Male infertility

Male infertility should be thoroughly evaluated, as there are many treatable causes of male infertility. We offer expert evaluation and treatment including microsurgery. The microsurgical procedures we perform include vaso-epididymostomy, vaso-vasostomy, microscopic sub-inguinal varicocelectomy and microsurgical testicular sperm extraction. We also offer electro-ejaculation for patients with spinal cord injuries and diabetics who have lost the ability to have an emission (the term electro-ejaculation is a misnomer as the procedure stimulates the patient to have an emission and not an ejaculation). Transrectal ultrasound is another procedure we use to diagnose and treat male infertility. The ultrasound of the prostate and seminal vesicles can help in the diagnosis of ejaculatory duct obstruction and we make the diagnosis using seminal vesiculography.

Why see a male infertility specialist?

While many forms of male infertility just like female infertility can be corrected it is not always best to correct something that will not have an impact on your ability to achieve a pregnancy and may delay more appropriate treatment. You may be treated very differently depending on your partner’s age (referred to as maternal age). This is critical to your care. Don’t lose sight of the forest for the trees. A specialist in male infertility, sometimes referred to an andrologist (but who is always a urologist), is very important to a couple in order to potentially treat and if not just advise the couple of their best options. Gynecologists, specifically reproductive endocrinologists are specialists in female infertility, not male infertility, and should not be evaluating men for infertility. While we have knowledge of some aspects of female infertility we leave the women’s care to the GYN doctors.

What is a TESE and what can you expect from it.

A TESE is a testicular sperm extraction. It involves making an incision in the scrotum, the sac that surrounds the testicle. This is an attempt to obtain sperm directly from the testicle. It involves opening the covering of the testicle called the tunica albuguinea. The tubules of the testicle are excised and the tissue is minced in order to check for sperm. This is typically done in the presence of an embryologist who will confirm that sperm is present or it is not. Obviously, one of the possible outcomes for the TESE will be that no sperm will be found. The more advanced form of the TESE is the micro TESE, which involves the use of an operating microscope to look for the most dilated tubules in hopes that those tubules will contain sperm. The micro TESE is a more involved procedure because it involves the delivery of the testicle from the scrotum in order to open it and view the entirety of the tubules. This involves anesthesia in my practice.
There are risks to any procedure and the TESE is no exception. The risks include infection, pain, bleeding, failure to find sperm and injury to the testicle. Depending on the patient's pain tolerance, the patients will be uncomfortable or even in pain for several days. The return to work and physical activity will depend on the patient and how extensive the procedure is. Typically the patient can return to work (depending on what they do in a day or so) and be back to full physical activity in one to two weeks.
Postoperatively the patients are encouraged to take at least the next day off from work and to ice the scrotum as much as possible for 24 hours. A small amount of external oozing of blood is not uncommon. While it may appear troubling, is far better to have external oozing than internal bleeding. Patients are to return at approximately one week for follow-up.

What does having no sperm mean?

When there is no sperm seen on semen analysis it is referred to as Azoospermia.
One of a few things is going on. I have seen patients not ejaculate and only produce pre seminal fluid and therefore there was no sperm. In most instances either sperm is not being made or it is not coming out.

When it is not coming out, that is called Obstructive Azoospermia. These patients can have an obstruction anywhere from the testicle to the prostate or be blocked by virtue of having been born without the vas deferens (the tube that connects the epididymis and the prostate).

When it is not being made or it is being made in insufficient quantity to appear in the ejaculate it is referred to as Non Obstructive Azoospermia (NOA). These are patients who may have sperm in their testicles in small quantities. The sperm then needs to be extracted to be used with the IVF/ICSI (in vitro fertilization/ intracytoplasmic sperm injection) procedure.

Cryopreservation of Sperm

Freezing of sperm is a process by which sperm can be stored and used for future fertility. The procedure that can be done using the thawed sperm will depend on how much sperm was originally frozen and how well the sperm responded to the freezing. Whole ejaculates that were frozen and thaw well may be used for IUI (in utero insemination), while other specimens that are not as good may need to be used with the IVF (in vitro fertilization) process. Frozen testicular specimens and epididymal aspirates do no produce the sperm quantities that can be used for anything other than the IVF process.

The better the quality of the sperm sample frozen the more likely it will survive the thawing process. As a rule of thumb half of the sperm that was good prior to freezing will survive the thaw. There are instances when sperm that appears viable prior to freezing will not be viable after the thaw process. We typically freeze smaller quantities of sperm, called test vials, to thaw before sperm is needed so that we are not caught off guard when we do need the sperm. In addition, in circumstances where sperm retrieval is performed, the sperm that is extracted may not be either good enough to freeze or may be so abnormally shaped that it is not worth freezing. If you have any questions about these issues please don't hesitate to ask.