This is measured by conducting a βhCG test on day 10 from the embryo transfer.

Our overall success rates numbers for all of our patients are over 40%. Please refer to the table above.

Couple with a good prognosis (Green), expect 40-60% fetal heart beat on ultrasound rate

MG + FG

MA + FG

Couple with average prognosis (Amber), expect 10-40% fetal heart beat on ultrasound rate

MA + FA

MP + FG

Couple with poor prognosis (Red), expect <10% fetal heart beat on ultrasound rate

MP + FP

MA + FP

MG + FP

This is measured by conducting a βhCG test on day 10 from the embryo transfer.

Our overall success rates numbers for all of our patients are over 40%. Please refer to the table above.

Couple with a good prognosis (Green), expect 40-60% fetal heart beat on ultrasound rate

MG + FG

MA + FG

Couple with average prognosis (Amber), expect 10-40% fetal heart beat on ultrasound rate

MA + FA

MP + FG

Couple with poor prognosis (Red), expect <10% fetal heart beat on ultrasound rate

MP + FP

MA + FP

MG + FP

This is measured by conducting a βhCG test on day 10 from the embryo transfer.

Our overall success rates numbers for all of our patients are over 40%. Please refer to the table above.

Couple with a good prognosis (Green), expect 40-60% fetal heart beat on ultrasound rate

MG + FG

MA + FG

Couple with average prognosis (Amber), expect 10-40% fetal heart beat on ultrasound rate

MA + FA

MP + FG

Couple with poor prognosis (Red), expect <10% fetal heart beat on ultrasound rate

MP + FP

MA + FP

MG + FP

Ovarian reserve is a term used to describe how fertile a woman is; the higher the ovarian reserve, the more likely the woman is to become pregnant. Women with low ovarian reserves can seek fertility treatment to increase their chances of pregnancy. One aspect of fertility treatment is using PRP to increase the ovarian reserve. PRP is injected into the ovaries, where the eggs are produced, so the growth factors can help heal the ovarian tissue and cells. New, healthy cells and tissues form which rejuvenates the ovaries and increased ovarian reserve. This is a very safealternative to contemporary fertility treatment such as IUI, IVF, and ICSI, when the ovarian reserve is the main reason for not becoming pregnant. It is also a beneficial addition to contemporary fertility treatment when the couple has multiple reasons for not being able to conceive naturally.

Ovarian reserve is a term used to describe how fertile a woman is; the higher the ovarian reserve, the more likely the woman is to become pregnant. Women with low ovarian reserves can seek fertility treatment to increase their chances of pregnancy. One aspect of fertility treatment is using PRP to increase the ovarian reserve. PRP is injected into the ovaries, where the eggs are produced, so the growth factors can help heal the ovarian tissue and cells. New, healthy cells and tissues form which rejuvenates the ovaries and increased ovarian reserve. This is a very safealternative to contemporary fertility treatment such as IUI, IVF, and ICSI, when the ovarian reserve is the main reason for not becoming pregnant. It is also a beneficial addition to contemporary fertility treatment when the couple has multiple reasons for not being able to conceive naturally.

Ovarian reserve is a term used to describe how fertile a woman is; the higher the ovarian reserve, the more likely the woman is to become pregnant. Women with low ovarian reserves can seek fertility treatment to increase their chances of pregnancy. One aspect of fertility treatment is using PRP to increase the ovarian reserve. PRP is injected into the ovaries, where the eggs are produced, so the growth factors can help heal the ovarian tissue and cells. New, healthy cells and tissues form which rejuvenates the ovaries and increased ovarian reserve. This is a very safealternative to contemporary fertility treatment such as IUI, IVF, and ICSI, when the ovarian reserve is the main reason for not becoming pregnant. It is also a beneficial addition to contemporary fertility treatment when the couple has multiple reasons for not being able to conceive naturally.

The endometrium is the innermost lining of the uterus. This lining should be made up of three, very smooth layers which will make it easy for the embryo to attach to. Sometimes, the endometrium is not smooth, and looks more like cauliflower, making it difficult for the embryo to attach. If the embryo is unable to attach, then normal menstruation will occur. Hysterosalpingo contrast sonography (hycosy) is a test to check the health of the endometrium. During the test, a catheter is placed through the vaginal opening, and into the uterus, using an ultrasound to guide the way. Special gel is then pushed through the catheter and will adhere to the endometrium, showing a clear image of how the tissue looks.

Both hyfosy and hycosy are effective, safe ways to show tubal patency and endometrium health. They do not contain any radiation nor harmful substances, and are quick, out-patient procedures that are very important when seeking guidance about fertility treatment.

The endometrium is the innermost lining of the uterus. This lining should be made up of three, very smooth layers which will make it easy for the embryo to attach to. Sometimes, the endometrium is not smooth, and looks more like cauliflower, making it difficult for the embryo to attach. If the embryo is unable to attach, then normal menstruation will occur. Hysterosalpingo contrast sonography (hycosy) is a test to check the health of the endometrium. During the test, a catheter is placed through the vaginal opening, and into the uterus, using an ultrasound to guide the way. Special gel is then pushed through the catheter and will adhere to the endometrium, showing a clear image of how the tissue looks.

Both hyfosy and hycosy are effective, safe ways to show tubal patency and endometrium health. They do not contain any radiation nor harmful substances, and are quick, out-patient procedures that are very important when seeking guidance about fertility treatment.

The endometrium is the innermost lining of the uterus. This lining should be made up of three, very smooth layers which will make it easy for the embryo to attach to. Sometimes, the endometrium is not smooth, and looks more like cauliflower, making it difficult for the embryo to attach. If the embryo is unable to attach, then normal menstruation will occur. Hysterosalpingo contrast sonography (hycosy) is a test to check the health of the endometrium. During the test, a catheter is placed through the vaginal opening, and into the uterus, using an ultrasound to guide the way. Special gel is then pushed through the catheter and will adhere to the endometrium, showing a clear image of how the tissue looks.

