In vitro fertilization (Ivf)
Intracytoplasmic Sperm Injection (Icsı)
What is Infertility?
If it’s not possible for a woman to become impregnated in spite of sexual intercourse for a year without any contraceptives, then the reason might be infertility.
In our society, women are the first ones to be blamed for it unfortunately. However, the reasons for infertility are 40% man, 40% woman, 10% both man and woman, 10% idiopathic (unknown). In other words, almost half of the reasons for infertility is due to male individuals.
The diagnostics process with the couples seeking for the treatment of infertility should start with the male individuals. Because it’s even possible to detect whether infertility is due to the male individual just by running a simple sperm analysis (semen test, spermiogram).
What is required for pregnancy?
• Oogenesis in the female individual’s body,
• Openness of the canals for these ovos to reach the uterus,
• Healthy and moving sperms that could reach healthy ovos
• And the fertilised eggs should be able to cling on the uterus.
Sperm Production and Ejaculation in Men
Sperm production starts in the canals called seminiferious tubule of the testicles in scrotum (bags covering testicles). Sperms are stored, activate and complete their priming (takes around 3 months) in epididymises which is the curvy organ right above the testicles.
Sperms in the epididymises enter the pelvis (into the groin) through vas deferens (seminal duct) during the ejaculation (discharge of semen). Secretions of prostate and seminal duct also mix with the semen and the activity and insemination (fertilization) of the sperms are increased.
Semen (ejaculate) is discharged through the urinary canal called urethra and the ejaculation is completed.
Sperm production starts during puberty in males. FSH and LH are released from the pituitary gland under the brain. From these hormones, while LH stimulates the secretion of testosterone, FSH stimulates the sperm production. This hormonal axle should function normally for the production and priming of the sperms.
The fluid in the semen (ejaculate) includes plenty of proteins, minerals, vitamins and fructose. All of those serve for the activity of the sperms in this fluid and the fertilization. Insufficiency of these agents could lead to infertility.
As a result, a perfectly functioning genetic formation, healthy organs and the setting provided by these and the hormonal (hormone stimulating testosterone and follicle) effect for the production, priming, storage, transfer and discharge of the sperms. Any problems occurring in this system might lead to male infertility.
Reasons for Male Infertility;
• VARICOCELE: It’s the most common reason for the male fertility that could be cured.
• SPERM DISORDERS: Problems regarding the sperm production or the priming of the sperm are the most common ones for the male infertility. In this case, priming of the sperms would be insufficient and/or the sperms can’t have the desired form or activity level. Or the production of normal sperms is insufficient (oligospermia) or none (azoospermia).
• HORMONAL REASONS: Hormones stimulating the sperm and testosterone production in the testicles are the LH and FSH hormones relased by a gland in the brain called pituitary gland. Various hormonal reasons such as low (ENDOCRINE HYPOGONADISM) or excessive production of these hormones, cells in the testicles having problems detecting these hormones, disorders regarding the testosterone production in the testicles could affect the sperm production mildly or severely. Desired effects could be achieved by curing hormonal insufficiencies with medication.
• IMMUNOLOGICAL REASONS: It’s the disorder of sperm activity and function due to the antibodies the person’s body produces itself against the sperms. Normally, sperms don’t have a direct connection with the body. In the cases where the barrier preventing this (blood-testicle barrier) is damaged due to reasons such as trauma, infection or surgery, blocking antibodies against the sperms directly connected to the circulatory system would be produced by the defence system of the body. Although the reason how the antibodies blocking these sperms effect the fertility couldn’t be discovered thoroughly, they prevent the sperm from moving into the vagina and woman’s reproductive systems and hanging on the ovaries of the female individual and from entering into the ovaries..
• OBSTRUCTION (Of Canals): Repetitive infections (especially sexually transmitted infections and epididytimis), past surgeries (including vasectomy) causes obstruction of the semen canals and prevents the transfer of sperms. While this obstruction could be seen on any part of the whole canal, it could be seen in various areas as well.
