Management of male factor infertility

General measures should include advice about stopping smoking and reducing alcohol consumption. Where a specific cause is identified, targeted treatment should be considered. In the majority of cases no cause for abnormal semen parameters can be identified, and assisted reproduction offers the only option for men to have their own genetic offspring.

INTRAUTERINE INSEMINATION

Intrauterine insemination (IUI) using washed sperm may be considered in cases where semen parameters show mild or moderate abnormalities. A systematic review (Cohlen et al. 2000) found that compared with timed intercourse, IUI resulted in increased pregnancy rates, both in natural cycles (OR 2.5, 95% CI 1.6— 3.9) and stimulated cycles (OR 2.2,95% CI 1.4-3.6). No difference was found between stimulated and unstimulated cycles (OR 1.8, 95% CI 0.983.3). As stimulated cycles are associated with a risk of multiple pregnancy, it may be prudent to consider IUI in a natural cycle in these cases. The evidence in favour of IUI has to be interpreted in the context of the overall prognosis for male infertility, which is poor, in the absence of assisted reproduction. Thus, although that IUI increases the relative odds of pregnancy, the absolute chances of conception remain low.

IVF/ICSI

Where semen parameters are poor, it may be appropriate to consider IVF treatment straightaway. In men with grossly reduced sperm concentrations (below 5 million/ml) ICSI is the treatment of choice. Obstructive azoospermia, in the presence of normal testicular volume and FSH levels can be treated by surgical sperm retrieval followed by ICSI. The prognosis for non-obstructive azoospermia associated with small atrophied testes and high FSH levels in poor and donor insemination (DI) may need to be considered.

DONOR INSEMINATION

Where surgical sperm retrieval is not possible, or when ICSI is not feasible, insemination of thawed frozen donor sperm may be considered. Donors are screened for hereditary conditions and blood-borne viruses. Tubal patency will need to be documented in the female partner and ovulation induction considered where cycles are irregular. Where ovulation has been demonstrated, monitoring of LH in blood or urine is carried out to time insemination approximately hours after ovulation. IUI has been shown to be more effective than intra-cervical insemination (ICI) in terms of pregnancy rates (OR 2.4, 95% CI 1.5-3.8) (Goldberg et al. 1999). Use of controlled ovarian stimulation has been used in women undergoing donor insemination leading to a higher incidence of multiple birth and should be avoided. Data from national donor insemination programmes suggest that the live-birth rate per cycle of DI is 10.3-11.6%. Cumulative pregnancy rates show little increase after the sixth cycle of treatment and women should therefore be offered other treatment such as IVF using donor sperm thereafter.

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