What’s New and What’s Rehash in the World of Male Infertility (Male Reproductive Medicine)

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#1)  Computer Assisted Semen Analysis (CASA)
Semen analysis has remained the cornerstone diagnostic test for male fertility evaluation for over a hundred years.  Typically, the test is performed by a technologist who assesses several characteristics of the specimen including volume, liquefication, pH, sperm density, motility and percent normal morphology.   Of course, inherent to that paradigm is the issue of variation in reports between different technologists and even by the same technologist on different days.    CASA eliminates that source of error as the computer will give the same answer day to day and different computers with the same software should, in theory, give the same interpretation.  CASA started about forty years ago, and, after many tweaks, now rivals manual semen analysis in assessment of sperm  concentration and determination of progressive motility; however, it still provides less than ideal comparison for sperm strict morphology.  CASA also has some difficulty in assessing the presence of debris, white blood cells and agglutination and may require manual input in cases of very low sperm concentration. 

Punchline,  At present CASA offers a higher cost option for a more rapid assessment of sperm concentration and motility for most samples;   Morphology is still better assessed by a technologist. 

The Yo Sperm test offers a home version of CASA (no morphology).  and now there are labs that offer the option of mailing in specimens for full analysis whether for standard analysis or CASA, though, again, mail in options are, as a rule, more expensive options. 

 

#2: Pre op imaging prior to surgical Sperm retrieval (SSR):    In cases of azoospermia (no sperm in the ejaculate), surgical sperm retrieval can sometimes find sperm within the testis and enable their use in an In Vitro Fertilization (IVF) cycle to initiate a pregnancy.    Odds of finding sperm in a SSR procedure differ depending on various factors including etiology of the azoospermia as well as hormone parameters and the findings on imaging, particularly in cases of non-obstructive azoospermia (NOA).

ULTRASOUND:  Ultrasound is an effective means of measuring testicular size and clearly smaller testes have, on average a worse prognosis.   Attempts have been made through a technique called Grey Scale ultrasound to determine the presence of larger tubules, Contrast Enhanced Ultrasound to determine the location of areas of greater testicular perfusion and Power Doppler ultrasound which again locates areas of higher vascularity.    However, data in improving the yield of SSR with any of these techniques is lacking.    More research is needed.

 

MRI:  Can also accurately assess testis volume, albeit at a much higher coast.

3) 4K-3d microscopy:  Orbeye4k-3D digital video microscope is likely a superior microscope with a $400,000 price tag but also likely delivers only equivalent results, though surgical times may be faster. 

4) Microfluidic Sorting:  imitates the pH and temperature conditions of the female reproductive tract within a fluid channel in an attempt to obtain higher quality sperm.  The Zymot microfluidic sperm selection device has been shown to result in specimens with diminished percentage of sperm dNA fragmentation.   Data showing clear advantage of using these techniques are still forthcoming.

5) Artificial intelligence:  used for morphology assessment prior to ICSI.  Motility has been correlated with the level of sperm DNA damage so, with AI, there may be improvements with respect to Sperm selection based on both motility and morphology.   Again, data on outcomes is lacking. 

 

In conclusion, most of the above is either fortunately or unfortunately either rehash or a promising new technology waiting to prove itself.  From the perspective of this author it is hard to understand why the above unproven or still evolving technologies were spotlighted while a new sperm function test with proven clinical utility was ignored.  That test is the Cap-score test which the author has written about previously and evaluates sperm capacitation as a metric to determine fertility

Author
Eric K. Seaman MD Dr. Seaman is a urologist specializing in the field of Male Reproductive Medicine and Surgery. Dr. Seaman Completed his Male Infertility Fellowship under the direction of Larry I. Lipshultz MD at Baylor College of Medicine Houston in 1996. Since that time he has focused his practice on the sub-subspecialty focus area of Male fertility and infertility.

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