2. Severity of the sperm defect

3. Age of the female partner

Varicocele: If a varicocele is found, sometimes surgery to ligate (tie off) the abnormally dilated veins is recommended. If the varicocele is of significant size (Grade II or Grade III), about two thirds of men undergoing the surgery will see some improvement in the sperm quality. The reported pregnancy rates following surgery are in the range of 40%, but most pregnancies occur 6-9 months following surgery, so age of the female partner needs to be a major consideration. If the initial sperm count and motility are in the severe male factor category, it is unlikely that this surgery will improve sperm counts enough to enable the couple to conceive without assistance.

Unexplained low sperm count: If there is a mild decrease in the sperm count or motility, the urologist may prescribe Clomiphene citrate, a fertility pill commonly used to treat women who fail to ovulate. Clomiphene (also called Clomid or Serophene) mildly stimulates the pituitary to make hormones that stimulate sperm production. Sperm counts should be re-analyzed 3-6 months after initiation of the medication to evaluate the effectiveness of this treatment. Again, if the sperm count is very poor to begin with, this strategy is less likely to be successful. As always, the female partner should be considered, as the time necessary to give these treatments a chance to work depends on how much time she has.

Mild male factor, unexplained cause: Intrauterine insemination (IUI): Enhanced sperm are placed directly into the uterine cavity, thus eliminating their passage through the vagina and cervix. For more information on IUI, please click on the button on the left NON-IVF Rx and go to IUI .

Recent data suggest that the pregnancy success rates following IUI in cases of mild male factor or unexplained infertility are reported to be approximately 5% per insemination cycle. This rate can be improved to about 9% per cycle if the female partner is induced to "super-ovulate" with injectable fertility medications such as Gonal-F. It is important to note that the average age of the female patients in the research study that reported these results was 32.4 years of age. Rates for success would likely decrease as the age of the female partner increases. Most authorities consider IUI to be ineffective in cases of severe male infertility. The ideal treatment, when surgical and medical management fails to improve sperm function, is in vitro fertilization and embryo transfer (IVF/ET), usually accompanied by Intra-cytoplasmic sperm injection (ICSI). Please click on ICSI above for more information, or IVF Tour on the left.

Moderate to severe male factor, unexplained cause: In vitro fertilization (IVF) with intra-cytoplasmic sperm injection (ICSI): Good fertilization rates can be achieved with the injection of a single live sperm directly into the egg.

Prior Vasectomy: Two choices – vasectomy reversal or IVF-ICSI with epididymal or testicular sperm extraction. Age of female partner and length of time since prior vasectomy are important factors in decision-making. It can sometimes take 6-9 months to recover adequate sperm counts following vasectomy reversal. Also, the greater the length of time between the vasectomy and the reversal, the greater the chances are that the surgery will be unsuccessful or that anti-sperm antibodies will form, preventing the recovered sperm from penetrating the eggs without IVF-ICSI. Any man undergoing vasectomy reversal should request that any vasal sperm seen at the time of the reversal be frozen in case subsequent scarring and re-obstruction occurs.

Prior vasectomy, congenital absence of the vas deferens (i.e. no sperm in the ejaculate but normal testicular sperm production, also referred to as obstructive azoospermia): IVF-ICSI with either Microsurgical Epididymal Sperm Aspiration (MESA) or Testicular Sperm Extraction (TESE).

With a MESA procedure, under local anesthesia and general sedation, an incision is made in the scrotum, exposing the epididymus, the tubules immediately adjacent to the testicles that collect the sperm. Using an operating microscope, an incision is made into these tubules and sperm is aspirated. Although millions of motile sperm can often be collected, this sperm has not acquired the ability to penetrate an egg and must be injected into eggs via the IVF-ICSI technique. The advantage of MESA over TESE for men with obstructive azoospermia is that sperm collected in this manner can usually be frozen, and even if his partner has to undergo more than one IVF procedure, the MESA should provide adequate sperm for all subsequent IVF procedures.

A TESE or testicular sperm extraction is a procedure that involves directly aspirating the sperm from the testes or obtaining sperm from a testicular biopsy. It is usually performed under local anesthesia block and can be done as an office surgical procedure. The disadvantage is that in many cases, testicular sperm is much more scarce and therefore difficult to freeze. Usually, there is only enough sperm recovered for one IVF case and if further IVF attempts are needed, the TESE procedure needs to be repeated.

Non-obstructive Azoospermia: Men with very poor sperm production in the testicles and no sperm in the ejaculate often demonstrate high blood FSH levels and sometimes low testosterone levels. The testicular size may be small. These men are usually considered to have relative testicular failure. TESE or testicular biopsy is usually the only option for them as there are no sperm in the epididymus and even testicular sperm production can be "patchy" and scarce within the testes. Men with this diagnosis who have been told they have no sperm on routine testicular biopsy frequently can be found, on further investigation, to have sperm present in a scattered distribution within the testicle. If so, these areas can be re-aspirated for IVF-ICSI with some degree of success, depending on the amount of sperm obtained.

Sertoli Cell Only syndrome: Complete absence of sperm progenitor cells and absence of spermatogenesis is a rare condition. Sperm donation or adoption are the only options in these cases.