Male Infertility

Cost Benefit and the Economics of Male Infertility Treatment

Economic factors have a major role in the decision-making process of male fertility treatment. The emphasis on specific male factor treatment has been diluted by the wide use of IVF as the global solution for all forms of male infertility. The approach is flawed and cost-prohibitive; more importantly, reversible and progressive conditions are bypassed and unattended. Numerous elegant studies have unequivocally established that specific medical and surgical treatments for male infertility are much more cost-effective than empiric IVF. Subfertile men require investigation and treatment prior to resorting to IVF as a management option.

Infertility affects 15% to 20% of couples with a male-related problem either directly responsible or contributory in up to 50% of all cases. Several recent developments in male infertility warrant brief discussion:

Referral to a Male-Infertility Specialist

Advances in recent years have transformed the care of infertile males into a highly specialized discipline. Almost all couples are highly motivated and demand the most expedient evaluations and treatments; referral to infertility specialists fulfills these goals. In most cases, the diagnoses and recommendations are readily reached and no time or effort is wasted in pursuing nonproductive treatment. We routinely see patients who had previously undergone unhelpful testis biopsy and exploration by urologists following an out-of-date algorithm with no provision for concurrent sperm extraction or reconstruction; as such, re-exploration and re-biopsy for TESE will be needed.

Genetic Testing and Male Infertility

Recent advances, namely IVF/ICSI with sperm extraction, have allowed us to overcome infertility problems previously considered to be unmanageable. As such, genetic testing is now mandatory in those contemplating treatments who are at risk for harboring genetic conditions that may have significant impact on the treatment outcome:

  • Chromosome abnormality such as Kelinfelter’s or translocations.
  • Cystic fibrosis: We now routinely test men with congenital vassal agenesis and vasoepididymal obstruction for CFTR carrier status. Female testing and genetic consultation are mandatory in those with CF genes. IVF with embryo biopsy and preimplantation genetic diagnosis may be performed if both partners prove to be CF-positive.
  • AZF deletion: Recent advances have found that a portion of the male chromosome is critical in normal spermatogenesis. Deletions of various sequences in this region in men with normal karyotype may be responsible for up to 13% of those with NOA and, to a lesser extent, severe oligospermia. AZF testing is based in PCR using DNA from peripheral lymphocytes. AZF-deleted men have no specific phenotypic patterns and testicular histology; many may be successfully managed with TESE. A certain deletion pattern precludes TESE as an option; proper testing will spare affected men unnecessary TESE attempts, in which sperm will not be found.
  • Oxidative stress and male infertility: The generation of reactive oxygen species (ROS) in the male reproductive track has become a real concern because of their potential toxic effects, at high levels, on sperm quality and function. High levels of ROS are detrimental not only to the sperm cell membrane but also to the integrity of sperm DNA; this phenomenon is especially problematic given the scarce cytoplasmic apparatus and defense mechanism available in the sperm cell. DNA fragmentation assay, SCSA, may be helpful in identifying those at risk for ROS-induced subfertility.

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