Infertility in Men

a microscopic image of an Intra-cytoplasmic sperm injection (ICSI) procedure

A common misconception is that infertility is primarily a woman’s “problem.” As part of the initial evaluation of a same-sex male couple, a semen analysis is requested and if indicated, we promptly refer patients to a urologist specializing in male fertility.

Treatments for male factor infertility are influenced by at least two significant factors: 

  1. Is the cause of the infertility identifiable?
  2. What is the severity of the sperm defect?


Intracytoplasmic Sperm Injection (ICSI) has revolutionized the treatment of male factor infertility. The ideal treatment for male couples with infertility challenges is in vitro fertilization and embryo transfer (IVF/ET), usually accompanied by Intra-cytoplasmic sperm injection (ICSI).

ICSI allows men who were previously incapable of producing adequate sperm, to father genetically related children. ICSI involves the placement of a single sperm directly into the egg using a microscopic pipette.

Men normally produce millions of sperm in each ejaculate. Some men have sperm defects such as a reduced sperm count, deformed sperm or sperm that cannot swim effectively. When any one of these abnormalities are present, it can prevent normal fertilization.

ICSI bypasses sperm defects because a single sperm is “selected” and placed inside the egg. ICSI is performed as a part of the IVF cycle. During IVF, the eggs are retrieved from your donor and taken to the embryology laboratory. In ICSI, a stereomicroscope is utilized to manipulate the egg(s). The egg is held in place while it is punctured by the micro pipette, and the sperm is inserted. IVF/ICSI is used in cases of severe male factor infertility and in other conditions such as failed fertilization in previous IVF cycles.

Prior Vasectomy

Couples have the option of a vasectomy reversal or IVF-ICSI with epididymal or testicular sperm extraction. It can sometimes take 6-9 months to recover adequate sperm counts following vasectomy reversal. Also, the greater the length of time between the vasectomy and the reversal, the greater the chances are that the surgery will be unsuccessful or that anti-sperm antibodies will form, preventing the recovered sperm from penetrating the eggs without IVF-ICSI.

Microepididymal sperm aspiration (MESA) and testicular sperm extraction (TESE) are outpatient surgical procedures used to harvest sperm from men in special circumstances as part of an IVF-ICSI. The length of time since prior vasectomy is a critical factor in decision-making. The physicians at LGBT Fertility work closely with several urologists to coordinate these procedures which are done in our facility in Frisco, Texas.

a diagram of Microepididymal sperm aspiration (MESA) and testicular sperm extraction (TESE) procedures

When a physician performs MESA procedure, he/she will put the patient under local anesthesia and general sedation. Then an incision is made in the scrotum, exposing the epididymis and the tubules immediately adjacent to the testicles that collect the sperm. Utilizing an operating microscope an incision is made into these tubules, and sperm is aspirated. Although millions of motile sperm can often be collected, this sperm has not acquired the ability to penetrate an egg and must be injected into eggs via the IVF-ICSI technique. The advantage of MESA over TESE for men with obstructive azoospermia is that sperm collected in this manner can usually be frozen, and even if his partner has to undergo more than one IVF procedure, the MESA should provide adequate sperm for all subsequent IVF procedures.

Testicular Sperm Extraction (TESE)

A TESE or testicular sperm extraction is a procedure that entails directly aspirating the sperm from the testes or retrieving sperm from a testicular biopsy. Generally, it is performed under local anesthesia block and can be performed as an office surgical procedure. In many cases, the disadvantage is that testicular sperm are much more scarce and consequently more difficult to freeze. Typically, there is only enough sperm recovered for one IVF procedure, and if further IVF attempts are needed, the TESE procedure will need to be repeated.

Non-obstructive Azoospermia (NOA)

Men with very poor sperm production in the testicles and no sperm in the ejaculate often demonstrate high blood FSH levels and sometimes low testosterone levels. The testicular size may be small. These men are usually considered to have relative testicular failure. TESE or testicular biopsy is usually the only option for them as there are no sperm in the epididymus and even testicular sperm production can be “patchy” and scarce within the testes. Men with this diagnosis who have been told they have no sperm on routine testicular biopsy frequently can be found, on further investigation, to have sperm present in a scattered distribution within the testicle. If so, these areas can be re-aspirated for IVF-ICSI with some degree of success, depending on the amount of sperm obtained.

Sertoli Cell Only Syndrome

Complete absence of sperm progenitor cells and absence of spermatogenesis is a rare condition. Utilizing your partner’s sperm or donor sperm are the only options in these cases.