The following sections describe Causes, Investigation and Treatment options in some detail. If you have specific questions of interest, use the tables below to find your subject area quickly.

Male Factors

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Investigations of Infertility

Semen analysis

Production of semen samples

Semen samples should be produced by masturbation at the Centre so that the analysis can take place immediately after production. However, if you feel you are unable to produce a sample on-site, please speak to one of our laboratory staff to discuss alternative arrangements.

Please make sure that you do not ejaculate for 3 days prior to producing a semen sample for analysis. This is important as it will ensure that the sample you produce on the day is at its optimum in terms of numbers and quality.

Results

The results of your semen analysis will be available after three days and will be discussed with you by your consultant. We do not give results out over the telephone, although you may request a written report.

Appointments

Appointments are required and can be arranged and booked via the Reception on 020 7403 3363 or Embryology Department on 020 7089 1440. Your will be required to complete a Registration form upon arrival if we have not sent one with your appointment letter.

The Analysis

The following will be assessed during the semen analysis: the number of sperm present within the ejaculate (the sperm count); the number of sperm that are moving (the motility); the number of sperm that are normally formed (the morphology); whether or not there are anti-sperm antibodies present; the ability of sperm to survive over a 24 hour period and whether or not there is any infection present within the sample.

What is a 'normal' semen analysis result?

A normal semen analysis will show the following: a semen volume of between 2 and 3mls; a sperm count of at least 20 million sperm per ml; at least 45% of the sperm will be motile; at least 30% of the sperm will be normally formed and less than 10% of the sperm will be affected by antisperm antibodies.

The degree of variance from these accepted normal values will be assessed and the implications explained by your consultant during a follow-up consultation.

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Repeated Centrifugal Analysis (RCA)

Some men with infertility problems are told that it is not possible to find any sperm in the ejaculate following routine semen analysis. This condition is called azoospermia. If these men wish to father a child using their own sperm it is then usually necessary to undergo a surgical procedure to try and extract sperm directly from the epididymis or from the testis. (PESA or TESE)

However, this surgery may not always be necessary. In some cases men who have been told that they have azoospermia do in fact produce some sperm that can be found in the ejaculate. The sperm is produced in very minute quantities and as a result can be missed during a routine semen analysis. Using advanced analysis techniques it may be possible for the embryologist to recover a few sperm from the ejaculate, which can then be cryopreserved (stored). This is carried out on several occasions and it may be possible to store enough sperm to be used in a treatment cycle. If sperm is collected using this method there will not be sufficient sperm to be able to fertilise eggs in the normal way and Intra-cytoplasmic sperm injection (ICSI) will always be required.

This technique is called Rapid Centrifugal Analysis (RCA). Firstly, the man will need to give several ejaculates for analysis over a period of weeks. Each of these ejaculates is then prepared by spinning in a centrifuge at very high speed. This concentrates all the cells in the sample, including any sperm cells, into a very small volume. It may then be possible for the embryologist to identify a few sperm using a very powerful microscope. If any sperm are seen then the ejaculate will be cryopreserved for future use.

Not all men who undergo this procedure will be successful. We have only recently started to offer this technique to patients and we are not able to say how successful it will be. However, we expect that about 25% of men will be able to collect enough sperm to be able to use in an ICSI cycle.

If these sperm are used during ICSI then around 65% of the eggs will fertilise following the injection of a single sperm. Pregnancy rates following IVF/ICSI are currently 22% per embryo transfer.

For any further information, please contact a embryologist on 020 7089 1440.

Hormone Assessment of the Male

In cases of azoospermia, blood analysis of hormones (FSH, LH and testosterone) will be taken. This will tell us if there is a blockage or if there is no sperm production within the testis. In the first instance, sperm can be retrieved through PESA or MESA or surgery might correct the problem. In the second instance, 50% of the cases, Testicular Sperm Extraction (TESA) will retrieve enough sperm to fertilize the egg. Exceptionally if the levels of testosterone are too low, in the most severe cases hormone replacement therapy will be advised.

Testicular Biopsy

Testicular Biopsy involves taking one or several small samples of the testes - either for analysis, or for the recovery of sperm in the most severe cases of azoospermia, for immediate test or cryo preservation for use later.

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Treatment Options

Percutaneous Epididymal Sperm Aspiration - PESA
Testicular Sperm Extraction - TESE

The total absence of sperm in the ejaculate is known as azoospermia. There are two main reasons for this occurrence:

1. A blockage or congenital abnormality, which prevents movement of the sperm between the testis (where sperm is produced) and the penis.

• Blockage can be the result of previous vasectomy or previous infection.
• Congenital abnormality presents as an absence of the tubes which carry the sperm from the testis to the penis. Some men are born with this 'congenital absence of the vasa'. This condition is likely to be associated with an abnormal gene for Cystic Fibrosis.

