Male Infertility is very common. Providing the best male infertility treatment in Delhi, over 40% of all infertility cases are because of the husband. Evaluation of male factor begins with a very simple and inexpensive test called Semen analysis that tells us about the quantity and quality of sperm produced. Basic abnormalities in semen analysis could be in the form of
Poor sperm count - Oligospermia, defined as count < 15 million (earlier 20 million) / ml Poor sperm motility - Asthenospermia Poor sperm morphology - Teratospermia Combination of the above - OAT or oligo-astheno-teratospermia Complete absence of sperm in the ejaculate - AzoospermiaAzoospermia or zero sperm count has to be differentiated from ‘Aspermia’ which means the man is not able to ejaculate at all, or there is no fluid in the ejaculation.
Not only is Male Infertility common, its incidence is increasing day by day. This phenomenon of rising male problems is observed globally. Faulty diet habits, environmental pollution, exposure to chemicals, smoking, alcohol abuse, sugary drinks, etc are all said to contribute to this problem.
Not just abnormalities in the semen parameters, erection or ejaculatory disorders can also contribute to infertility. Some of them are:
Retrograde ejaculation (ejaculate goes back into the bladder instead of coming out) Anejaculation (inability to arrive at orgasm) Impotence or erectile dysfunction Hypospadias (sperm is deposited outside the vagina) Sexual dysfunction or infrequent intercourseMale Infertility is becoming more common so now almost one in twenty men is sub-fertile. Half of all IVF/ICSI cycles are done for male factor worldwide. For most men the diagnosis of infertility comes as a shock because they never thought this could happen to them.
So why does it happen?
Most common cause appears to be genetic. In all males there is one X and one Y chromosome. This Y chromosome has lot of important genes that help in normal sexual differentiation and sperm production. Absence of certain genes or breakage of Y chromosome leads to impaired sperm production. Almost 2/3rd of all males with unexplained male factor have this problem. Other rare causes include an obstruction to passage of sperm from testis (site of production) to urethra (site of ejaculation). This could be anywhere - from epididymis to vas to ejaculatory ducts. Sexually transmitted infections sometime lead to this condition. Obviously men who had undergone vasectomy would have blockage. Complete blockage leads to Azoospermia or zero sperm. Anti-sperm antibodies in some men Erection or ejaculation disorders. This is common in men with hypertension, diabetes, those who’ve had pelvic surgeries and those with neurological disorders. Hypogonadotropic Hypogonadism is found in 5% of all Male Infertility cases. Here the problem is with a gland in the brain which does not function well.There are numerous tests that are done to evaluate Male Infertility. But first and foremost important test is Semen Analysis. It is important to have semen analysis done at a place where the embryologist performing it is expert and experienced. At Janini IVF, one of the best IVF centres in India, our team of experienced embryologist headed by Dr Akanksha Mishra would ensure a complete and thorough evaluation of your case. Every patient walking into our clinic, the best male fertility centre in Delhi, is subject to semen analysis and you get a detailed report which would mention all the parameters of semen including count / motility / morphology / pH of semen / total volume of semen / presence of Leukocytes / viscosity / liquefaction time / and additional tests like semen fructose assay for Azoospermia patients to rule out obstructive Azoospermia.
Apart from the semen analysis, there are case to case scenarios where one would need additional testing. For example if there is severe oligospermia (< 5 million sperm/ml) or Azoospermia (0 sperms) then one may be subjected to additional genetic, hormonal and imaging tests.
Dr Dalal who has a passion for treating Male Infertility examines and evaluates all Male Infertility cases at Janini IVF himself. One of the few FNB degree holders of the country, Gold Medalist Dr Dalal has the privilege of having had training from one of the most reputed Andrology centres of the world - ‘Androfert’ at Brazil. He is one of the most experienced surgeon in micro-TESE procedure (more details elsewhere) which is the best procedure for successfully harvesting sperm in even the most difficult cases of Azoospermia. This proficiency of his is well-known in peer groups because of which he is frequently called upon by many other IVF centres to perform micro-TESE on their patients. He is absolutely passionate about giving babies to difficult cases of Azoospermia with their own sperm who are asked to go for sperm donation at other IVF centres.
