Male Infertility

不孕症：夫妻結婚後，每週維持2~3次的頻率性行為，且沒有採取任何避孕的措施，超過一年以上，仍然沒有懷孕稱之為不孕症，若想懷孕生子則必須接受不孕症治療，讓不孕症專科醫師做療程規劃。

Non-genetic Causes of Male Infertility

Penis: Hypospadias, Epispadias, Penile curvature

Testes: Cryptorchidism (undescended testes), Testicular torsion, Testicular atrophy, Varicocele, Traumatic injury

Vas deferens: Congenital absence of the vas deferens, Infection and inflammation of the reproductive tract

Endocrine: Hypogonadism, Hyperprolactinemia

Sexual dysfunction: Ejaculation disorders leading to inability to ejaculate or semen not entering the vagina properly, causing infertility, Erectile dysfunction preventing successful intercourse

Environmental and lifestyle factors: Long-term wearing of overly tight underwear, Excessive heat exposure, Smoking and alcohol consumption. These factors can negatively affect sperm quality and lead to male infertility.

Male Infertility Evaluation Items

General Medical History Review:

Includes assessment of family medical history, reproductive history, sexual activity, medication history, social habits, and occupational background.

Basic Semen Analysis:

Evaluates sperm count, concentration, morphology, and motility to determine the possibility of male infertility.

Advanced Semen Analysis:

Includes the Hyaluronic Binding Assay (HBA) and Sperm DNA Fragmentation Analysis.

HBA (Hyaluronic Binding Assay):
This test predicts sperm maturity and fertilization potential. Mature sperm are capable of binding to hyaluronic acid in the matrix surrounding the egg's cumulus cells. When binding occurs, enzymes are secreted from the acrosome of the sperm head, allowing the sperm to penetrate the egg's shell and fertilize it.
Sperm DNA Fragmentation Analysis:
If all standard infertility tests are normal but infertility or recurrent miscarriage persists, a sperm DNA fragmentation test may be considered. Using molecular biology techniques, this test identifies potential causes of male infertility. It includes:
- Y chromosome microdeletion analysis in cases of oligospermia (low sperm count) or azoospermia (no sperm)
- Sperm DNA fragmentation detection
- Assessment of mitochondrial membrane potential in sperm

Azoospermia: Causes, Diagnosis, and Sperm Retrieval Options

Azoospermia refers to a condition where no sperm are found in the ejaculate after at least two semen analyses. It is one of the more complex causes of male infertility, accounting for approximately 15% of all infertile men. Azoospermia can be categorized into two main types:

A. Obstructive Azoospermia (OA)

Men with obstructive azoospermia typically have normal testicular size and sperm production, and hormone levels are often within normal ranges. The issue lies in a blockage along the sperm transport pathway, preventing sperm from appearing in the ejaculate. Common causes include:

Previous vasectomy
Infections
Congenital abnormalities
Compression from epididymal cysts or scarring

For couples hoping to conceive naturally, microsurgical reconstruction (such as vasovasostomy or vasoepididymostomy) may be considered first. However, if reconstruction fails or other infertility factors are present, surgical sperm retrieval can be performed, with a nearly 100% success rate in these cases.

Ｂ. Non-Obstructive Azoospermia (NOA)

This type involves impaired sperm production within the testes. Testes are often smaller, and hormone levels are usually abnormal. Potential causes include:

Severe varicocele
Undescended testes (cryptorchidism)
Chromosomal abnormalities (e.g., Klinefelter syndrome)
Y chromosome microdeletions
Severe orchitis
Brain tumors affecting hormonal regulation
Pituitary hormone disorders
History of chemotherapy

Although sperm production is severely reduced, some areas of the testicular tissue may still produce sperm. In these cases, testicular sperm extraction (TESE) procedures may be attempted. The success rate for microdissection TESE (micro-TESE) is approximately 60%.

Even patients with azoospermia or severe oligospermia can achieve fatherhood through surgical sperm retrieval combined with assisted reproductive technology (ART).

🛠 Types of Surgical Sperm Retrieval Techniques

Based on the site of retrieval, the procedures are categorized as follows:

🧪 Testicular Sperm Retrieval:

TESA (Testicular Sperm Aspiration)
TESE (Conventional Testicular Sperm Extraction)
micro-TESE (Microdissection Testicular Sperm Extraction)

🧪 Epididymal Sperm Retrieval:

PESA (Percutaneous Epididymal Sperm Aspiration)
MESA (Microsurgical Epididymal Sperm Aspiration)

🧬 Benefits of Microsurgical Techniques

Microsurgical techniques increase sperm retrieval rates and minimize tissue damage.
Percutaneous and conventional methods are simpler and shorter in duration, but:
- MESA yields higher-quality, motile sperm with less damage to the epididymal tissue.
- micro-TESE enables precise identification of seminiferous tubules under a microscope, improving retrieval success while preserving testicular structure—even in severely impaired cases.

🔍 How Is micro-TESE Performed?

Under general anesthesia:

The pubic area is shaved and sterilized.
A midline incision (4–5 cm) is made in the scrotum.
The testicles are exposed.
Using a surgical microscope, the surgeon locates seminiferous tubules with diameters greater than 300μm.
Only small portions of testicular tissue are removed, minimizing damage.
Blood vessels are clearly identified and preserved, reducing the risk of testicular injury.
Postoperative impact on testicular function and structure is minimal.

🔍 How Is MESA Performed?

Under general anesthesia:

After preparation, a 4–5 cm midline scrotal incision is made.
The epididymis is carefully dissected and examined under a microscope.
Enlarged, fluid-filled ducts are identified.
A fine needle is used to aspirate yellowish, semi-transparent epididymal fluid, which typically contains motile sperm.
Microsurgical precision allows for minimal tissue damage and better sperm quality.

🤝 Final Notes

With proper diagnosis and treatment, many azoospermic men can still retrieve viable sperm and conceive via assisted reproductive technologies. Microsurgical sperm retrieval procedures are highly effective options.

Before proceeding with IVF and microsurgical sperm retrieval:

Be aware that sperm may not be found, and eggs retrieved on the same day will need to be frozen.
If no sperm are found or sperm quality is insufficient (leading to poor fertilization or embryo development), sperm donation may be considered for future fertility plans.

For patients with azoospermia or severe male infertility, consultation with a fertility specialist is essential to determine the best course of action.

Male Infertility Treatment Methods

Intrauterine Insemination (IUI):

In cases of male infertility, motile sperm are selected from the semen sample, washed, and then inserted into the female partner's uterine cavity at the appropriate time to increase the chances of fertilization.

Intracytoplasmic Sperm Injection (ICSI):

As part of the IVF process, ICSI involves using a microscopic injection needle to directly inject a single sperm into the cytoplasm of an egg to achieve fertilization.

Electroejaculation (EEJ):

For individuals who are unable to ejaculate normally, electroejaculation uses electrical stimulation to induce ejaculation and retrieve sperm.

Microsurgical Testicular/Epididymal Sperm Extraction (micro-TESE/PESA):

In cases of obstructive azoospermia (no sperm due to blockage), sperm may be retrieved directly from the testicles or epididymis through microsurgery.

Sperm Donation (Donor Sperm IVF):

For men diagnosed with azoospermia or who have genetic disorders, donor sperm IVF may be considered as a treatment option.