The most successful uses of medication to treat male infertility have been with gonadotropic hormones (LH and FSH) to treat patients with hypogonadism (low blood levels of LH and FSH), steroids (immune system blunting medication) to treat the over-active immune systems of men with sperm antibodies, antibiotics/anti-inflammatories to treat infections, and clomiphene (a hormone pill) that enhances sperm counts. Although only one in four men will respond to clomiphene, there are occasional cases in which oligospermia (a low sperm count) is the only problem (i.e. normal motility, morphology and sperm function), and in these cases a therapeutic trial of clomiphene is a reasonable treatment option. Steroids such as prednisone will reduce sperm antibody levels and thereby increase sperm movement and function in nearly one half of cases of antibody problems. Nearly all cases of hypogonadism will respond to replacement hormone therapy, but this is an uncommon cause of male infertility.
Surgical therapy may include varicocele repair, sperm duct microsurgery, microsurgical vasectomy reversal, transurethral resection of the obstructed ejaculatory duct, or sperm harvesting procedures such as testicle, epididymis or vas deferens sperm retrieval. Most of these are safely and effectively performed as outpatient procedures under general anesthesia, or local anesthesia with or without intravenous sedation.
It is our conclusion that varicocele correction can dramatically enhance semen parameters (65% of our cases) and pregnancy rates (45% of our cases) when compared to pregnancy rates for untreated cases (10-20%). Our 45% mean pregnancy rate is higher than most reported in the medical literature. This is based on an extensive review of the medical literature on varicocele correction as well as a critical analysis of our own results. Varicoceles are the most common and treatable diagnosis in our experience. Nearly 60% of patients evaluated at Male Fertility Specialist have varicoceles, yet they are not the cause of infertility in many cases. It takes a knowledgeable clinician and quality laboratory testing to determine when it is appropriate to correct a varicocele, and at what point after correction there has been sufficient improvement to justify continued efforts at natural conception, or when the level of improvement has only been sufficient to allow conception through medically-assisted methods. Our varicocele size specific data indicates a one year pregnancy rate of 60% for men with large varicoceles. This type of practice specific data is critical to the credibility of any clinician treating male infertility so that he can properly advise couples on comparing treatment options. This approach to the patient with varicoceles is a distinguishing feature of Male Fertility Specialists which will enhance the referring physician's services.
In the current era of infertility treatment for male factors, sperm duct microsurgery has been increasing in its frequency. The incidence of the need for this surgery has increased from 10% of our cases 10 years ago, to its present level of 25% of our cases. Experience and the technical expertise of the microsurgeon are critical to success. Dr. Buch personally inspects the sperm samples in the operating room at the time of the procedure in order to determine the correct level to reconnect the obstructed sperm ducts and at which level to harvest sperm for use in assisted reproductive techniques. Other surgeons are dependent on time delayed interpretation of slides sent from the operating room to the pathologist whose interpretation of the slide does not reflect the expertise of an infertility specialist.
The most common reason to perform sperm duct microsurgery is to reverse a vasectomy. Dr. Buch has performed numerous successful vasectomy reversals since 1985 using the most up-to-date microsurgical techniques. He has reported his success rates in medical journal articles and seminars, and he has been a pioneer in the use of frozen sperm from the site of the vasectomy reversal. The frozen sperm provides a "back-up plan" for future attempts at pregnancy should sperm fail to return to the ejaculate in spite of a technically excellent microsurgical vasectomy reversal. Currently, 95% of our clients who have a straight-forward vasectomy reversal (vasovasostomy) will have successful return of sperm to the ejaculate, and 65% will achieve pregnancy by natural means. This compares favorably with the 85% natural pregnancy rates of all couples trying to get pregnant (those who are not associated with a vasectomy reversal). When sperm returns after a successful vasectomy reversal, the natural pregnancy rates can be enhanced by use of medication for persistent sperm antibodies, and through the use of sperm processing (washing) in combination with insemination of the female partner.In cases where the time from the vasectomy to the attempt at vasectomy reversal has been more than 10 years, there is an increased chance of a secondary blockage in the ducts closer to the testicle, which are called the epididymis. Even in these technically more demanding cases called epididymovasostomy (EV or VE), our success rate for return of sperm is 80% and our natural pregnancy rate is 50%. Currently, our patient with the longest duration from vasectomy to successful vasectomy reversal with return of sperm in the ejaculate is 27 years!
Although we routinely perform both first time and repeat vasectomy reversals, we are often approached regarding the possibility of combining sperm retrieval procedures with in-vitro fertilization (IVF) as an alternative to vasectomy reversal or in cases where there is no chance to correct the duct obstruction such as congenital absence of the vas deferens. Since we and others have documented that pregnancies can be achieved from frozen-thawed vas deferens, epididymis or testicle sperm used in a special type of IVF called ICSI (intra cytoplasmic sperm injection), it is not necessary to retrieve the man's sperm at the time of the wife's egg retrieval for IVF. We currently recommend that couples who desire this as a vasectomy reversal alternative or for those who have non-correctable duct obstruction, that the man have his sperm retrieval and freezing before the wife starts her IVF cycle. In this way, both partners do not need to have medical procedures performed on the same day, and the entire situation becomes less stressful while maintaining high success rates. However, since sperm retrieval combined with IVF-ICSI costs more than vasectomy reversal on a cost-per-pregnancy basis, we encourage our clients to consider vasectomy reversal with sperm freezing as the most cost-effective option!
As of May 2004 our package price for vasectomy reversal is $8,300 (this includes surgeon's fee, hospital and anesthesia fees). Sperm freezing adds $500 to this cost. Please call ahead to verify current costs.
Approximately 500,000 men in the United States each year have an elective sterilization procedure known as vasectomy. This is an office procedure performed under local anesthesia (i.e. novacaine), and it takes 20 minutes to complete. Vasectomy is a safe and effective form of permanent contraception that permits a rapid return to work. We use instruments and techniques which do not require scalpel incisions, and we have noted increased patient comfort levels and decreased complications when compared to more traditional techniques. Although no medical studies have looked at physicians' personal preferences for method of elective sterilization, Dr. Buch notes that many urologists such as he (those doctors who perform the majority of vasectomies) have chosen vasectomy as their preferred method of family planning. Another unique service offered at Male Fertility Specialists is the opportunity to bank frozen sperm prior to vasectomy in case there is a change of circumstances in the future.
Legacy Male Health Institute, P.A encourages you to consider a vasectomy reversal with sperm freezing as the most cost-effective alternative.
