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Learn more about Microscopic Vasectomy Reversal
Learn more about Sperm Aspiration for ICSI
Two of Dr. Silber's patients relate their experiences receiving care at the Infertility Center of St. Louis.
The Y chromosome in the era of intracytoplasmic sperm injection: a personal review - Fertility and Sterility
There is no more confused medical care in our field than what is delivered by many urologists to the couple that suffers from "male infertility." In fact, many couples are told to delay the IVF treatment they should have had sooner (because of the wife's advancing age) in order just to wait for some dubious treatment of the male partner to increase his sperm count. Numerous control studies have demonstrated that administering clomid or nutritional supplements to the male, or performing varicocoele surgery, does nothing to improve his sperm count, and the often suggested testosterone supplements just lowers rather than raises his sperm count, and may eve n render him totally sterile.
Anatomy of the normal testicle.
Route of sperm transport from the testis to epididymis to the vas deferens.
Many husbands in infertile marriages are sent to urologists who then almost always in some communities recommend "varicocoelectomy." This is a procedure to tie off a varicose vein of the testicle. More than 15% of all men on the planet have a varicose vein of their left testicle, and most of these men are quite fertile. It is a completely benign and normal variant of testicular anatomy. Yet often the husband is subjected to this completely meddlesome surgery, often on both sides, despite the absence even of a varicocoele, and despite its ineffectiveness in anyway improving his sperm count. It is however ironically quite effective in delaying the treatment the couple really needs, all while the wife's eggs keep getting older. Furthermore, if done clumsily, bilateral varicocoelectomy can reduce the husband's merely low sperm count down to a zero sperm count.
Let's give a few examples:
I recently saw a physician couple (he was an anesthesiologist and she was an OB-GYN) who had needed IVF because the wife was already 40 years old (old eggs) and the husband had a very moderately low sperm count of 21,000,000 sperm per cc. They went to a very famous IVF center, which wanted the husband, mind you a physician, to be seen by a urologist before they went to the IVF. The urologist proceeded to order many thousands of dollars of absolutely unnecessary testing, including hormone assays, scrotal ultrasound, and sperm "DNA fragmentation," all of which added to the urologist's income. After all these worthless tests, he recommended bilateral varicocoelectomy, even though in truth the patient did not even have a varicocoele. (Even if he did have bilateral varicocoeles, this would have been a useless procedure.) Post-operatively the husband, mind you a physician, now had zero sperm count (because of interference with blood supply) instead of 21,000,000 per cc.
Another recent example is a man who had a perfectly normal sperm count, and the couple was about to undergo IVF at a well known IVF clinic which recommends, for some inexplicable reason, that the husband see a urologist "just to make sure" everything was OK. Again, after a series of useless but expensive "andrological" tests, the urologist came up with a most terrible meddlesome recommendation. He told the couple they would have better results with the IVF if instead of using his normal ejaculated sperm, they should perform a testicle biopsy and use testicular sperm, which in truth would give worse results than the ejaculated sperm. Not withstanding this terrible advice, he suggested that first they should do a bilateral varicocoelectomy, even though the sperm count was normal and the wife was in her 40's.
So what is appropriate treatment for male infertility in an infertile couple? For most men with low sperm counts, there is no treatment which will raise the sperm count, since sperm counts are genetically determined. It is best in cases of low sperm count to go directly to IVF and ICSI (which is injecting sperm into the egg) before the wife becomes so old that her older eggs become a compounding problem. Many physicians will try IUI first, intra-uterine insemination, but this is a waste of time and money. Washing the sperm and inserting it into the uterus will do nothing to get the sperm closer to the egg than sexual intercourse, although it may help the patients to feel like they are "doing something." The correct treatment for low sperm count is to go directly to IVF and ICSI. Any other treatment or testing is a waste of valuable time, not to mention, money.
Here's a perfect example:
Dear Dr. Silber, Dr. DeRosa, and your wonderful staff,
My husband and I would like to take this opportunity to thank you for everything you do to help couples achieve their dream of becoming parents, and to share our story. We hope it might encourage someone else.
