Recommendations before treatment.

The difference between treating the infertile male and helping achieve a pregnancy.

Basic Male Infertility Testing.

Role of the physician to treat the infertile male.

The Ten Most Common Treatment Mistakes an Infertile Male Should Avoid.

Treatment of male infertility (solve the medical problem(s) causing infertility) and using reproductive technologies to help the female partner conceive are totally different approaches that lead to the same objective: to have babies. This concept is not well understood by patients and physicians treating male infertility. The basic approach of male infertility specialists is to help the male improve the chance of conception by resolving the cause(s) of the problem. More often than not, these specialists do not have the other side of the equation in mind, and the most important one, the female partner. They do not realize that AGE OF THE FEMALE is the MAIN predictor of pregnancy. So in some cases they spend years treating the male and when finally there is some success the female is too old to produce her own eggs. While there may be success on fixing the man’s problem (producing sperm) they may face failure to get a pregnancy for the woman’s old age. With that in mind, many times it is better NO TO TREAT the husband and send the couple to an infertility specialist for more advanced treatment.
Any treatment on males to improve the chance of success must include a definite period of time and it should not go beyond one year if the female is 30 years of age or younger or less than six months if the female is 30-35 years of age. Males whose spouse is more than 35 years old should NOT mess around with fertility treatments and are advised to go directly to advanced reproductive technologies as fertility declines rapidly in females over 35 years of age.
It is recommended that before males accept fertility treatments should consult with a female infertility specialist.

The basic testing of male fertility.

To start, a semen analysis MUST be done BEFORE any procedure to conceive is attempted on the female patient. Post-coital tests may give some information but they are not accurate and are affected by several factors so the results may be misleading. If the semen analysis is normal and the medical history is unremarkable, the doctor's focus will shift toward detecting problems with the wife. If the semen analysis reveals abnormalities, however, the doctor may recommend a physical examination and other laboratory tests on the male. Keep in mind that the armamentarium to treat male infertility is very limited compared to the female. Although there is a plethora of surgical interventions and treatments to help the male overcome his infertility, most of them if not all are ineffective. So the most successful approach is the use of techniques such as intrauterine insemination or in vitro fertilization or ICSI to help the couple conceive rather than treating the cause(s) on the male. These techniques do not fix the male’s problem they just overpass it allowing the wife to get pregnant.
The following discussion will help you understand what procedures and tests are available and when they should be used.

Oligozoospermia (fewer than 20 million total normal motile sperm per milliliter)

if the sperm count shows a concentration lower than 20 million sperm per milliliter, I'll first try to eliminate toxic substances or recent illnesses as possible causes. Depending on the couple’s history this may suggest that they are candidates for artificial insemination with your husband’s sperm (AIH) or in vitro fertilization.

Moderate Oligozoospermia (fewer than 10 but more than 5 million total normal motile sperm per milliliter)

If the semen analysis shows a total normal motile sperm count between 5-10 million still the patients may be candidates for artificial insemination or in vitro fertilization with ICSI.

Severe Oligozoospermia (Less than 5 million total normal motile sperm per milliliter)

if the semen analysis shows a total normal motile sperm count below 5 million the most successful treatment may be ICSI.

Azoospermia

Azoospermia, the condition in which the semen contains no sperm, may suggest a lack of sperm production or that the ducts transporting sperm are blocked or retrograde ejaculation. An ultrasound examination may show a blockage of the ejaculatory ducts where they enter the prostate. Role of the physician to treat the infertile male.

In any kind of infertility problem, the patient who is going to be treated in one way or another to achieve a pregnancy is the woman. Therefore, any infertility diagnosis and treatment must be initiated and remain under the control of the female patient doctor. So, what role the urologist or male infertility specialist should play with the infertile couple? This is what common sense and our experience indicates to advice you.

1 .- ¿Diagnosis may be carried out by any physician but the final treatment decision to achieve a pregnancy must be in the hands of the infertility specialist seeing the woman.

2 .- ¿The most important help a male infertility can do is to help you the patient and the physician treating the couple understand the effects of the male condition on the offspring. Is the man going to pass to his children a condition that may be lethal or severely reduce their quality of life?

