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MALE BY PHILIP WERTHMAN, MD


OVERVIEW Of the 15% of couples having difficulty conceiving,


almost half have a male factor as the sole or contributing cause. It is currently recognized that the quality as well as the quantity of sperm greatly influences reproductive outcomes. It was once thought that assisted reproductive technologies (ART) such as Intrauterine Insemination (IUI) and more so, In-Vitro Fertilization with Intracytoplasmic Sperm Injection (ICSI) had the power to overcome almost any sperm defect but data show that this is not true for many patients. New data has repeatedly demonstrated that significantly damaged sperm leads to lower pregnancy rates with IUI or IVF as well as an increased miscarriage rate up to fivefold that of a pregnancy achieved with normal sperm. It has been said that in the last 5 years there hasn’t been any significant improvement in pregnancy rates with IVF and that is most likely because scientific techniques to improve egg and embryo quality have been maximized. The next major jump will come from focusing on sperm quality and maximizing it. Using abnormal sperm without making any attempt to qualify the level of damage, search for the cause or treat it will not be the accepted initial approach to fertility treatment for much longer.


There are two fundamental treatment strategies used to address sperm deficiencies;


1. Identify and treat the problem to improve semen parameters, 2. Bypass the problem by using the sperm that are available. The classic teaching is that if there are more than 5-8 million motile sperm in the washed semen sample and the strict morphology of the sperm is greater than 4% normal, the couple would be a candidate for a variable number of IUI cycles. If the semen parameters are worse than this, IVF would be employed because of higher success rates under these conditions.


Unfortunately, the way practice patterns have developed, too few men are referred for appropriate evaluation until treatment strategy #2 has failed and the couple has undergone a significant number of treatments and considerable expense. Even then only a fraction of men are referred for evaluation for their underlying problem and many couples are encouraged to use donor sperm unnecessarily.


The scope of male infertility is so widespread and unfortunately the evaluation and treatment have never been standardized among general urologists other than the few fellowship-trained male fertility specialists. This has led to inconsistent diagnoses, recommendations and treatments that patients receive from their urologists. Many urologists are inadequately trained and ill-equipped to deal with complex patients presenting with male infertility. An attempt to address


INFERTILITY UPDATE


THE RESOURCES LISTED IN THIS DIRECTORY ARE UNSCREENED AND SHOULD NOT BE VIEWED AS RECOMMENDATIONS OR ENDORSEMENTS, EITHER EXPRESS OR IMPLIED, BY THE AFA. 48


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