2. A poorly functioning testis, resulting in low sperm production.

• This may happen when the testis has been affected by conditions such as mumps, infections, trauma, testicular torsion or undescended testis, OR
• genetic abnormalities may be the cause. It is now recognised that up to 15% of men with azoospermia may carry abnormal genes responsible for their infertility. It is therefore important to perform a genetic screen to check this, not only to understand the problem, but also to assess the risk of transmission to the child.

However, in many cases, the reason for azoospermia will remain unknown.

Techniques for Sperm Recovery

In most cases the procedure will be performed in the Day Case Unit (DCU). You will be admitted one hour prior to the operation and will be discharged two to three hours later.

PESA

• The technique called Percutaneous Epididymal Sperm Aspiration, or PESA, is generally used where there is a blockage.
• Under local anaesthetic, sperm is aspirated directly from the epididymis, (tube containing the sperm), with a very fine needle which has been inserted through the scrotal skin.
• An embryologist will then check the sample for the presence of sperm, under a microscope.

TESE

• The technique called Testicular Sperm Extraction, or TESE, is used in cases of non-obstructive azoospermia, or if PESA has been unsuccessful.
• This technique involves the collection of sperm directly from the testis.
• The patient may require an additional injection of intravenous drugs, to achieve a mild degree of sedation.
• A special needle, which allows the surgeon to recover several samples of testicular tissue from different locations, is used.
• A sample from the testicular biopsy will be sent for Histological examination in order to obtain a tissue diagnosis and also to rule out the risk of Testicular Cancer, which is known to occur slightly more frequently (1%) in men with non-obstructive azoospermia.

After the Procedures?

Patients are generally informed on the same day whether sperm has been found or not. However, in the most difficult cases, a two to three day period of tissue incubation is necessary before sperm can be recovered.

Recovered sperm will be frozen for later use. There are generally enough sperm to perform several IVF / ICSI cycles.

The chance of recovering sperm is almost 100% if there is a simple blockage. With abnormalities of the testes, the average recovery rate is around 50% - 60%.

It is therefore important to understand that there is no guarantee of finding sperm even when the pre-operative tests seem encouraging.

Immediate Post Procedure Symptoms?

• You will start to feel some discomfort when the local anaesthetic wears off, a couple of hours after the end of the procedure.
• You will be given a prescription for antibiotics and painkillers.
• After a PESA, men are generally able to resume work a couple of days later. Convalescence takes 4-5 days after a TESE.
• In our experience complications are rare. Whilst some bruising or swelling can occur this rarely requires additional treatment, although post operative haematoma (a mass of clotted blood in the tissue) has been described in other literature. Furthermore, two cases of post-operative testicular atrophy have been reported worldwide.

IVF treatment following PESA / TESE?

Sperm extracted surgically is not able to fertilise eggs by routine IVF, so Intra Cytoplasmic Sperm Injection, or ICSI, is essential.

Fertilisation rates are 50-60% and the chance of pregnancy mainly related to the woman's age, with an average of 25% per cycle.

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Microepididymal Sperm Aspiration (MESA) Percutaneous Epididymal Sperm Aspiration (PESA) & Testicular Sperm Extraction (TESE/TESA)

Total azoospermia (total absence of sperm in the ejaculate) can be due either to a blockage, absence of the vas deferens or to a failure of the testes to produce spermatozoa. The degree of this failure can be variable.

In the first instance, it is quite easy to recover sperm directly from either the testis itself or from the epididymis, which is like a small reservoir appended to the testis. However, the sperm that is collected is not able to fertilise the egg in the natural way and ICSI is always necessary. This leads to a fertilisation rate of around 65%.

In cases of testicular failure, it is now possible in around 50% of cases to collect at least a few sperm by performing one or multiple testicular biopsies. Provided some motile sperm are recovered, the chance of fertilization of the egg is again extremely good.

In both circumstances, it might be possible to freeze some sperm at the time of this operation so that it can be uses during subsequent IVF/ICSI cycles, if the first one was unsuccessful.

Sperm can be recovered either by open surgery needle or aspivatio. During Microepididymal Sperm Aspiration (MESA) - the scrotum is opened and under microscope sperm is aspirated from the epididymis.

Percutaneous Sperm Aspiration (PESA) is a less invasive technique whereby a small needle is inserted through the skin directly into the epididymis to aspirate sperm.

Testicular Biopsy involves taking one or several small samples of the testes - either for analysis, or for the recovery of sperm in the most severe cases of azoospermia. These operations are done as day cases under general or local anaesthesia with or without intravenous sedation.

Long Term Sperm Cryopreservation

Men may wish to have their sperm cryopreserved and stored in some circumstance:-

• Prior to undergoing Vasectomy.
  
  
• Prior to the treatment of some cancer which may involve the removal of a testicle or treatment such as chemotherapy or radiotherapy which may render them infertile.

Their sperm can be stored for a long period of time and used later on for infertility treatment such as insemination of their partner or IVF.

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Vasectomy and Vasectomy Reversal

An increasing number of men have requested vasectomies over the last 20 years as it is a simple and reliable method of achieving male sterility.