My husband and I are high school sweethearts who wanted to start our family not long after we were married. I don't know why, but I had a feeling that it would be hard for us. After about a year of trying to get pregnant I went to my OB doctor to see if something was wrong. It was determined that I may have a condition called polycystic ovarian syndrome which causes me not to ovulate regularly. Then it was my husband's turn to get checked out. We were shocked to find out that his sperm count was only ONE, especially when a normal count is like twenty million! My husband was a normal healthy 32 year old man with no history of childhood illness or injuries. We visited several urologists who told us that he is young and suggested he take some expensive vitamins and wait to see if they help. Then we went to a local reproductive endocrinologist who told us that if I wanted to become pregnant I would need a sperm donor because my husband had nothing to work with. This was hard to hear and very discouraging.
Instead of continuing to "try" for a baby we just started praying and saving money. I wasn't sure what we were going to do but I knew it would be expensive! We looked into foster parenting, adoption, sperm donors and IVF. Meanwhile everyone I knew, worked with, and was related to was pregnant! I was happy for them, but at the same time sad for myself. I had days where I wondered if I'd ever be a mom, but deep down I always had this peace that God gave me that we would eventually be parents.
Then one summer day I was flipping through the channels and saw this show on the Discovery Health channel about IVF. It was Dr. Silber and his staff in St. Louis. The couples had fertility issues similar to ours. That show gave me so much hope! I researched Dr. Silber and when I saw that he specialized in male infertility and difficult IVF cases I knew he was the doctor for us.
We flew up to St. Louis the following December for a consultation with Dr. Silber. We were afraid that he might say that we were not good candidates for IVF, but instead he said we were great candidates for it! He was so warm and sweet and encouraging. You could really tell that he cared. We left feeling so excited and couldn't wait to come back! So the next summer we started the process.
The staff is so patient and kind. We live in Florida and they were so good about explaining things over the phone and making sure we understood all our meds, blood work, and ultrasounds that needed to be done before coming back up to St. Louis for the egg retrieval. After the procedure we had six embryos that made it to the three day gestation and freezing process.
December 13, 2011 we had two embryos implanted in my uterus. We had the best Christmas of our lives being able to tell our entire family that after eight years of marriage, and six years of trying, God had blessed us and we were FINALLY going to have a baby!!!! On August 16, 2012 our dreams came true and our little miracle baby was born!
We just celebrated our first Christmas with our baby girl Madison and we are still pinching ourselves! We are so grateful to God for leading us to Dr. Silber and for this beautiful, healthy baby girl! We are now planning our next trip to give Madison a brother or sister! There are no words to tell you just how thankful we are for all of you and what you mean to our family!
Chris and Casey Click (and baby Madison)
Palm Bay, FL
But there are unusual cases where the man can be induced to make sperm with just medical treatment, like the rare Kallman's Syndrome, related by this patient:
Shortly after Chris and I met, he told me he had a condition called Kallman Syndrome, where the man can make no sperm, and he was not able to have children. At least that is what he had been told for years and years. I thought there had to be a way with so many advances in that area.
A couple years after we married, we started looking into our options. Before we found out about Dr. Silber, we heard of another physician. We saw them and were told, Sorry, no deal. We were devastated and started to look into adoption.
A woman I worked for at the time knew our situation and had known someone who went to Dr. Silber. She showed me the website and Chris and I were impressed and set up a consultation. We were even more impressed and actually hopeful for once.
It took us some time to get the process started but once we were ready, we called and said it was Go Time. From the first person you speak to in the office all the way to Dr. Silber and Dr. De Rosa, everyone was so incredibly reassuring, professional, and kind.
On Aug 28, 2011, our procedures started and on Sept 12, 2011, we found out Dr. Silber and Dr. De Rosa are definitely miracle workers and we got the great news we were pregnant. We were beyond thrilled as well as our families! From that day on, our lives have been a whirlwind.