• RETROGRADE EJACULATION (Reverse Ejaculation): With retrograde ejaculation, the semen can’t be discharged from the tip of the penis and it goes in the bladder. Seminal ducts release the semen into the bladder from the level of prostate gland from both sides. If there is an imbalance or disorder in the functions of the area on bladder neck and it can’t be closed due to this reason, semen would go into the bladder instead. This is one of the reasons why the semen can’t be transferred into the vagina and it results in infertility. Diseases or conditions effecting the nerve system, past surgeries on the bladder neck or prostate (any prostate surgeries: the functions are definitely effected through open surgery, resection, vaporization with laser or thermotherapy), use of some medications could lead the retrograde ejaculation. The most significant symptom for the patient would be when little or no semen is observed during ejaculation, or when the ejaculation is not as usual during the orgasm.
• GENETIC REASONS: Genetics has one of the most significant roles in terms of fertility. This is because the half ring structure in the DNA and the half DNA ring in the woman’s ovaries should normally merge. However, numerical and structural disorders in the chromosomal structure, indispositions and discontinuities in Y chromosome would affect the fertility of the male individual and the desired improvement wouldn’t be possible.
• UNDESCENDED TESTICLE:This occurs when one or both of the testicle don’t descend to the sacs as of the babyhood.
• PROBLEMS REGARDING SEXUAL INTERCOURSE: No erection or not being able to maintain the erection for a sufficient amount of time, rapid ejaculation, problems due to pain and psychological reasons during the sexual intercourse could lead to male infertility. In some diseases, the ejaculation doesn’t occur even though the sperm production continues.(sexual problems)
• LONG-TERM MEDICATIONS: Medications used for the treatment of cancer and body building pills (pills such as doping and steroid causing hormonal disorders) could lead to infertility. With the male individual who would receive chemotherapy and would like to have children in the future, alternative treatments instead of chemotherapy (e.g.: retroperitoneallymph node dissection instead of chemotherapy for testicular cancer) should be preferred or the sperms should be frozen before chemotherapy.
• USE OF ALCOHOL AND CIGARETTE: It might cause reproduction disorders for the male individual.
• SYSTEMIC DISEASES: Medical conditions such as diabetes, asthma, chronic kidney and liver diseases could affect the male fertility.
How Is The Male Infertility Diagnosed?
The examination of the male patient is carried out by an urologist. In the examination, general health condition of the patient, habits (alcohol, cigarette use etc.), frequency of sexual intercourse, and physiological sexual functions such as erection and ejaculation are questioned. After obtaining the detailed patient history, physical examination is also carried out. Afterwards, fertility is examined through semen analysis (spermiogram) . The person to get a spermiogram should stop sexual activity for a period of 3-4 days. Semen amount, pH level of the semen, viscosity and liquefaction time, number of sperms, sperm activity and rate, sperm concentration, leucocyte number in the sperm and structural Characteristics of the sperms are examined during the semen analysis. At least 2 spermiogram results of different periods would be required for an accurate sperm analysis.
In case of any problems with the spermiogram, further tests would be requested.
In case of a low sperm concentration detected during the semen analysis, your doctor would probably ask for the evaluation of hormonal tests (e.g. FSH, LH, TESTOSTERONE). In case of any deficiencies regarding hormonal levels, a sperm number that could allow reproduction through normal ways can be achieved by creating these deficient hormones with a long-term treatment.
VARICOSELE, in other words, enlargement and varicosity in the venous blood vessels of testicles, is a very common condition seen among male patients. This could affect number and quality of sperms. A surgical operation could be required for the treatment.. It’s the most treatable reason of the male infertility.
Low or no sperm amount and concentration doesn’t mean infertility that is certain and impossible to cure. An examination would be needed to see if the reason is an insufficiency of production or the transfer of sperms. For example, if the sperm amount is low and if there is no retrograde ejaculation, your doctor could ask for transrectal ultrasonography and the examination of main seminal ducts and prostate in order to check if there are any blockages in the main seminal ducts (ejaculator ducts). It would be possible to detect any calcification, cyst pressure or even a blockage due to a stone in the seminal duct. .
"In case of no sperms detected during the sperm analysis (azoospermia), a biopsy would be conducted on the testicles to find out if there is any sperm production in the testicles. These biopsies should be conducted on various areas on the testicles and the mapping of testicles should be carried out. This is because the sperm production might be available only in limited areas of he testicles. It might be impossible to detect any sperms after a biopsy conducted on only one area of the testicle. This doesn’t mean that there is no sperm production in the whole testicle. " .