After a detailed history and thorough physical examination, including local genital examination, additional tests are ordered deepening on the semen analysis report. If semen report is normal, no further testing is required. But if we find severe oligospermia (count < 5 mn/ml) or Azoospermia (No sperms in the sample) you may be subjected to additional tests :
Hormone testing - serum FSH, LH, Testosterone, Prolactin Karyotyping and Y chromosomal micro-deletion study Trans rectal ultrasound if there is suspicion of ejaculatory duct obstruction (low volume, acidic pH of semen) CFTR gene mutation study of the wife if you have bilateral absence of vas deferensScrotal ultrasound which most IVF centres believe in doing is a totally useless test and we don’t do it here. Reason being, varicocele (a condition for which the testing is done) is only relevant if seen on a clinical examination. Varicoceles that are detected by scrotal ultrasound are not relevant at all. So scrotal ultrasound is a waste of money.
There are many sperm function tests which try to determine the functional competence of the sperm in fertilising the egg. It is believed these tests would help in determining line of management. Some of the sperm function tests include the Sperm survival assay, Sperm zona free hamster egg penetration assay (SPA), sperm binding assay and sperm DNA fragmentation index (DFI). Out of these tests only DFI is worth doing as other tests have not been found to be much useful in published literature.
What is DFI and how is it done?
DFI is DNA fragmentation index and basically tells us how intact the sperm DNA is. So if for any reason there is a damage to the sperm DNA the DFI could be high. Higher the DFI higher is the sperm DNA damage. High DFI can lead to infertility and is also a prognostic marker of failed fertilisation in IVF. So DFI can be a cause of infertility that conventional semen analyses won’t diagnose. It can also reduce the pregnancy rates in IUI treatment. For DFI testing we do a test called SCD or Sperm chromatin dispersion test. Sometimes we also offer TUNEL - Terminal deoxynucleotidyl transferase dUTP nick end labelling for sperm DNA fragmentation but it is more laborious. We have a cut-off of 30 in order to consider it significant and offer altered line of management like TESA with ICSI.
Who should go for sperm DNA fragmentation index or DFI testing?
(a) Patients who have poor semen report (b) Age more than 40 (c) Diabetes (d) Leukocytospermia (pus cells in semen) (e) Previous repeated miscarriages (f) Previous multiple IVF or ICSI treatment failuresSo what causes DNA damage or high DFI?
(a) Environmental factors like pollution (b) Chemical exposure - either occupational or otherwise (c) Oxidative stress eg fever, infection, smoking, alcohol abuse, etc. (d) Unhealthy lifestyle (e) Excessive weight gain (f) Presence of varicoceleWhat is the treatment of high DFI?
(a) We may prescribe be a course of antioxidants for 2-3 months (b) Extracting testicular sperm is the best option. It has been found that testicular sperm is healthier than ejaculated sperm with a lower DFI. Probably less exposure to oxidative stress plays a role (c) Stop Smoking and take alcohol only in moderation (d) Weight loss (e) Varicocelectomy if grade 2/3 varicocele presentThe treatment for Male Infertility has to be individualised keeping in view the duration of married life, presence of coital problems, reports of the wife - if they are normal or not, severity of the abnormal semen analysis report, age of the couple and duration of infertility. Various treatment modalities available at Janini IVF include :
Antioxidant tablets or sachets Clomiphene citrate Injectable hormones (HMG, FSH) for Azoospermia or severe oligospermia. Indeed, HMG forms an integral part of treatment for a condition called Hypogonadotropic Hypogonadism Varicocele repair surgery ICSI (for oligospermia) MESA (micro surgical epididymal sperm aspiration) or PESA (per-cutaneous epididymal sperm aspiration) for OBSTRUCTIVE AZOOSPERMIA TESA (testicular sperm aspiration) or micro TESE (micro testicular sperm extraction) for Non-obstructive Azoospermia Testicular sperm mapping Electo and vibro ejaculation for patients with ejaculatory disorders Sperm freezing IMSI or PICSIOne of the best IVF centres of India, Janini IVF is one of the very few clinics that offer micro-TESE treatment for zero sperm count patients. Micro dissection TESE is the latest advent in the realm of Male Infertility management and it is nothing short of a miracle. Indeed, micro-TESE procedure has the HIGHEST CHANCE of harvesting sperm successfully even in those men who have had no sperm harvest in a previous TESA attempt. Considered to be the FINAL LINE OF MANAGEMENT of Non-obstructive Azoospermia, if even micro-TESE procedure which is performed by an experienced surgeon especially trained to perform it yields no sperms, then sperm donation is the only remaining option. Micro-TESE have given countless men a smile on their face to have their own genetic baby when everything else had failed earlier. Sperms found are not only used for ICSI but extra sperm are also FROZEN so that if there is a need we don’t need to go for a repeat procedure again.
