Treatment of Male Factor Not From Azoospermia
Medical treatment of reversible infectious or endocrine causes of male subfertility, such as sexually transmitted diseases and thyroid disorders, tends to be efficacious. Although injections of exogenous FSH have been reported to improve pregnancy rates, the benefit is less clear for clomiphene citrate, an estrogen antagonist at the hypothalamus and pituitary that promotes gonadotropin release. Exogenous testosterone is not recommended in the treatment of male subfertility because of negative feedback inhibition at the pituitary that results in decreased spermatogenesis, but the combination of testosterone and an antiestrogen may be of benefit. Antioxidant food supplements have been evaluated (59). Glutathione, carnitine, and vitamin E do not appear to affect semen parameters, but administration of zinc and folic acid were associated with improved sperm concentration and morphology (60). The diagnosis and treatment of azoospermia (no sperm on semen analysis) will be discussed separately from other forms of male factor infertility.
Table 32.5 Frequency of Some Etiologies in Male Factor Infertility
No demonstrable cause 48.5 Varicocele 37.4
Idiopathic abnormal semen 26.4 Idiopathic 25.4
Varicocele 12.3 Testicular failure 9.4
Infectious factors 6.6 Obstruction 6.1
Immunologic factors 3.1 Cryptorchidism 6.1
Other acquired factors 2.6 Low semen volume 4.7
Congenital factors 2.1 Semen agglutination 3.1
Sexual factors 1.7 Semen viscosity 1.9
Endocrine disturbances 0.6 Other 5.9
TOTAL 103.9a 100 aMore than 100% because of multiple factors. From The ESHRE CAPRI Workshop Group. Male sterility and subfertility: guidelines for management. Hum Reprod 1994;9:1260–1264, and Burkman LJ, Cobbington CC, Franken DR, et al. The hemizona assay (HZA): development of a diagnostic test for the binding of human spermatozoa to the human hemizona pellucida to predict fertilization potential. Fertil Steril 1988;49:688–697, with permission.
Varicocele Repair A varicocele is an abnormal dilation of the veins within the spermatic cord. Varicoceles are present in 15% of normal men and 40% of men seeking infertility treatment, but semen parameters are lower among infertile men with varicoceles (61,62). The pathophysiologic effects of a varicocele appear to be mediated by an associated rise in testicular temperature, reﬂux of toxic metabolites from the left adrenal or renal veins, or higher reactive oxygen species (61,63). Although treatment is associated with improved semen parameters in some studies, it is not clear whether varicocele repair definitely improves fertility (61,64,65). Treatment is typically considered if the varicocele is palpable and the semen analysis is abnormal, but is not indicated if IVF would be required to treat the female partner and the existing semen analysis would be acceptable for ICSI. Treatment methods include surgical repair and percutaneous embolization. Complications of treatment include infection, varicocele persistence, recurrence, and hydrocele formation (61).