It could be possible to detect the areas with wider seminifer tubules in the testicles and to produce a higher amount of sperms by conducting biopsy on these areas. The sperms produced could be used for microinjection method. This operation is called TESE (testicular sperm extraction).
How Is The Male Infertility Treated?
The treatment of male infertility is carried out by applying specific treatments depending on its reasons. In some severe cases, the treatment may not be possible. Combined treatments as mixes are administered typically.
For instance, a male patient has varicocele and a bad sperm quality and concentration, and only microinjection (ICIS) could be attempted in this case. In microinjection, the sperm is injected in the ovaries outside the body unnaturally and the insemination occurs outside the body. Inseminated ovary is placed in the uterus and then the pregnancy would be expected. However, in this operation, the female individual would need to receive a heavy hormone treatment (this might have serious side effects) in order to produce a high number of eggs; the transfer of eggs outside the body and the transfer of inseminated eggs into the uterus require separate operations. All these operations are quite abrasive and costly, and are quite far from being equivalent to a natural pregnancy.
However, while the sperm quality might get back to normal levels by treating the varicosele through a surgical operation and a normal pregnancy might be achieved, sperm number might not get back to normal levels, but the concentration and quality of the sperms could improve in some patients. This improvement might allow injection. During the operation called in utero insemination, sperms are injected directly in the uterus with the help of an injector, and insemination in the uterus is achieved. In this operation, there wouldn’t be any need for a hormone treatment, pregnancy would be more similar to normal methods and it would be less costly. As mentioned in the part regarding microinjection (ICSI) above, this would cause less problems for the patient and the family instead of microinjection which causes many problems, is unnatural and costly.
In case of the existence of a varicocele, the chance of benefiting from the surgery becomes more especially when the level of varicocele is high and there is a disorder regarding the testical improvement. Varicocele operation is called varicocelectomy. Today, varicocelectomy is conducted either under optical zoom or microscopic view on the groin canal level. After this operation that takes around 30-60 minutes, the patient is released on the same day or the next. Semen analysis would be conducted on the 3rd, 6th and 12th months after the surgery to monitor the improvement of the sperm quality.
If there is a blockage in the ejaculator canal and the ejaculation is not possible due to this reason, then the blockage would be opened from the urethra on the tip of the penis through anaesthesia. This operation is called the transurethral resection of ejaculator duct, or TUR(ED).
In case a patient who had vasectomy wishes to have another child, these ducts could be reopened (vasostomy).
In case of a blockage in the spididym duct and the sperm can’t be transferred due to this blockage even though it’s produced, transfer of the sperm out could be achieved by making an anastomosis (bridge) connection between the part of this duct before the blockage and vas deferans.
Treatment of the disorder resulting in infertility varies depending on the specific condition. Retrograde ejaculation would be observed in the cases where the contraction area on bladder neck can’t be closed completely. In order to prevent this type of retrograde ejaculation, medication that would enable the contraction on the bladder neck to be closed completely and the normal ejaculation is maintained.
Sperm production might be affected due to deficiency of hormones needed for the production. Providing these deficient hormones could maintain sperm production. However, it should be noted that the desired response to this treatment might be taken in around 9-12 months after a long-term treatment.
It might also be possible to start using various vitamins and minerals (L-carnitine, L-arginine, vitamin E, zinc, folic acid, celenium etc.) in order to increase sperm activity.
Assisted Reproductive Techniques
Intra uterine insemination (Iui)
In this technique, after processing the sperms obtained from the male while monitoring the ovulation period, all active sperms are directly injected into the uterus with a special injector during ovulation.
In vitro fertilization (Ivf)
In this technique known in other words as “Tube Baby”, fertilization of the ovaries obtained from the female patient with the sperm obtained from the male patient outside the female patient’s body in a petri dish or a tube prepared in the lab environment is aimed.
Intracytoplasmic Sperm Injection (Icsı)
This technique is an advanced step of the IVF technique. In vitro fertilization of sperm and eggs are also in question in this one. However, unlike IVF, the natural fertilization wouldn’t be expected, an done of the healthy sperms would be selected and injected into the egg with special microscopic injectors and then the fertilization would be monitored.