The pregnancy went very smoothly until the last few weeks when I had some blood pressure issues, but all went well and on May 16, 2012, Connor Robert graced us with his presence and has been an absolute blessing ever since. We will forever be grateful for Dr. Silber and his team. They gave us the best gift anyone could ask for.
Thank you from the bottom of our hearts,
Chris and Kim Blase
Azoospermia and Vasectomy Reversal
However, there are many infertile couples in whom the male is completely azoospermic (that is, no sperm at all in the ejaculate). For these cases, the urologist is actually needed, but again often his treatment is poorly performed. For example, I recently saw a couple from Texas that needed a vasectomy reversal procedure. He had had a vasectomy in the past, and needed a reversal to try to have another child. He went to a urologist in Texas who offers "money back" guarantees. I have re-operated on many of the patients of this doctor who failed reversal attempts and I know that none of them ever had their money returned as he always had room in his "contract" to wiggle out.
Poor result with non-microsurgical vasectomy reversal.
Perfect result with two layer microsurgical vasectomy reversal.
Epididymal blowouts must be repaired or bypassed microsurgically in order to have high success with vasectomy reversal.
Perfect microsurgery to bypass epididymal obstruction.
Perfect microsurgery to correct obstruction even for a huge area of missing vas.
The doctor he saw lied to him on three counts. Firstly, he told him post-op after the vasectomy reversal that he now had sperm in his ejaculate and that the vas reconnection had been successful. But there was no sperm in the ejaculate, and when we did his re-operation a year later, we found that the two cut ends of the vas were nowhere near each other. Therefore he could never ever have had sperm in his ejaculate after his previous surgery. The second lie was that the doctor said he had found sperm in the vas fluid when he did the vas reconnection. But there were epididymal blowouts indicating there could not have possibly been sperm in the vas fluid. The third lie was that he could possibly have had a successful reversal even if a vas reconnection had been performed, because what he needed was a reconnection of the vas to the epididymis proximal to the blowout site.
So taking all three of these lies into account, we re-operated on this patient who supposedly had had a successful vasectomy reversal back home in Texas, doing a rather extensive procedure to free up all the surgically induced scar tissue, and reconnected the vas [video] to the epididymis on both sides. Now he truly is fertile, with normal sperm count, and has successfully impregnated his wife finally, with no need for IVF.
Azoospermia Not Caused by Vasectomy
If the azoospermia is not caused by a previous vasectomy, it is usually not correctable with reconstruction, and then sperm retrieval [video] with IVF and ICSI is necessary. In fact, we were the center that invented sperm retrieval with ICSI [video] for azoospermic men in the 1990s, and have the greatest experience and expertise with it.
Microsurgical puncture of obstructed epididymal tubule to obtain sperm.
Elegant microsurgical retrieval of sperm from the testes and epididymis from azoospermic male.
We pioneered ICSI in 1992.
We first invented and perfected the techniques of sperm retrieval, IVF, and ICSI in azoospermic men.
MESA: Microsurgical Epididymal Sperm Aspiration.
There are two entirely different situations and causes for no sperm in the ejaculate (azoospermia): obstructive and non-obstructive. For obstructive azoospermia, aside from vasectomy, which is reversible with reconstructive microsurgery, there are men who were born with absence of the vas. Most of them have a mutation on their CF (cystic fibrosis) gene or chromosome 7, but do not have cystic fibrosis. They just never developed a vas deferens in fetal life, and they do not discover they have this problem until they get married, try to have children, and discover they have no sperm in the ejaculate. There is no vas to reconstruct and so the only way they can have children is to microsurgically retrieve sperm from their epididymis and inject this sperm into the wife's eggs via IVF. This procedure is virtually 100% successful.
