Correctable and noncorrectable conditions

Male factors contribute to half of infertility cases and about a third are due to male factors alone, yet “many clinicians evaluate the woman extensively, and often invasively, before considering the male partner,” says urologist Peter N. Kolettis, MD. “Simultaneously testing both partners is necessary to determine the least invasive, most effective treatment.”

Male infertility should be evaluated not only to identify correctable fertility problems, but also to uncover and address underlying medical or genetic pathology, such as testicular or pituitary tumors or abnormal cystic fibrosis genes. “While some causes of male infertility are not correctable and require assisted reproduction, many are treatable,” he says.

Kolettis begins assessment with a medical history, physical examination, and at least two semen analyses. Both hormonal and genetic testing may be indicated, depending on the results, which can reveal the underlying cause of infertility or indicate significant pathology that can affect the health of the patient and their offspring. A potentially treatable male factor problem is present in 50% of cases.

The most common abnormality is a varicocele, which Kolettis corrects with microsurgical varicocele ligation. Other correctable causes of infertility include obstruction, such as after a vasectomy, or complications from hernia surgery, hormonal deficiency, and ejaculatory dysfunction. Between 4% and 10% of the 500,000 US patients who undergo vasectomy each year eventually will seek a reversal. Success rates depend on time since vasectomy and other factors, but 30% to 75% of men are able to impregnate their partners following reversal.

Kolettis, who has performed approximately 400 microsurgical procedures for infertility, including vasectomy reversals, varicocele ligations, and sperm retrieval procedures, also identifies and treats hormone deficiencies, such as hypogonadotrophic hypogonadism.

Kolettis can correct ejaculatory duct obstruction with transurethral resection. Congenital and inflammatory epididymal obstructions are potentially correctable as well. If the obstruction is not correctable, or if the patient does not desire correction, then sperm can be retrieved for in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI).

Other causes, such as nonobstructive azoospermia and bilateral congenital absence of the vas deferens (associated with mutations of the cystic fibrosis transmembrane conductance regulator gene), are not correctable and require advanced reproduction technologies, such as sperm harvesting and IVF, to establish a pregnancy.

The most significant advance in treating severe male infertility is IVF with ICSI. In obstructive azoospermia, sperm can be collected from the testis or through microsurgical epididymal aspiration, which retrieves the greatest number of sperm and facilitates cryopreservation. With mild male factor infertility, intrauterine insemination is an effective option. UAB embryologist Phillip A. Kretzer, ELD, uses customized sperm processing media for these procedures resulting in impressive success rates.

“Infertility is a couple phenomenon,” Kolettis says. “Clinicians should evaluate partners simultaneously and avoid invasive testing in the woman until the man has been evaluated.”

For more information
Dr. Peter Kolettis
Phillip Kretzer
1.800.UAB.MIST
mist@uabmc.edu