position. That is, it moves up and down. This condition does not
affect fertility unless the testis is pressed or hit at its higher position.
Surgical correction may be indicated for
cosmetic reasons. Hormonal treatment for this condition is controversial.
Hormonal treatment is based on the assumption that the hormones will increase
the size and weight of the testis, and thus being heavy it will not go up. This
is possible only in childhood, but has the disadvantages of possible mild
masculinization and shorter height of the child. Moreover, some adults have a
large and heavy testis that still goes up and down (retractile) despite its
Surgical Treatment of Torsion of the
Torsion of the testis is an emergency. Surgical treatment should preferably
be within 6 hours following the start of the condition.
The scrotum is opened and both testes
are delivered. The testis that suffers torsion is usually black and surrounded
by bloody fluid. The torted testis is rotated in the opposite direction to undo
torsion. Hot towels are applied to the testis to increase the blood flow to it.
If the testis comes back to life and its color turns white (more or less) again,
it is preserved and fixed in the scrotum such that it does not rotate again. If
it is dead, it is removed. The other testis is fixed as well because it is known
that if a testis undergoes torsion, the other one is liable to the same
A hydrocele is a collection of fluid
that occupies the space between two of the layers
that surround the testis. This fluid may be watery (serous), or may be
blood or pus. Collection of watery fluid may occur without a known cause or
following surgical treatment for varicocele
if not performed properly.
Pus collects due to infection. Blood collects due to trauma (accidental
blows), tumors, as a complication of surgery or following
Hydrocele causes enlargement of the
scrotum which may in some cases be painful.
This condition requires surgical
treatment if it is very large, or if it is very tense causing pressure on the
testis, or if it is enlarging progressively.
Surgical treatment is termed "hydrocelectomy".
It consists of evacuation of the fluid and removal of a large part of the layers
that surround the testis underneath the skin of the scrotum. These layers are
the ones that produce the watery fluid.
Surgical Correction of Obstruction:
In cases of infertility due to
obstruction of the
sperm track, options are medical treatment,
surgical treatment and ICSI
. ICSI is performed using sperm that is surgically extracted from the
testis. Accordingly, since surgical intervention is performed anyway, it is
advisable to perform surgical correction together with ICSI or on its own.
If performed in the hands of an expert,
success rate of surgical correction of obstruction ranges from 60% to 90%
depending on the method of correction, whether conventional (60%) or
Microsurgery is the
pperformance of correction using very small instruments that match the
diameter of the sperm track (0.1-2mm), under visualization with the surgical
microscope. This also involves the use of ultra thin sutures. This achieves a
higher success rate (90%) in comparison to conventional surgery that is
performed with the regular instruments and sutures without magnification.
surgeries for obstruction are one-day surgeries. Patients leave the hospital in
the same day and can return to daily activities in one day. The results appear
somewhere between 3 to 12 months after surgery.
There is a number of surgical
techniques to chose from according to the exact site (or sites) of obstruction.
For example, if the site of obstruction is at the junction of the
vas and epididymis,
we resort to epididymovasostomy (see later), and if the site is along the vas,
we use vasovasostomy (see later)..etc. The site (or sites of obstruction can be
estimated before surgery by chemical markers
of obstruction and Ultrasonography.
During surgery, the site or sites of
obstruction are pointed out very accurately by
vasography or by inserting a fine probe
along the track to see where it stops. Commonly, there are multiple sites of
obstruction rather than a single site.
It has to be noted that following
obstruction for long periods, Antisperm
antibodies become abundant in semen and decrease sperm motility. Thus,
following surgical correction and re-appearance of sperm in semen, its motility
may be slow. Accordingly, natural pregnancy may or may not occur. If it does not
occur, intrauterine insemination may be
resorted to, and not necessarily ICSI.
If the lower most part of the
vas (where it joins
the tail of the epididymis) is occluded,
we perform an EV. This is when we connect the body of the epididymis
to a higher part of the vas deferens beyond its
lowermost part to bypass obstruction (see the illustration).
Thus, sperm leave the testis, enter the
head of the epididymis, proceed to its body and out to
the vas without having to pass through the tail of the epididymis or the
lowermost part of the vas where the occlusion is present.
This is the technique used whenever the
vas is occluded far from the epididymis so as epididymovasostomy is not
possible. It consists of cutting the occluded segment of the vas and
reconnecting the cut ends. Again, this can be done in the conventional way or
the microsurgical way. Vasovasostomy is also performed when reversal of
vasectomy is desired. Microsurgical vasectomy
reversal or vasovasostomy carries around 90% success rate in terms of
re-appearance of sperm in semen.
This is a technique designed by the
author of this website; Dr.Shaeer, and is published
and applied internationally. It aims at correction of
obstruction resulting from previous surgeries
such as hernia repair, by connecting the part of vas deferens
present inside the pelvis with the one in the scrotum,
bypassing the occluded segment of the vas. This is performed by laparoscopy
(abdominal endoscope) through very tiny incisions. You can view the technique
Trans Urethral Resection of the
Ejaculatory Ducts (TURED)
If obstruction is in the
ejaculatory ducts, the
obstructing tissue can be cut by inserting a narrow endoscope into the urethra
(under anesthesia) up to the ejaculatory ducts and cutting under vision.
Assisted Reproduction (IVF / ICSI / IUI)