In both types of sperm retrieval, obstructive and non-obstructive, it is important to use precise microsurgical techniques rather than just "needle sticks" to have the highest percentage of success and also the least amount of pain or complications. Unfortunately, this is not always the case, and some husbands have fairly horrible experiences, which just shouldn't happen. For example, I just recently saw a couple who had gone through 10 IVF cycles with retrieval sperm for congenital absence of the vas at a reputable IVF clinic, with over 20 embryos transferred but no pregnancy. Each time he had the sperm retrieval done with a needle stick rather than microsurgery, and each time relatively poor quality sperm were used because the urologist could not see where in the epididymis he was poking. So he retrieved mostly older sperm with a lot of DNA fragmentation, thus explaining the wife's failure to conceive. Furthermore, he had a great deal of pain and swelling with each crude needle stick procedure making his wife frustrated when he became less and less enthusiastic with each IVF cycle at the thought of going through another one. Also, the sperm the urologist had retrieved was so poor that the laboratory would not freeze it, even though the proper approach would have been to obtain good quality sperm that would freeze well and obviate any further need for sperm retrieval.
In 60% of men with apparently no sperm, there are tiny microscopic foci of tubules with small numbers of sperm that are adequate for successful ICSI.
There are countless cases I have seen of this kind of mismanagement of male infertility at office IVF centers that have no microsurgical knowledge of the male. Just recently we saw an azoospermic patient who had been diagnosed at 10 years of age with a rare condition called Kartagener's Syndrome, where their ciliated cells in the lungs and nose and even the epididymis (the tiny duct which carries sperm out of the testicle into the vas deferens) are unable to move. The tiny hair-like cilia can't wiggle and sweep the fluids along well, but modern treatment makes it a minor condition except for one thing: they have no sperm in the ejaculate.
This patient wasted years of time, energy, and money going through worthless testing, while his wife's eggs were getting older. When he finally reached our clinic, the same day I performed a microsurgical sperm retrieval under local anesthesia, which resulted in our obtaining millions of vigorous motile sperm perfect for IVF. His previous clinic had thought that his Kartagener's Syndrome would make his sperm non-motile and nonfunctional even for IVF, but clearly that was not the case. The sperm were perfectly normal. They just couldn't get out of his epididymis into the ejaculate.
The second type of azoospermia is "non-obstructive." This means there is not any obstruction, but the patient "appears" to have just no sperm production at all in his testes. Usually this is partly just an illusion, in that the majority of such patients do have a tiny amount of sperm production in their testes, but just not quantitatively enough sperm production to "spill over" into the ejaculate. These cases should usually, but not always, be successful in retrieving enough sperm for successful IVF and ICSI.
Very small testes but absolutely no damage.
Another recent example of the poor quality of male infertility treatment at many IVF clinics I saw recently was even more tragic than what I have already described. This was a patient with non-obstructive azoospermia who was sent by his clinic to a urologist who did a useless varicocele operation on both sides in a highly scarred and difficult inguinal area, because the cause of the azoospermia was undescended testis, as well as very destructive testis biopsy on both sides. The result was that in addition to azoospermia, he now also had no testosterone production either. This poor patient became a eunuch as a result of the overzealous and poorly performed attempt at sperm retrieval he had to suffer through.
A good example of the one of the most difficult cases of azoospermia is the so-called Klinefelter's in which the azoospermic man has two X (47XXY) chromosomes instead of one X (46XY) chromosome. It used to be thought that these men could never father children and had the worst prognosis of any male infertility. In truth, most of these cases have been successful in our hands.
Klinefelter's histology shows no sperm production in most of the testicle but there are testosterone producing cells.
A microsurgical inspection however will usually find a tubule with normal sperm, as depicted here.
Despite very tiny testicles, these men usually have adequate, though modest, testosterone production, and shockingly we can usually find enough sperm in these tiny testicles for them to father children via ICSI. But great care must be taken in this type of microsurgery to preserve their very reduced but adequate testicular function.
