Infertility affects 15% of the couples of reproductive ages, while a male factor is a contributory cause in 50% of the cases.1 Fortunately, up to 75% of men with a male factor infertility will be diagnosed with a treatable condition. Nearly all causes of infertility can be helped with assisted reproductive technologies (ART) such as Intracytoplasmic Sperm Injection (ICSI).
Among 10 different types of infertility causes, the success rate using ARTs to treat male factor infertility ranks the third highest at 25.3%, following 28.3% for unknown factor and 26.4% for ovulatory dysfunction (CDC, 2017).
The laboratory technique of ICSI has been revolutionary in treating male infertility because the only absolute criterion for successful ICSI is having at least one viable sperm. Then, the sperm can be directly injected inside the egg, bypassing the need for sperm binding. It is very rare that no viable sperm can be found, in which case donor sperm is needed.
A conventional in-vitro fertilization (IVF) or intrauterine insemination (IUI) may still be tried if there are enough motile, normally shaped sperms in your semen sample. However, ICSI is generally recommended when:
- Spermcount or motility is extremely low
- Very few sperms are normally shaped
- Previous IVFs have failed
- Normal sperm production in testicles but no sperm in semen
- Low sperm count
- High numbers of abnormally shaped sperm
- Sperm DNA fragmentation
- How to improve female factor infertility IVF success
- 1. Hormonal therapies may be an option to increase sperm count
- 2. ICSI is usually the most effective treatment for severe male infertility
- 3. Genetic counselling and pre-implantation genetic testing
- 4. Choose IVF clinics with high-resolution microscopes
- 5. Optimize lifestyle factors to improve sperm quality
Normal sperm production in testicles but no sperm in semen
Blocked vas deferens (tubes)
Some males will receive the diagnosis of obstructive azoospermia. This is when the testicles make sperm but a blockage in the tubes (vas deferens) prevents them from getting into semen. In the case of physical blockage, patients can undergo a testicular or epididymal sperm aspiration where viable sperm is obtained from the male reproductive tract. The obtained sperm is then often used in ICSI to achieve fertilization.
Genetic diseases such as cystic fibrosis
Some genetic mutations can cause absent vas deferens. Nearly 95% of men with cystic fibrosis have congenital bilateral absence of the vas deferens.2 In addition, 47% of the patients with epididymal obstruction could also carry a mutation in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene. Similar to the case of physical blockage, sperm can be surgically obtained from the testicles and used in ICSI.
Retrograde ejaculation is another treatable condition that produces no semen although the testicles make normal sperm. In this case, the semen flows backwards into the bladder rather than out through the urethra during ejaculation. Sperm can be collected from the urine or surgically from the testis. ARTs including IUI, IVF or ICSI can then be used to conceive.
Low sperm count
There may be multiple reasons for a low sperm count. Some patients have reduced spermatogenesis due to hypogonadotrophic hypogonadism. It may be caused by a congenital condition such as Kallmann syndrome or acquired due to a pituitary lesion. In addition, men with a history of steroids abuse can also suffer from reduced testosterone levels and low sperm count.
Gonadotrophin therapy including using luteinizing hormone (LH) and follicle-stimulating hormone (FSH) can stimulate sperm production.3 It has been reported that ongoing therapy for 16 months could result in high levels of sperm count, at which point both ART and natural conception could be attempted.4
Y chromosome microdeletions
Some men with severely low sperm count may have microdeletions of the Y chromosome. Fortunately, these patients could be treated with ICSI and the clinical outcomes do not differ from other patients with normal Y chromosomes.5,6
High numbers of abnormally shaped sperm
Abnormally shaped sperms have difficulty binding and penetrating female eggs to achieve fertilization. However, ICSI has been shown effective for even the most severe form of abnormal sperm morphology. It is recommended that when the rate of normal sperm morphology drops below 4%, ICSI should provide better outcomes than a conventional IVF.7
Reassuringly, the success rates of ICSI for 0% normal sperm morphology do not differ from those that have 1% normal sperm morphology.8 The live birth rate for men with 0% normal sperm morphology is 40% using ICSI, highlighting that as long as one viable sperm can be found, ICSI is a highly effective treatment.
Sperm DNA fragmentation
Between 1-2% of couples who experience pregnancy loss, the cause of miscarriage is unexplained and may actually lie in the male DNA. Researchers from The Endocrine Society reported that in these couples, the male partners who have twice as much sperm DNA damage and a four-fold increase in the level of oxidative stress.9 Sperm DNA fragmentation increases with advanced age and it is mostly a concern for men aged over 40.
