WHAT ARE OTHER TREATMENTS FOR SPECIFIC CONDITIONS THAT CAUSE MALE INFERTILITY?

Hormonal Drugs

Hormone therapy has been effective for women with infertility problems but has been disappointing in men except in a few specific cases:

• Gonadotropin-releasing hormone (GnRH) is beneficial for men with gonadotropin deficiency and hypogonadism.
• GnRH may be useful for restoring sperm production after chemotherapy treatments.
• Sperm production occasionally responds to low doses of estrogen and testosterone or testosterone alone, menotropins (Pergonal, Repronal), clomiphene citrate (Clomid), human chorionic gonadotropin (hCG), or human follicle stimulating hormone (r-hFSH).
• Prolonged treatment with follicle-stimulating hormone (FSH) prior to ICSI may improve implantation rates.

Nonhormonal Agents

Bromocriptine. Bromocriptine (Parlodel) is used in men whose infertility is related to excess prolactin manufactured by the pituitary.

Antibiotics. Infections interfering with infertility may be successfully treated with antibiotics.

Antihistamines. Studies report that certain antihistamines that block mast cells may be beneficial for some men with low sperm count. Mast cells are inflammatory immune factors that may play a role in lower sperm quality. Studies have reported that two such agents used overseas, ebastine and tranilast, improved pregnancy rates. Similar antihistamines in the US are fexofenadine (Allegra), loratidine (Claritin), and cetirizine (Zyrtec).

Sildenafil (Viagra). One interesting study suggested that the anti-impotence agent sildenafil (Viagra) may have some properties that enhance fertility, including increasing sperm motion and capacitation (the explosion of energy in the sperm that aids the act of fertilization).

Varicocele Repair

Varicocele repair for fertility should be considered generally when the following conditions are met:

• When the varicocele can be felt during a physical examination.
• When the male partner has abnormal semen quality or abnormal sperm function test results.
• When the couple has known infertility and the female is either fertile or can be treated for her infertility.
• (Young men not in partnerships but who may want to have children later on may also be candidates if they meet the other two qualifications.)

The procedure does not appear to be at all beneficial for improving fertility in men whose varicoceles are very small. In general, evidence is weak on the effects of varicocele repair on pregnancy. In a review of 12 studies, pregnancy rates after a year were 33% in couples in which the men were treated compared to 16% in untreated couples. Of two well-designed studies, however, one showed no higher pregnancy rate while the other reported significant improvement.

Varicocelectomy. Repair of a varicocele (varicocelectomy) in men with infertility problems is a common surgical practice. The procedure involves tying off the swollen and twisted veins. Recovery takes six days and most men cannot resume full activity for about three weeks. This technique eliminated 90% of varicoceles.

Recent techniques use laparoscopy techniques, which employ tiny incisions (less than an inch). This approach has quicker recovery, although the procedure itself takes longer. It also has a higher rate of complications than with the standard approach.

Varicocele Embolization. A nonsurgical technique called varicocele embolization may eventually prove to be an effective and less painful treatment for varicoceles. It involves inserting a narrow tube through a small incision in the neck or leg. Tiny steel plugs are passed through the catheter that block off the affected veins. It takes 15 to 45 minutes under local anesthetic. This is not yet widely available and it may not be appropriate in some men.

Miscellaneous Surgical Procedures

Obstructions in the area of the ejaculatory ducts have been successfully treated by excising or scraping the area where the prostate gland surrounds the urethra. Undescended testicles of young boys may be repositioned surgically to prevent later infertility. It is important to perform the operation before age two to prevent the destruction of most of the sperm-producing cells, which occurs if the testicles remain in the abdomen.

Treatment for Retrograde Ejaculation and Failure of Emission

Men with retrograde ejaculation and failure of emission caused by surgery, severe disease, or spinal cord injury are treated with various methods.

• Drugs known as alpha-adrenergic agonists, including phenylpropralamide, ephedrine, and pseudoephedrine, stimulate muscle contraction and help ejaculation.
• If they are not effective, electrovibration (or electrical stimulation) is often beneficial, even in men with spinal cord injuries.
• The tricyclic antidepressant imipramine (Tofranil) is often beneficial for some men with retrograde ejaculation after surgical procedures.
• In men with retrograde ejaculation, sperm can still be prepared for IVF. The man takes sodium bicarbonate four times a day to reduce the acidity of the urine. After ejaculation, the man urinates or has a catheter (a tube) inserted to withdraw urine, which is then submitted for washing techniques to separate out the sperm.

With any of these methods, the sperm can be collected for intrauterine insemination or assisted reproductive techniques. Spontaneous conception is possible, but not common, even with these treatments.

Techniques for Men with Spinal Cord Injury

Procedures that assist ejaculation are helping men with spinal cord injury conceive children. Ejaculation was achieved in all men in one study group with the use of vibratory or electronic stimulation. The sperm was then inserted into the women using self-insemination, IUI, IVI, or ICSI. Nearly a third of the couples achieved pregnancy, a success rate that approaches natural conception.

Vasectomy Reversal (Vasovasostomy)

Vasovasostomy. For men who wish to conceive after vasectomy, reversal surgery (vasovasostomy) may restore fertility. In vasovasostomy the severed ends of the vas deferens (which were cut during vasectomy) are reconnected to reestablish the flow of sperm. The reversal procedure is difficult; it involves sewing together the two ends of both tubes, each with pinhead sized openings.

Pregnancy Rates after Vasovasostomy. Pregnancy rates of over 50% have been reported after a vasovasostomy. One study reported that when successful conception occurs, it does so at an average of one year after the surgery.

A successful reversal is more likely if the following conditions are present:

• The section removed during vasectomy was not long.
• The original procedure was performed on straight sections of the vas deferens.
• The pieces joined during the vasovasostomy are of equal size.
• The closer in time the vasovasostomy is to the original vasectomy the better. (In one large study, the pregnancy rates were 76% for those who had vasectomy less than three years before reversal surgery decreasing to 30% for those with vasectomy more than 15 years prior. The lower rates as time goes by are probably due to increasing chance for obstruction of the epididymis and the development of anti-sperm antibodies.)

Reversal versus ART. Vasovasostomy is still a better choice than ART, even with the newer techniques such as ICSI . In one study the pregnancy rate for vasovasostomy was 52% while success after an ICSI technique ranges between 25% and 30%. In addition, a vasovasostomy does not pose a risk for multiple births. A 2000 study concluded that vasovasostomy was even a more cost-effective way to achieve fertility in men with partners above 37 years of age. Even for men who have failed vasovasostomy, a repeat procedure appears to be less expensive than embarking on fertility treatments at that time.

ART may be the better approach than reversal for men with evidence of anti-sperm autoantibodies due to vasectomy or for those whose vasectomy was conducted more than 15 years before.

Treating Anti-sperm Autoantibodies

ART is the best approach at this time for men with evidence of anti-sperm autoantibodies due to vasectomy or other causes. High doses of corticosteroids may be useful in conjunction with intrauterine insemination. Their effectiveness, however, is not proven and they have potentially serious side effects with prolonged use. Interesting research is testing a factor called fertilization antigen (FA-1), which may be able to remove autoantibodies from the sperm surface. Some experts believe, however, that immune factors are not significant in causing infertility, and that many men can still conceive despite antibodies to their sperm.