In most cases of infertility the male role is important but certainly pales in comparison to what our female patients have to endure. Although I offer to provide the couple with syringes filled with saline so the male partner can experience the joy of taking fertility shots, not a single guy has taken me up on this offer so he can better commiserate with his significant other. However, in men who require a testicular biopsy there is a more equitable distribution of effort as the couple moves through fertility treatment. Just remember that testicular sperm cannot fertilize without IVF and ICSI. I know that this seems pretty obvious to most patients but last year I had a couple come in for fertility. The man had undergone a vasectomy. I explained the option of vas reversal vs. IVF/ICSI in a 40 minute consult. We again discussed the process in a follow-up visit. Once the sperm was obtained the woman came in to discuss IUI. I explained that IUI was not an option and that was why we had spent a lot of time discussing IVF in the first place. I know that I went over the whole IVF process in excruciating detail. But she claimed no knowledge of any of this in spite of all the paperwork that I had given her and my detailed diagrams etc. She is probably out there in cyberspace as we speak bashing me and my clinic but what can you do.???
So how can you go from no sperm to baby? Here is the roadmap as I present the “Question of the Day” from the book that my Mother calls “the best book he has written yet!”
34. Can men with azoospermia father children?
When the male partner has either obstructive or nonobstructive azoospermia, the use of IVF and ICSI may still enable the couple to successfully achieve pregnancy. Sperm from the testis or epididymis are essentially unable to fertilize an egg without ICSI. To obtain sperm for use in IVF, a needle aspiration of the testis or epididymis can be performed under local anesthesia. If the male partner has nonobstructive azoospermia, a urologist usually performs a testicular biopsy in the hospital while the patient is under general anesthesia. In either case, the testicular tissue or the sperm aspirate can be frozen in liquid nitrogen and maintained relatively indefinitely. If a testicular biopsy reveals no mature sperm, then the only option is to use donor sperm or to pursue adoption. Occasionally, the sperm retrieved in this fashion is of exceedingly poor quality. In such cases, a repeat testicular biopsy on the day of egg collection for IVF or even use of a cryopreserved specimen from an anonymous sperm donor may be considered as a backup plan.
Rarely, men with diabetes or those taking certain antihypertensive medications may suffer from retrograde ejaculation. In this condition, there is no emission of fluid with male orgasm because all of the fluids travel backward into the bladder instead of out through the urethra. Retrograde ejaculation can easily be diagnosed by checking the post-ejaculation voided urine for sperm. Sperm present in the man’s urine can be washed and used for either insemination or IVF. Pretreatment with bicarbonate the night before sperm collection may improve sperm quality by increasing the pH of the urine.
One final (and interesting) cause of azoospermia is anabolic steroid abuse. Some men with azoospermia may have used testosterone or other steroids as part of their strength and conditioning training. High doses of these steroids can suppress sperm production. In such patients, sperm production can be reinitiated by stopping the steroids and placing the men on gonadotropin therapy (analogous to ovulation induction in women). Although clomiphene citrate has been used to improve sperm quality in men, most studies reveal it to have little to no benefit.