A couple attending the infertility clinic have been investigated and the husband’s
semen analysis was described as oligozoospermic.
Evaluate the options available to the couple. (20 marks)
Common mistakes
● Taking a history and doing a physical examination – this would have been done before
the investigations
● Details of investigations for infertility are irrelevant
● Discussing treatment of zoospermia
● Offer a procedure and then state that it is most unlikely to succeed – if so, why offer it in
the first place? If you were the patient, would you accept it?
● You have been asked to evaluate the options and not to outline how to investigate the
infertile couple
● Failure to evaluate the treatment options
A good answer will include some or all of these points
● Assumption – repeat semen analysis remains abnormal and female investigations are
normal
● Options – four main ones:
● Identify cause of oligozoospermia and correct if treatable. This is the most cost
effective option and there is no need for invasive procedures, which may be associated with higher pregnancy rates.
May need referral to a urologist. Modification of lifestyle to remove risk factors
● Assisted conception techniques: artificial insemination with husband’s sperm (AIH)
or donor sperm (AID) and intrauterine insemination – sperm preparation and concentration.
Only extra requirement is sperm preparation. Success rate may be
improved by induction of ovulation. Use of husband’s sperm, therefore biological
father – more acceptable; AID – least likely to be accepted at the outset (as first suggestion); AIH and AID cheaper than IVF
● Advanced assisted conception techniques:
● IVF – expensive and low success rate; may still need donor sperm
● Gamete intrafallopian transfer – cheapest of the three; may still need donor
sperm;
● Intracytoplasmic sperm injection (ICSI) – if sperm cannot fertilise or are morphologically abnormal; expensive and associated with the complications of superovulation and OHSS
● Adoption: child not biological offspring of parents
Sample answer
It is to be assumed that the semen analysis was performed at least twice in this couple and that
the results were basically similar.
Therefore, there is no need to repeat the semen analysis. In
the first instance, the cause of the oligozoospermia should be identified if possible.
If treatable,
this will be the most suitable option to be offered. However, in most cases the cause is difficult
to identify and treatment is neither a logical nor a satisfactory option. If there is no known
cause, the husband should be referred to a urologist for further evaluation and management if
necessary.
Sometimes a simple modification of lifestyle, such as working habits, smoking,
drugs, etc., may be all that is necessary to improve the quality of the semen. Therefore, before
referral, information about lifestyle factors that could influence semen analysis should be
elicited and appropriate counselling offered.
The second option is AIH. In this case, the sperm have to be prepared so that only normal
ones are present and, in addition, the concentration is significantly improved. This may go in
tandem with ovulation induction in order to improve the success rate.
For this option, the
only requirements are facilities for sperm preparation and introduction into the cervical canal.
The main advantage is involvement of both partners and the offspring will be genetically from
both parents. However, AID may be another alternative. In this case, the biological father is a
donor.
Psychologically, this may be more difficult for the couple to accept.
Advanced assisted conception techniques may be offered in two different ways.
The first is
IVF where ovulation induction is undertaken followed by fertilisation with the husband’s
sperm (specially prepared) if they are morphologically normal, or by ICSI using spermatids
aspirated from the testis.
This option is expensive and some couples may not be able to afford
it, especially where it is only available privately. Also, ICSI is likely to be an option only in
highly specialised tertiary centres or private units. Complications with these advanced techniques may negate their availability.
The last option for the couple is adoption. This is complex, time consuming and very
lengthy, which make it a very frustrating option for the couple.
In addition, the couple are not
the biological parents of the adopted child and may be apprehensive about this.
Oligozoospermia is a complication that must be handled with sensitivity and adequate empathy.
The treatment options are many but the couple have to be comfortable with the one they
eventually choose.
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