How is micro-TESE done?
Dr Dalal had been fortunate to visit and learn from the best Andrology (Male Infertility) centre in the whole world - “Androfert” at Sao Paulo, Brazil under Dr Sandro Esteves. During micro-TESE which is usually performed under general anesthesia, the testis is opened surgically and visualised with a microscope (40x magnification). Areas which seem to have dilated, white, thick tubules are retrieved with forceps and passed into the embryology laboratory to check the presence of sperm. An intense search is continued until the Embryologist signals for a success or until 25-30 tissue samples are sent and no result is found.
How does micro-TESE give success when a simple TESA has failed?
A testis is a dynamic organ. When there is a damage in sperm production there are some pockets that remain that continue making sperm. In a blind procedure like TESA where only a needle in injected one cannot make out such areas so we miss out on them. But in a micro-TESE the entire testis is seen under magnification. So if there are areas of sperm production, we will find sperm.
What determines success for micro TESE?
Micro TESE is an extremely skilful and delicate procedure. Easier said than done, even top urologist surgeons do not have the technical skill to perform it because of lack of exposure. Moreover, having a skilful surgeon alone is not enough. You need a very, very good embryologist who will painstakingly scan every minute tubule of the testis FOR HOURS continuously and let the surgeon know about the presence of sperm. It is very difficult to generate this skill in the embryology side. Fortunately for Janini IVF, Dr Mishra’s extensive years of experience come in handy and this is what differentiates Janini IVF from other IVF centres in Delhi. While at Lilavati Hospital Dr Akanksha Mishra had extensive exposure to micro TESE procedures performed by Dr Rupin Shah. People might claim to be having micro-TESE, but the chances of them telling you that they have used only your sperm is dismal. We at Janini IVF try our level best to use only your sperm as far as possible and most of the times we are successful in doing that. All extra sperm after ICSI are frozen so that we have a backup of those precious sperms also.
As micro TESE is invasive many patients ask why not we try putting a thin needle and checking for sperms first. If we find, well and good - we can use them for ICSI and our job is done. If we don’t - only then we go for a micro TESE procedure. So taking this approach has the advantage that micro TESE can be avoided if TESA is successful. This approach is practical and has the advantage of having the best chance of finding sperm.
Disadvantage of this approach is giving general anaesthesia for TESA (we normally do it under local numbing agent) and extra time taken.
How is it done?
Step 1 - advanced testicular mapping is done by performing TESA on multiple sites of the testis. The sample is immediately scanned for sperm and if sperm are found the procedure is abandoned right here.
Step 2 - if no sperm is found with testicular mapping we proceed with micro TESE.
With simultaneous Mapping + micro TESE approach our patents at Janini IVF get the highest chance of using their own sperm for having a baby with least amount of surgery needed.
TESE is a simpler version of micro TESE where under local anaesthetic a small cut is made on the testis and a tiny bit of tissue sent to embryology lab. TESE at Janini IVF is only done for OBSTRUCTIVE Azoospermia patients who have no production problem. Patients with production problem of sperm (NON OBSTRUCTIVE AZOOSPERMIA) - micro TESE is more advisable as chances of finding sperm with a simple TESE is lesser than microTESE.
TESA is even simpler and quicker than TESE. In TESA all we do is put a thin needle inside the testis and aspirate the contents. This is done under local anaesthesia. TESA is preferred to be done where the production of sperm is not at fault, for example in Obstructive Azoospermia cases.
Per-cutaneous epididymal sperm aspiration and Micro-surgical epididymal sperm aspiration are minor procedures done to extract sperm in Obstructive Azoospermia cases. Here the advantage is instead of the testis, only the epididymis (a small tube behind the testis meant for sperm passage) is aspirated so the testis is left untouched. PESA or MESA cannot be done in cases where the sperm production is at fault.
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