TESE: Techniques for Retrieving Sperm in Cases of Non-obstructive Azoospermia
The Wrong Way
There are many different approaches for trying to retrieve sperm from the testes of non-obstructive azoospermic men (TESE, which means "testicular sperm extraction"). Some of these approaches, such as needle biopsy or multiple needle biopsy (TEFNA), have a low success rate for finding the few sperm that are being made within the azoospermic testicle. It is like trying to find a needle in a haystack by blindly thrusting a pitchfork into it. This is not a nice way to treat a man's testes, but it is also fraught with failure. A similar approach which is given a more civilized name is called "testicular mapping." This approach is just as blind as TEFNA, but at least a record is kept of which of up to 30 or 40 blind needle sticks (if any) into the testicle actually find sperm. But the truth is that subsequently following this "map" often results in the drawing of a different and contradictory map. So blind needle sticks, no matter what you call it, yields an unsatisfactory success rate for non-obstructive azoospermia, and can indeed even be damaging.
The Disastrous "Microdissection" Procedure
A microsurgical approach is far more successful, but if performed incorrectly or with a non-physiological premise, can be highly destructive, and result in considerable loss of testicular tissue. This is the case with the so-called "microdissection" technique popularized in New York under the completely mistaken guise that it conserves testicular tissue, when in truth instead it does the opposite, and it actually destroys the testicle. With this destructive "microdissection" approach to TESE, a large horizontal incision is made in the outside shell of the testis (called the tunica albuginea), which only exposed one of the eleven anatomic lobules of the testis. This incision makes no anatomic sense if you are trying to sample the entire testis to find the few sperm it is producing. So then the "microdissection" surgeon basically opens up the entire inside of the testis, turning it inside out to look at every single cubic millimeter of the testis, which plays complete havoc with its blood supply and causes massive intra-testicular swelling and subsequent fibrosis.
An assembly of great rabbi experts on medicine and ethics from all over the East Coast of the United States met in February 2011 first in New York and later in Lakewood Yeshiva in New Jersey. They decided strongly against the testis destructive "Microdissection" procedure popularized in New York City, and decided strongly in favor of the testis sparing stem cell distribution "Micro-TESE" technique described by Dr. Silber.
The argument put forth for this expensive and destructive approach is the false premise that the tubules of the testes which actually have sperm in them are dilated under the microscope, and the tubules which have no sperm are not dilated. That is nice theory, but not true. At least half the time when you find a so-called dilated testicular tubule, there is still no sperm in it. Furthermore, at least half of the cases of non-obstructive azoospermia are "maturation arrest," and in such cases there are no grounds for even speculating that the larger tubules have sperm.
So nitpicking your way through the entire interior of the poor man's testicle to try to find dilated tubules is a fool's mission, and leads to massive testicular destruction. We have seen so many patients after they have had TESE with "microdissection" elsewhere, who are not only without any sperm any longer, but also no longer even make testosterone, that they have actually become eunuchs because of this sort of "microdissection" TESE. They have literally become castrated.
Dr. Silber teaches the proper way to do micro-TESE for azoospermic men in Japan.
All anatomic lobules are sampled, but staying on the periphery to that there is no testis damage such as always occurs with the "microdissection" technique. With this anatomic stem cell approach, the highest chance of sperm retrieval is achieved, but with no testis damage.
For example, I recently saw a 37 year old physician who used to work in New York, but now had moved to the mid west, who was azoospermic, and had undergone "microdissection" TESE at a very famous IVF center 15 months earlier. No sperm were found after a 3 1/2 hour "microdissection" surgical procedure. His pre-operative FSH was in the normal range (1.5 to 12.4) as is usually the case with maturation arrest, and his pre-operative testosterone was also normal (371), as is usually the case with any type of non-obstructive azoospermia. In fact he had had the appearance of a normal androgenized male, with normal beard growth, muscle mass, voice and bone strength. But now 15 months after his "microdissection" TESE in New York, his FSH was 75.3, his LH was 50.5, and his serum testosterone was less than 90, indicating he was now a eunuch. Furthermore his testicular ultrasound verified complete testis fibrosis, and very little testicular blood flow. He was basically castrated, and will have to go on testosterone replacement for the rest of his life in order to have normal sexual function, muscle strength, bone density, and general sense of well being. We have knowledge of many such cases, and just have to bluntly condemn this approach to microsurgical TESE.