For this group of patients, it is best to find an IVF clinic that is equipped with digital high magnification for assessing the level of DNA fragmentation and selecting the healthiest sperm for ICSI. For example, using polarized light microscopes would be more ideal as compared to the traditional white light microscopes.10,11
How to improve female factor infertility IVF success
1. Hormonal therapies may be an option to increase sperm count
Some patients are eligible to try simple hormonal treatments such as Gonadotrophin therapy to improve sperm numbers. If sperm concentration reaches normal levels, natural conception, intrauterine insemination and conventional IVF are possible.
2. ICSI is usually the most effective treatment for severe male infertility
ICSI is a highly effective treatment for most male infertility causes, even when sperm motility, morphology and concentration are severely impaired.
3. Genetic counselling and pre-implantation genetic testing
For patients who have male infertility due to genetic abnormalities, counselling is recommended as they can have offspring with a lethal disease. Pre-implantation genetic testing is also recommended to all patients during the embryo selection process to prevent passing on genetic abnormalities or implantation failures.
4. Choose IVF clinics with high-resolution microscopes
For patients who have diminished genetic quality, such as high level of DNA fragmentation, High-resolution, polarized microscopes can help select the healthiest sperm for ICSI. This is especially important for males over the age of 40.
5. Optimize lifestyle factors to improve sperm quality
Health and lifestyle factors are known to affect sperm count and quality. Adverse lifestyle factors that should be avoided include:
- Steroids and drug use
- Weight gain
- Sextually transmitted diseases
- Kamel RM. (2010). Management of the infertile couple: an evidence-based protocol. Reproductive Biology and Endocrinology10 21 10.1186/1477-7827-8-21
- Souza, D. A. S., Faucz, F. R., Pereira‐Ferrari, L., Sotomaior, V. S., & Raskin, S. (2018). Congenital bilateral absence of the vas deferens as an atypical form of cystic fibrosis: reproductive implications and genetic counseling. Andrology. https://doi.org/10.1111/andr.12450
- Rajkanna, J., Tariq, S., & Oyibo, S. O. (2016). Successful fertility treatment with gonadotrophin therapy for male hypogonadotrophic hypogonadism. Endocrinology, Diabetes & Metabolism Case Reports, 2016, 150124. https://doi.org/10.1530/EDM-15-0124
- Yong, E. L., Lee, K. O., Ng, S. C., & Ratnam, S. S. (1997). Induction of spermatogenesis in isolated hypogonadotrophic hypogonadism with gonadotrophins and early intervention with intracytoplasmic sperm injection. Human Reproduction (Oxford, England), 12(6), 1230–1232. https://doi.org/10.1093/humrep/12.6.1230
- Liu, X. ‐, Wang, R. ‐X., Fu, Y., Luo, L. ‐L., Guo, W., & Liu, R. ‐Z. (2017). Outcomes of intracytoplasmic sperm injection in oligozoospermic men with Y chromosome AZFb or AZFc microdeletions. Andrologia, 49(1), n/a–n/a. https://doi.org/10.1111/and.12602
- Liu, X., Qiao, J., Li, R., Yan, L., & Chen, L. (2013). Y chromosome AZFc microdeletion may not affect the outcomes of ICSI for infertile males with fresh ejaculated sperm. Journal of Assisted Reproduction and Genetics, 30(6), 813–819. https://doi.org/10.1007/s10815-013-0009-y
- Li, Bo, Ma, Yefei, Huang, Jianlei, Xiao, Xifeng, Li, Li, Liu, Chuang, … Wang, Xiaohong. (2014). Probing the Effect of Human Normal Sperm Morphology Rate on Cycle Outcomes and Assisted Reproductive Methods Selection. PLoS ONE, 9(11), e113392. https://doi.org/10.1371/journal.pone.0113392
- Pereira, N., Neri, Q. V., Lekovich, J. P., Spandorfer, S. D., Palermo, G. D., & Rosenwaks, Z. (2015). Outcomes of Intracytoplasmic Sperm Injection Cycles for Complete Teratozoospermia: A Case-Control Study Using Paired Sibling Oocytes. BioMed Research International, 2015, 6. https://doi.org/10.1155/2015/470819
- European Society of Human Reproduction and Embryology. “Delivery rates in IVF are affected by the age of the male partner: Study of almost 19,000 treatment cycles shows decline in success rate with increasing male partner age.” ScienceDaily. ScienceDaily, 3 July 2017. <www.sciencedaily.com/releases/2017/07/170703083236.htm>.
- Vermey, B. G., Chapman, M. G., Cooke, S. & Kilani, S. (2015).The relationship between sperm head retardance using polarized light microscopy and clinical outcomes. Reprod Biomed Online 30, 67-73, doi:10.1016/j.rbmo.2014.09.011.
- Kilani, S. C., Michael. (2011). The use of polarized light microscopy in IVF. Expert Review of Obstretrics and Gynecology 6, 241-246, doi:10.1586/eog.11.17.