3 .- ¿Unfortunately, male infertility is still poorly understood and we do not have answers for most of the conditions found. We may find that the most important factors to achieve a pregnancy in men, such as volume, sperm counts, sperm motility and sperm morphology, are abnormal. However, that is not the problem but a symptom of conditions that require diagnosis. While there are easy conditions to diagnose (genetic problems such as cystic fibrosis, post-vasectomy infertility, chromosomal translocations, retrograde ejaculation due to diabetes, reproductive tract infections, childhood mumps, testicular surgery or radiation treatment, to mention a few), many more may not be easily diagnosed and the majority of them will not respond properly to treatment

4 .- ¿Your male infertility specialist and you must understand that volume of the ejaculate and sperm counts may be the only factors that may respond to treatment provided that we find the problem(s) causing them. Sperm motility and morphology most likely will not show any response. So do not waste time and money trying to fix them.

5 .- ¿He must be in close communication with the physician seeing your spouse and informing him/her of the findings and probability of success within a year or less time.

6 .- ¿No urologist or male infertility specialist should initiate any treatment to directly get the female pregnant as they do not have the experience and training necessary to do it. Most complications in pregnancy such as multiple order pregnancies (three or more babies) are induced by physicians without adequate training.

7 .- ¿The most important job of your urologist or male infertility specialist is to help understand if you are going to pass the condition, cause of the infertility, to your offspring so you and your spouse decide if it is worth to attempt a pregnancy with your own sperm.

The Ten Most Common Treatment Mistakes the Infertile Male Should Avoid.

1 .- ¿If your sperm counts are below one million per ml. There is no point in taking medications, surgery or alternative medicine to improve it. Try to find the cause(s) of the problem then go directly to assisted reproductive technologies. It is unlikely that you will reach the amount of sperm sufficient to impregnate your partner.

2 .- ¿Varicocele repairs. Avoid them! Period. It has not been proven that they are effective in solving infertility problems. Those claiming that varicolectomies (repair of the varicocele) improve the chance of conception have a vested interest as they are the ones benefitting from the surgery.

3 .- ¿If the varicocele causes discomfort or it bothers you, then go ahead and treat it surgically. Treatment for infertility is not warranted. If there are few sperm in the ejaculate do not accept to have testicular biopsies or surgery to extract sperm from the epidydimis.

4 .- ¿Avoid supplements to improve sperm counts or other characteristics of the ejaculate. They are useless!!!!

5 .- ¿Do not accept empirical treatment with drugs such as FSH, hCG or clomiphene citrate (CC). While the first ones may be employed in very specific cases of male infertility, the last one (CC) has no place in the treatment of infertility

6 .- ¿Live a balanced, healthy and stress free life to improve the chance of conception.

7 .- ¿Do not wait too long. Do not forget that your partner’s age is the BEST predictor of pregnancy. If she is below 30 years of age you may wait sometime expecting a spontaneous pregnancy if your sperm counts are within normal limits. If she is over 35, do not wait. Be as aggressive as possible; go directly to in vitro fertilization treatment. If she is 30-35 wait no more than 6 months to initiate a more aggressive therapy.

8 .- ¿If you are having an exploratory biopsy due to complete lack of sperm in the ejaculate ALWAYS ask the physician to freeze any sperm obtained in the procedure. Ask to distribute the sperm in 5-6 vials for multiple attempts of ICSI. The sperm can be used later to initiate a pregnancy. There is no reason to have more than one biopsy unless there are other mitigating circumstances. If he/she does not feel the need to freeze sperm then he/she does not have your best interest in mind. Go to another physician who cares about you.

9 .- ¿The physician treating your wife for infertility should be the one directing the process to achieve a pregnancy. All other care givers should understand that their role is to give information and support to the infertility specialist seeing your wife and should abstain from initiating therapy on their own.

10 .- ¿Always seek a second opinion. Consult he physician seeing your spouse before surgery or initiating an expensive and prolonged treatment to improve male infertility.