Chairman of Urology
Weill Cornell Medical Center
Former President, ASRM
Director, Male Reproductive Medicine
Mount Sinai Medical Center
As we mentioned in a previous chapter, reproductive endocrinologists are often the first doctor to see the semen analysis and to stumble upon a possible issue. Given the reproductive endocrinologist’s focus is getting the couple pregnant through treatments to female patients, they will often be inclined to direct the couple to Intrauterine Insemination (IUI) or In Vitro Fertilization (IVF).
IUI is the process whereby sperm is injected directly into a woman’s uterus. The technique is considered minimally invasive, does not require the woman to use hormone therapy, and typically costs $300 - $3,000. IUI can plausibly lead to a live birth in the context of a male factor issue if there is a sufficient total motile count (often 3 - 5 million sperm) but success rates in this context with IUI are generally around 10% per treatment.
IVF is the process where a woman’s ovaries are stimulated with hormones to grow a large number of eggs. Thereafter, those eggs are surgically retrieved, then fertilized in a laboratory with a man’s sperm. Thereafter, the fertility clinic’s laboratory attempts to grow the resulting embryos to a stable and hearty state, then transfers them back into the woman’s uterus.
Each cycle of IVF typically cost $18,000 - $23,000, most patients consider the process to be daunting and, as you can see below, most successful IVF patients must undergo multiple cycles. While many couples with a male factor diagnosis are told IVF has high rates of success, most will still require at least two treatments.
For couples where both the woman and the man have independent fertility challenges, IVF is often a practical solution. The reason is that it can take months for a man’s semen parameters to return to normal with treatment, but if the woman’s fertility is quickly dissipating, that timeline is simply too long.
There are circumstances where there is no female issue, and only a male factor issue, and IVF is still a requirement. One example are men with non-obstructive azoospermia (also known as testicular azoospermia) and who must have sperm surgically removed from their testicle to father a child. In this case, because so few sperm are retrieved, they must be injected directly into the eggs in a process called ICSI (Intracytoplasmic Sperm Injection). ICSI can only take place in a laboratory and thus retrieving the woman’s eggs, and performing IVF is a requirement.
However, in many other circumstances where there is only a male fertility issue, it is debatable whether IVF should be considered before other less invasive and less costly options are explored. As we’ll cover in the coming lessons, a man’s fertility can often be improved by adjusting that man’s lifestyle, regulating his hormonal pathways, surgically treating a varicocele (if one exists), and other measures that are less drastic than IVF.
If a couple has advanced to IVF, there is debate as to when the ICSI fertilization technique itself is useful. As we covered in our lesson on the semen analysis, the data does not necessarily support using ICSI if the only detectable male issue is of a morphological nature. This is worth dwelling on because ICSI is a delicate procedure, a small percentage of eggs are often destroyed in the process, it’s costs are non-trivial ($1,500 - $3,000) and there is data to suggest it may impact the resulting children. We’ve built a whole course devoted just to ICSI and if you have further questions, we encourage you to take a look.