Many people like to listen to books and are very familiar with the story of Cheng Biaojin and his three axes that set Wagang. Cheng Bite Jin is a famous character in novels such as “Say Tang” and “Sui Tang Romance”. This straightforward, rough and fine general used an axe as his weapon, and his moves were the three moves, but with these three axes he fixed Wagang and became the king of the world. Since then, Cheng Biaojin’s three axes have become a household saying, used to illustrate that as long as you use the trick, you can be sure of success.
For male infertility treatment is the same, medication, artificial insemination or in vitro fertilization is also the three axes of medical doctors to treat male infertility. Because infertility is about 40% male factor, 40% female factor, and 20% because of the current level of medical science, no clear cause can be found, which may be related to both men and women. There are many causes of male infertility, but except for the obvious varicocele, the cause is often not found, and data show that about 60-75% of the causes are not found (some data report 25%, some report 44%); in most clinical cases, the cause is not found, and often empirical treatment, medication, artificial insemination or in vitro fertilization is the three axes of medical doctors to treat male infertility. Let’s look at a few cases.
I. Case presentation
Case 1: Male infertility patient, 38 years old, semen routine has been showing oligozoospermia, before coming to our hospital has been using spermatogenic drugs for 5 years, the cost of drugs spent nearly 100,000, but still did not achieve the purpose of fertility, because the patient has been using drugs for too long, so the patient is recommended to choose assisted reproductive technology.
Case 2: Male infertility patient, 32 years old, semen routine has always shown oligospermia, before coming to our hospital has used 2 years of spermatogenic drugs, the author carefully asked the patient medication, found that the patient intermittent medication, at most 2 weeks of continuous use of drugs, so the patient is recommended to use regular drug treatment first.
Case 3: Male infertility patient, 32 years old, semen routine has been showing weak sperm, ready to perform IVF, the patient requested to use the best and most expensive spermatogenic drugs to improve the success rate of IVF, because the IVF stage does not require the use of expensive drugs, the author suggested that the patient can simply use drugs.
Case 4: Male infertility patient, 30 years old, semen routine has been shown to be oligospermia, ready to carry out IVF, and firmly request the second generation of IVF technology, the patient believes that the better the technology the more expensive the better, in accordance with the principle of treatment of disease, the author still suggested that the patient first take the first generation of IVF technology.
II. Case analysis
There are generally three treatment options for male infertility, medication, artificial insemination and IVF, but there are also issues such as simultaneous treatment of female spouses and lifestyle adjustments.
Fertility is a combined effort of both men and women, and sometimes one party improves, the overall fertility will be greatly improved; for both spouses, the one with strong fertility can also compensate for the one with weak fertility, so we should pay attention to the simultaneous treatment of female spouses; and, because female fertility is closely related to age, the choice of treatment measures must also take into account the age of the female partner, especially when the female spouse is older. If an infertile couple has sex ≤2 times per month, this may be a factor in infertility and it is recommended to increase the frequency of sex appropriately. Sperm can survive in the posterior vaginal vault and cervix of the woman for more than 48 hours, so infertile couples are advised to have sex every 2 days before ovulation to maintain the presence of sperm in the fallopian tubes for 12 to 24 hours; oocytes have a very short survival time and sex after ovulation often does not result in pregnancy. There is no evidence that drinking small amounts of alcohol can damage male fertility, but alcohol abuse can damage several organs of the body, including the testes and liver, and even lead to testicular atrophy; smoking has an effect on female fertility, and it is still controversial whether it has an effect on various parameters of male semen routine and male fertility, but more and more studies support that smoking is a risk factor for male infertility. Therefore, attention is paid to the correction of bad habits: avoid smoking, no alcohol abuse, no sauna, etc. (similar to the mechanism by which fever affects fertility). Environmental and occupational risk factors, have the potential to affect fertility and are sometimes more pronounced than those in genetics or medical treatment. These risk factors are heavy metals (such as lead, cadmium, etc.); endocrine disruptors, such as methotrexate, bisphenol A, tetraoxydiphenyl dioxane, etc.; and occupational factors, such as work in hot environments, work exposed to radiation, etc. One should try to stay away from these risk factors.
Medication is preferred, but patients should be aware of the effects of medication and the duration of medication. The probability of pregnancy for azoospermia patients is 0. If there is sperm, there is a probability of pregnancy, but for male infertility patients, the worse the semen routine parameters are, the lower the probability of pregnancy is, the role of medication to improve the semen routine parameters is to improve the probability of pregnancy. The human spermatogenesis cycle is 70-74 days, about 3 months, so if you take empirical drug treatment, the course of treatment should generally have 1 to 2 spermatogenesis cycles, that is, 3-6 months, such as poor results, you need to consider assisted reproductive technology, rather than unlimited use of more expensive spermatogenic drugs; in the case of hypogonadotropic patients, the general duration of drug use is 12 to 18 months. Moreover, the medication should not be interrupted, because the spermatogenic cycle is continuous.
