It is a thorough review of the male factor infertility experience, such as has never been presented before in a single post. We will mainly talk about Intracytoplasmic Sperm Injection (ICSI) as the major point there.
It is known well that the inability to conceive after 12 months of unprotected intercourse is generally defined as infertility. Almost 15% of reproductive age couples experience infertility and at least 30-40% of them are attributed to the male factor infertility. Many barriers in access to care for the male factor infertility are known to exist even where such care is available and affordable that may lead to an underestimation of the problem. The rich experience gained recently was more typical in underlining that men with such a diagnosis reacted in the ways comparable to men in couples where the diagnosis was female, mixed, or of unexplained origin.
Moreover, the arrival of ART treatments to hitherto ART-deprived settings can have a major, positive impact on gender relations, especially in infertile marriages, and is cited to lead to increased male adoption of ART, especially for the male factor infertility. Yet, major patients with severe male factor infertility could not be treated with IVF only, and those patients would have to rely on donor sperm or even adoption. ICSI addressed these shortcomings of IVF and revolutionized the treatment of patients with severe male factor infertility in whom the male partners were presumed to be the cause of recurrent failed attempts at IVF or whose semen parameters were unacceptable for conventional IVF.
Actually, the male factor infertility is often defined by abnormal semen parameters but may be present even when the semen analysis is normal. The male factor infertility can be due to a variety of identifiable and reversible conditions, such as ductal obstruction and hypogonadotropic hypogonadism. In recent decades, the incidence of the male factor infertility has been increasing supporting a decline in sperm quality and fertility outcomes worldwide over time.
Hormonal profile and/or endocrine referral may be considered in some patients undergoing evaluation for the male factor infertility focusing primarily on the hypothalamic-pituitary testicular axis. Endocrine disorders are uncommon in men with normal semen parameters.
While there are no universally accepted semen analysis reference ranges for scoring sperm morphology there could be strict morphological criteria indeed. Values that fall outside these criteria suggest the male factor infertility and indicate the need for additional clinical and/or laboratory evaluation.
Azoospermia is believed to be present in 1% of all men and accounts for 10-20% of the male factor infertility. Etiology of azoospermia is commonly categorized into either obstructive or post-testicular (adequate sperm production in the presence of ductal obstruction), or non-obstructive or testicular azoospermia (absence of sperm production).
In ART, ICSI is an alternative for couples with the male factor infertility and low or absent fertilization rate in previous conventional IVF cycles. ICSI outcome depends on several factors that include oocyte quality, patient age, and the quality of the spermatozoa selected to be injected into the oocyte.
On top of ICSI, several evidences have demonstrated that Intracytoplasmic Morphology Selected sperm Injection (IMSI) significantly improves embryo quality, implantation and pregnancy rates when compared to ICSI; however, the results are controversial. In most cases, IMSI is positively associated with implantation and/or pregnancy rates in couples with previous and repeated implantation failures and in patients with the male factor infertility. Furthermore, the effect of IMSI on the chromosomal status or aneuploidy of the embryos is still controversial since many studies comparing ICSI and IMSI show conflicting results.
In addition, the blastocysts from the IMSI group showed a tendency for better quality by an increment on Grade “A” when compared with those from the conventional ICSI. This in an indication that might explain the better outcomes of IMSI in cases of the male factor infertility since the initial contact between the blastocyst and maternal tissues is by adhesion of the trophoblast to the uterine epithelium and cell-to-cell interaction. This interaction is believed to be critical for implantation, so the trophoblast quality highly influences the chances of embryo implantation and reduces the chances of miscarriage.
IMSI also increases the likelihood of fertilization, implantation, and pregnancy in patients with oligoasthenozoospermia compared to ICSI cycles for the couples undergoing first IVF and the male factor infertility. Men with severe oligozoospermia or cryptozoospermia may be encouraged to cryopreserve ejaculated sperm in anticipation of IVF due to the risk of transient azoospermia that may exceed 50%. It is currently thought that conventional techniques of cryopreservation may represent a barrier to men with severe male factor infertility due to perceived diminished post-thaw sperm recovery. Indeed, sperm loss after cryopreservation of very low numbers of ejaculated sperm has post-thaw retrieval rates ranging from 59 to 100%. This may represent a disadvantage of the use of ejaculated sperm in these men.