Unfortunately approximately 3% of men regret their decision and request vasectomy reversal. These requests are more common if the vasectomy has been carried out at a time of personal or emotional crisis or following divorce.

It is important that vasectomy should not be considered a readily reversible method of birth control, however, as even in the best hands pregnancy rates are less that 50%. Because of this pre-vasectomy patients may consider freezing and banking of semen prior to their operation. This service is offered in centres licensed by the Human Fertilisation and Embryology Authority.

Before a Vasectomy

The sperm produced by each testicle collects in a tightly coiled tube called the epididymis. It is during their passage through the epididymis that the sperm achieve their ability to move and fertilise an egg. The epididymis leads into a thicker tube, the vas deferens. This can be felt in the scrotum of most men. The tube passes through the seminiferous vesicles and the prostate gland before leading into the urethra (the tube within the penis). It takes approximately 60 days for a sperm to be produced and a further 14 days to pass through the epididymis and vas deferens.

The Vasectomy Operation

This operation involves cutting and removing a section of the vas deferens on each side. Thus, the passage of sperm is interrupted and cannot reach the outside world. However, men produce sperm continuously from the time of puberty and continue to do so after vasectomy. In most cases the operation does not interfere with the function of the testes.

After Vasectomy

The sperm produced by the testes has nowhere to go after a vasectomy and collects in the epididymis. This may result in "blow out", sperm leakage and scar formation. In addition anti-sperm antibodies develop in 60% of vasectomized men. These "after effects" are only important if vasectomy reversal is contemplated.

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Vasectomy Reversal

Regret about vasectomy may be more common than suggested by the number of men requesting reversal (many couples request donor insemination rather than reconstructive surgery).

Prior to vasectomy reversal the surgeon may suggest screening for antibodies. Achieving a pregnancy may be difficult if high levels are detected.

The operation may be performed using macroscopic, microsurgical or laser assisted techniques. Most operations require a general anaesthetic, although uncomplicated procedures are sometimes performed under local anaesthetic or epidural. The operation can take up to three hours, but can usually be performed as a day case procedure. However 7-10 days convalescence is required post operatively to assist the healing process.

An incision across the scrotum is required to expose the cut ends of the vas deferens. At this time it is important to ensure that sperm are present in the fluid that leaks out of the end of the vas. If this is not the case there maybe a co-existing blockage in the epididymis and the operative procedure is then more complicated. The surgeon performing the operation may choose to reverse one side at a time. This allows the opportunity for repeat surgery on the other side if the first reversal is unsuccessful. Repeat reversal attempts on the same side however have a very low chance of success.

Methods of Vasectomy Reversal

i. Vasovasostomy

Here the cut ends of the vas deferens are opposed and sutured together. Patency of the vas deferens can be achieved in 80% - 90% of cases. However, only 30 - 40% of patients achieve a pregnancy following vasectomy reversal.

ii. Vaso-epididymostomy

Here the cut end of the vas deferens is joined to a tubule within the epididymis. Results achieved by this method are less good than with vasovasostomy.

Reasons for poor results:

• More than 10 years between vasectomy and reversal carries a poor prognosis
• Too much vas deferens removed at the time of the original operation
• The presence of high levels of anti-sperm antibodies
• Very rarely the testes may atrophy due to damage to the blood supply at the time of operation
• Age of the female partner > 35

Difference between patency and pregnancy rates.

Not every couple will achieve a pregnancy even if sperm appear in the ejaculate following reversal. Gradual scar tissue formation may cause stricture and finally re-blockage of the vas. In addition the semen quality after vasectomy reversal may be poor and IVF/ICSI may still be necessary to achieve a pregnancy. Anti-sperm antibodies may appear in the ejaculate after vasectomy reversal. These attach to the sperm and decrease their fertilising capabilities.

Treatment of anti-sperm antibodies.

• "Washing" the sperm sample has not proved to be very successful as antibodies are tightly bound to the sperm.
• Steroid tablets may help but have major side-effects if used in high doses.
• In vitro fertilisation (IVF) may be suitable for some cases. If spontaneous conception fails to occur - this may be a good option in order to test the fertilising capabilities of the sperm. If the sperm are unable to fertilise the egg in the normal way intracytoplasmic sperm injection (ICSI) is indicated.

Follow-up after Reversal

Sperm may appear in the ejaculate up to a year after vasectomy reversal. If this does not occur, further investigation is indicated. The female partner should already have been fully investigated. For the male partner - testicular biopsy should be considered prior to further surgery to ensure that the testes are still functioning normally.

Percutaneous Epididymal Sperm Aspiration (PESA)

If reversal has failed, sperm may be retrieved surgically from the epididymis and used for IVF/ICSI. The retrieved sperm is fragile with low motility and usually has to be injected into the egg in order to achieve fertilisation. Occasionally reconstructive surgery can be performed at the same time. PESA is indicated for patients with congenital absence of the vas or irreparable and bilateral damage to the vas or epididymis.

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