For artificial insemination, it is generally recommended to do 4 to 6 cycles continuously, the specific number of cycles is determined by the reproductive gynecologist, and the information shows that the cumulative success rate of 3 cycles of artificial insemination is about 20%. However, whether IUI can be done depends on the specific judgment of the semen upstream test, which generally requires the concentration of grade a and b sperm higher than 3X106/ml after semen upstream (or more than 30 grade a and b sperm per high magnification field of view after upstream).
In vitro fertilization (IVF), the world’s first IVF baby was born in 1978 in the United Kingdom through the joint efforts of Professor Edowrds and Dr. Steptoe, a miracle in the history of human medicine, for which Professor Edowrds was awarded the Nobel Prize in Medicine in 2010. This was the first generation of IVF, in which sperm and eggs were placed in the same medium and allowed to unite naturally, or “conventional fertilization” as it is known, but sometimes fertilization failed for various reasons. ICSI is an important tool to solve the problem of conventional fertilization failure and to achieve fertility with severe oligospermia and testicular sperm retrieval. Pre-implantation Genetic Disease Diagnosis (PGD), a third generation IVF technology, is mainly for couples with certain specific chromosomal abnormalities or hereditary diseases, which can be used to select normal embryos to obtain healthy offspring. In the IVF stage, generally women can only take more than 10 oocytes, and if more ovulation is promoted, the woman is prone to superovulation and danger; if the woman’s ovaries are not functioning well, even fewer oocytes will be taken, and for these oocyte numbers, the number of sperm available to the man is generally sufficient, so generally the man does not need to use expensive spermatogenic drugs.
The treatment of all diseases is the same and is based on the principle of moving from simple to complex and from non-invasive to invasive. It is not advisable to choose too high technology, because the higher the technology, the more human intervention, the more troublesome and costly; as long as the intervention, it is not the natural state, and the more intervention, the further away from the natural state, then the higher the potential genetic risk. So generally first medication, if it does not achieve the goal, then consider artificial insemination; if it does not achieve the goal, or can not do artificial insemination, then consider IVF.
Combined with the cases for analysis.
Case 1: The patient has been using spermatogenic drugs for 5 years, and the cost of the drugs has cost nearly 100,000, so the patient is advised to choose assisted reproductive technology. Current studies have shown that almost none of the pharmacological treatments for idiopathic male infertility have been proven effective by modern evidence-based medical evidence. However, some small sample studies suggest that some treatments may be effective in a small proportion of patients with idiopathic male infertility, and this retains some hope for further exploration of pharmacological treatments for idiopathic male infertility. 2010 European guidelines for male infertility clearly state that androgen therapy, chorionic/uremic therapy, bromocriptine, alpha-blockers, corticosteroids, and magnesium supplementation are not effective for idiopathic There are reports suggesting that anti-estrogen-androgen combinations and FSH therapy may be effective in a subset of patients with idiopathic male infertility, but further studies are needed; the only recommendation is for pharmacological treatment of patients with hypogonadotropic hypogonadism (which has been validated in clinical practice and is widely accepted). The male spermatogenesis process is 64 days, i.e., release from the basal membrane of the seminiferous tubules into the lumen; followed by maturation in the epididymis, which takes about 2 to 12 days (about 2 days on average for men with high sperm production and about 6 days for men with low sperm production), and a spermatogenic cycle takes about 3 months; therefore, if empirical drug treatment is taken, the course of treatment should be at least 1 to 2 spermatogenic cycles, i.e., 3 to 6 months, and the efficacy of empirical treatment is poor Therefore, it is generally necessary to consider assisted reproductive technology. This patient has been on medication for 5 years and should have opted for assisted reproductive technology long ago.
Case 2: The patient was on intermittent medication for a maximum of 2 weeks continuously. A spermatogenic cycle lasts about 3 months, so if empirical medication is taken, the course of treatment should be at least 1 to 2 spermatogenic cycles, so this patient is advised to undergo regular medication first.
Case 3: This patient entered the IVF stage and requested the most expensive and best medication. Because in the IVF stage, generally women can only take more than 10 egg cells, and for these number of egg cells, the male partner only needs to find 10 or so sperm, so the simplest and cheapest medication can be used.
Case 4: Male infertility patients entering the IVF stage directly request the second generation IVF technology. Because the higher the technology, the more human intervention, the more troublesome and costly it is; the more intervention is far from the natural state, then the higher the potential genetic risk, so this patient is advised to choose the first generation IVF technology first.
III. Summary
Medication, artificial insemination or IVF are the three axes of medical doctors to treat male infertility, and usually medication first; if it does not achieve the goal, then consider artificial insemination; if it does not achieve the goal, or cannot do artificial insemination, then consider IVF.