93 THE SURGICAL APPROACH TO INFERTILITY
Randall B. Meacham M.D., Alex J. Vanni

1. How common a problem is infertility?

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Infertility is the inability to establish a pregnancy during 1 year of well-timed intercourse. This affects 15% of all couples in the United States. In 50% of such couples, the woman is responsible; in 30% of couples, a male factor prevents pregnancy; and in 20% of couples, it is a combination of both.

2. What are the odds that a fertile couple will become pregnant after a single episode of well-timed intercourse?

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During a given ovulatory cycle, 18% of fertile couples become pregnant after well-timed intercourse.

3. What is the best timing for intercourse if a couple is trying to conceive?

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Sperm can survive in the cervical mucus for 48 hours. To achieve pregnancy, therefore, the most effective timing of intercourse is every other day, starting a few days before ovulation.

4. What environmental factors may play a role in male infertility?

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Although reproductive function is relatively durable, various toxins have a negative impact on male fertility. Cigarette smoke and alcohol have been implicated as dose-dependent gonadotoxins, as have recreational drugs, including marijuana, cocaine, and heroin. Radiation (in amounts as low as 200 rads) can influence spermatogenesis, as can chemotherapeutic agents. Calcium channel blockers may interfere with the ability of sperm to fertilize eggs.

5. Can a vasectomy be successfully reversed?

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Yes, but the success rate is affected by the amount of time since the original vasectomy. Among patients who are less than 3 years from vasectomy, the conception rate after reversal is roughly 75%. This success rate declines to about 50% when the reversal is performed 3-8 years after vasectomy and further declines to 30% when 15 or more years have passed.

6. What is in vitro fertilization (IVF)?

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With IVF, eggs are harvested from a woman and combined with sperm in a laboratory setting. The resulting embryos are then transferred to the uterine cavity, where they mature into a fetus. In a specialized version of this technology (i.e., intracytoplasmic sperm injection), an individual sperm is injected into each egg, thus facilitating fertilization and allowing pregnancy even in the presence of small numbers of motile sperm.

7. What is the role of IVF in male infertility?

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Because use of IVF greatly reduces the number of motile sperm needed to generate a pregnancy, it can be quite helpful in men with poor semen quality. The IVF team needs only as many motile sperm as there are oocytes (eggs) to be fertilized.

8. Can sperm obtained directly from the testicle be used to generate a pregnancy?

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For the past several years, it has been recognized that incubation of testicular tissue generally yields small numbers of motile sperm. Through the use of IVF, such sperm can generate pregnancies. Even among men suffering from severe testicular failure, it may be possible to retrieve adequate sperm for use in IVF.

9. What is the role of sperm freezing in the treatment of infertility?

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Sperm can be frozen (cryopreserved) with relative ease. After they are cryopreserved, sperm remain viable for extended periods (years). Cryopreservation can be helpful among men planning to undergo treatment with chemotherapy or radiation therapy.

10. Does wearing boxer shorts versus tight underwear affect male fertility?

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No.
KEY POINTS: SURGICAL APPROACH TO INFERTILITY

1. Infertility is defined as the inability to establish pregnancy during 1 year of well-timed intercourse.
2. In 50% of infertile couples a female factor prevents pregnancy, in 30% of couples a male factor prevents pregnancy, and in 20% of couples infertility is due to a combination of both female and male factors.
3. The most common cause of male infertility is varicocele.

11. Because normal levels of testosterone are necessary for sperm production, is it helpful to give subfertile men additional testosterone?

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Although decreased levels of testosterone can cause impaired male fertility, giving additional testosterone to men with normal testosterone levels can actually cause a dramatic decline in semen quality. Administration of exogenous testosterone causes the patient to cease production of native testosterone within the testes. The resultant decrease in intratesticular testosterone actually results in a decline in sperm production.

12. What is the most common cause of male infertility?

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Varicocele, a collection of dilated veins above one or both testes. Among men presenting for treatment of infertility, 40% have a varicocele. Correction of varicocele leads to improvement in semen quality in 70% of patients.

13. If we can clone Dolly (a sheep derived from cloning a fully differentiated mammary cell), can we clone humans?

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Although for a number of critical ethical reasons cloning technology is not currently used in human reproduction, it theoretically allows the cloning of any individual, creating a genetic duplicate. However, cloning probably will not play a role in the treatment of human infertility.

14. Is IVF associated with an increase in genetic abnormalities?

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This issue is controversial, but probably no. At least one recent publication suggested that infants conceived by either intracytoplasmic sperm injection or IVF have twice the risk of major birth defects compared with naturally conceived infants.

15. Will giving supplemental testosterone improve male fertility?

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No. Exogenous testosterone induces a profound decrease in spermatogenesis and has been explored as a means of male contraception.

16. What is cloning as it pertains to humans?

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Just like Dolly the sheep, human cloning involves nuclear transplantation of the desired clone into an egg devoid of its nucleus. Rather than creating whole human beings, the more controversial ethical dilemma is whether to permit cloning of cells or organs for subsequent transplantation in order to cure human disease.

17. Are undescended testes associated with male infertility?

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Yes. Cryptorchidism is associated with male infertility. The decreased fertility correlates with severely reduced total germ cell counts in prepubertal undescended testes. Bilateral testicular maldescent does decrease semen quality. Interestingly, unilateral cryptorchidism may impair semen quality as well. This suggests that both the abnormally descended testis and its normally positioned counterpart are adversely affected. Surgical repositioning of the testis improves semen quality; the earlier it is done, the better.

References
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