Skip to content
Home » Andrology » Management of male infertility

Management of male infertility

Generic management strategies:

  • Weight loss
  • Physical activity
  • Cease smoking
  • Reduce alcohol
  • Anti-oxidants
    • May improve semen parameters – but no recommendation can be made for treatment (EAU/AUA)
  • Selective oestrogen receptor modulators (SERMs)
    • Tamoxifen or clomiphene
    • Increase LH and FSH production by pituitary
    • May have minor improvement in semen analysis parameters – but well outweighed by IVF (AUA), no recommendation (EAU)
  • FSH analogues/FSH – may improve semen parameters in men with idiopathic infertility

 

Specific management – define as pre-testicular, non-obstructive (testicular), obstructive

 

Pre-testicular

Hypogonadotropic hypogonadism (incl Kallmann syndrome)

  • Low FSH and low T
  • Treat with HCG and recombinant FSH (as LH and FSH substitute)
  • Stimulates spermatogenesis -> successful pregnancy 16 – 57 %

 

NB testosterone monotherapy should not be prescribed in men with low testosterone who may want to pursue fertility in the future – exogenous testosterone provides negative feedback which reduces GnRH, therefore LH/FSH suppression and may impair or stop spermatogenesis.

This often recovers with testosterone cessation, but can be many months (avg 6 months, up to two years)

 

Testicular (non obstructive) – high FSH (> 7.6) and small testis

Y chromosome testing and counselling (AZfA and AZfB poor prognosis), karyotyping.

Sperm retrieval – mTESE recommended by guidelines – no role for biopsy prior to planned retrieval in non obstructive azoospermia

Varicocele repair

 

 

Post-testicular (obstructive) – normal FSH (< 7.6) and normal size testis

Congenital bilateral absence of vas

  • Microscopic (MESA) or percutaneous (PESA) epididymal sperm aspiration
  • Testicular sperm aspiration (TESA)

Vasectomy

  • Vasectomy reversal

Ejaculatory duct obstruction

  • TURED for post-inflammatory obstruction and cystic obstruction – pregnancy rates 20 – 25 % after TURED
  • MESA/PESA, TESE/mTESE
  • Seminal vesiculoscopy and stone removal

 

If female partner has poor ovarian reserve or patient preference -> can proceed straight to sperm retrieval and IVF/ICSI in obstructive azoospermia.

 

TURED

Findings suggestive of ejaculatory duct obstruction include:

  • Dilated SVs > 15 mm
  • Ejaculatory duct dilation > 2.3 mm
  • Dilated vasal ampulla > 6 mm
  • Midline or paramedian prostatic cysts

AUA guideline:

  • Seminal vesicle aspiration can reveal the presence of sperm -> consider TURED.
  • 63 – 83 % improvement in semen parameters
  • 60 % conversion from azoospermia to some sperm in ejaculate
  • Congenital causes (eg. Mullerian duct cyst) likely to have better improvement cf. acquired obstruction from infection etc.
  • Pregnancy rates 20 – 25 % (EAU guideline)

Complications:

  • Re-stenosis
  • Bleeding
  • Pain
  • Epididymo-orchitis / UTI
  • Urinary retention
  • Haematuria
  • Incontinence
  • Urine reflux to ejaculatory ducts/SVs

Sperm retrieval is a very viable alternative depending on patient/partner factors.

 

Tips:

  • TRUS guided injection of methylene blue into seminal vesicles
  • Scope looking at veru – precisely identify ejaculatory duct openings
  • Pinpoint haemostasis to avoid obstructing the newly opened ducts
  • Passage of ureteric catheter to ducts to confirm open
  • Catheter overnight