The Right Way to do TESE
The proper way to do the microsurgical TESE is what I would call the "anatomic stem cell" approach to micro TESE. Firstly, the incision in the tunica albuginea should be vertical rather than horizontal, so as to expose peripherally every one of the eleven anatomic lobules. There is no reason even to penetrate into the interior of the testis. If you look at the well established diagram of intra-testicular microanatomy, you can see that all testicular sperm producing tubules traverse from the inside of the testis to the periphery and then back again to the inside. If there are any spermatogenic stem cells anywhere in the patient's testis, sperm will be found in the periphery of that tubule. Spermatogenic stem cells may be very few in men with non-obstructive azoospermia, and there are over 300 tubules in those eleven anatomic lobules. If there is a single spermatogenic stem cell in one of those tubules, it will propagate that one tubule and sperm will be found on the periphery without having to damage the testicle at all.
Stem cell approach. Sample all anatomic lobules peripherally.
With a single elegant vertical (rather than horizontal) incision, all anatomic lobules can be exposed without invading the inside of the testicle, and doing no harm to it.
Spermatogonial stem cell approach to non-obstructive azoospermia.
Normal spermatogenesis: Mage Stain.
The purpose of the microsurgery is not to dig around the inside of the testicle on a fool's mission, but to stop the microscopic bleeders on the periphery with pinpoint accuracy, and to close the tunica albuginea with microscopically thin sutures in order to prevent reduction in testicular volume with subsequent pressure atrophy. With such an "anatomic stem cell" approach, microsurgical TESE will give the best success in finding sperm for ICSI, and also will cause only miniscule loss of testis tissue, and NEVER result in testicular atrophy and eunuchism.
Normal testis anatomy. Stay on periphery, but expose every anatomic lobule.
Perfect microsurgery: stay on periphery for maximum number of sperm.
Microsurgical TESE is not "Microdissection" TESE
The procedure is done under local anesthesia where the risks and dangers of general anesthesia are not factors. The patient feels no pain and is wide awake and can watch the procedure on the TV screen if he so chooses.
The New York microdissection operation as opposed to our micro-TESE stem cell based procedure.
The anatomic stem cell approach to microsurgical sperm retrieval does no harm at all to the testis, but the so-called "microdissection" procedure is devastating to the testis.
With the microsurgical approach we advocate, under local anesthesia, a full inspection is made of every anatomic lobule on the periphery of the testis, without any "digging around" inside as is done in the New York "microdissection" approach. So we find any sperm that might be "hiding" in the testis, without doing any harm. It is also dramatically less expensive, and you can just get up and walk away painlessly when it is finished.
With the New York "microdissection" technique, the following tragedy is common: see the photo of what the testis looks like after a New York "microdissection" procedure. Note that most of this man's testis has been replaced with a scar inside, and he is no longer even producing testosterone, let alone any sperm.
So in summary, male infertility treatment, short of IVF and ICSI, should be limited to microsurgery for azoospermia, and careful thought has to go into making your choice of where to go for such treatment.
Evaluation and Treatment of Male Infertility. (PDF, 17 MB) Clinical Obstetrics and Gynecology, 2000.
Listen to Dr. Silber on Health and Wellness with Monica Adams discussing egg freezing, male infertility, and mini-IVF on KMOX in St. Louis.
Listen to Dr. Silber and Joan Hamburg discuss male infertility, mini-IVF, fertility preservation, and infertility trends on WOR Radio in New York. February 2, 2012. (12:57 min)
Listen to Dr. Sherman Silber and Joan Hamburg discuss the remarkable infertility treatment meeting that recently took place in Hong Kong. WOR New York, February 28, 2013. (9:26 min)
If you have any questions, you may call us at (314) 576-1400.