Both hyfosy and hycosy are effective, safe ways to show tubal patency and endometrium health. They do not contain any radiation nor harmful substances, and are quick, out-patient procedures that are very important when seeking guidance about fertility treatment.

Some common types of STIs/STDs:
(LGV) Lymphogranuloma venereum
Chlamydia
Gonorrhoea
HPV (human papilloma virus)
Syphilis
HSV (herpes simplex virus – type 2)
Trichomonas Gonorrhea
Ureaplasma parvum
Chancroid
Mycoplasma genitalium

Ways of testing/screening for STDs/STIs
Many STDs and STIs can be detected from a simple blood sample, while others can only be detected from urine or a swab (inside of mouth, urethra, cervix, discharge, or sores).

Why should you get a routine STD/STI screening?

All sexually active people can acquire, therefore, spread STDs and STIs, so routine screenings not only protect you, but your spouse and potential child as well. A routine STD/STI screening means that you get tested for STDs and STIs even though you are not showing symptoms. This routine screening is similar to other yearly health screening like female health screening (gynecological/pelvic exams), mammograms (breast health), and men health screenings. It is important to receive routine screenings because early detection of diseases means earlier treatment and better health.

We offer a partial and a full STD/STI screening package. The partial package (STD screening for PCR [polymerase chain reaction – an analytical laboratory technique]) uses a swab sample (vaginal, urine, urethral, semen) to test for Chlamydia, Gonorrhoea, Gardenerella, Trichomonas, Mycoplasma species, Ureaplasma species, and HSV 2. The full package includes both a blood test for HIV, HCV, HbSAg (hepatitis B antigen), and RPR (syphilis), and a swab tests for Chlamydia, Gonorrhoea, Gardnerella (bacertial vaginosis), Trichomonas, Mycoplasma, Ureaplasma, and HSV 2. We also offer individual STD/STI testing.

Some common types of STIs/STDs:
(LGV) Lymphogranuloma venereum
Chlamydia
Gonorrhoea
HPV (human papilloma virus)
Syphilis
HSV (herpes simplex virus – type 2)
Trichomonas Gonorrhea
Ureaplasma parvum
Chancroid
Mycoplasma genitalium

Ways of testing/screening for STDs/STIs
Many STDs and STIs can be detected from a simple blood sample, while others can only be detected from urine or a swab (inside of mouth, urethra, cervix, discharge, or sores).

Why should you get a routine STD/STI screening?

All sexually active people can acquire, therefore, spread STDs and STIs, so routine screenings not only protect you, but your spouse and potential child as well. A routine STD/STI screening means that you get tested for STDs and STIs even though you are not showing symptoms. This routine screening is similar to other yearly health screening like female health screening (gynecological/pelvic exams), mammograms (breast health), and men health screenings. It is important to receive routine screenings because early detection of diseases means earlier treatment and better health.

We offer a partial and a full STD/STI screening package. The partial package (STD screening for PCR [polymerase chain reaction – an analytical laboratory technique]) uses a swab sample (vaginal, urine, urethral, semen) to test for Chlamydia, Gonorrhoea, Gardenerella, Trichomonas, Mycoplasma species, Ureaplasma species, and HSV 2. The full package includes both a blood test for HIV, HCV, HbSAg (hepatitis B antigen), and RPR (syphilis), and a swab tests for Chlamydia, Gonorrhoea, Gardnerella (bacertial vaginosis), Trichomonas, Mycoplasma, Ureaplasma, and HSV 2. We also offer individual STD/STI testing.

Some common types of STIs/STDs:
(LGV) Lymphogranuloma venereum
Chlamydia
Gonorrhoea
HPV (human papilloma virus)
Syphilis
HSV (herpes simplex virus – type 2)
Trichomonas Gonorrhea
Ureaplasma parvum
Chancroid
Mycoplasma genitalium

Ways of testing/screening for STDs/STIs
Many STDs and STIs can be detected from a simple blood sample, while others can only be detected from urine or a swab (inside of mouth, urethra, cervix, discharge, or sores).

Why should you get a routine STD/STI screening?

All sexually active people can acquire, therefore, spread STDs and STIs, so routine screenings not only protect you, but your spouse and potential child as well. A routine STD/STI screening means that you get tested for STDs and STIs even though you are not showing symptoms. This routine screening is similar to other yearly health screening like female health screening (gynecological/pelvic exams), mammograms (breast health), and men health screenings. It is important to receive routine screenings because early detection of diseases means earlier treatment and better health.

We offer a partial and a full STD/STI screening package. The partial package (STD screening for PCR [polymerase chain reaction – an analytical laboratory technique]) uses a swab sample (vaginal, urine, urethral, semen) to test for Chlamydia, Gonorrhoea, Gardenerella, Trichomonas, Mycoplasma species, Ureaplasma species, and HSV 2. The full package includes both a blood test for HIV, HCV, HbSAg (hepatitis B antigen), and RPR (syphilis), and a swab tests for Chlamydia, Gonorrhoea, Gardnerella (bacertial vaginosis), Trichomonas, Mycoplasma, Ureaplasma, and HSV 2. We also offer individual STD/STI testing.

Day of Insemination

The Ericsson method is carried out on the day that the mother is expected to ovulate and involves separating the X (female) and Y (male) sperm and then artificially inseminating the selected sperm into the female. Careful tracking of the monthly cycle is highly advised, and no in-vitro fertilization is needed.

It relies on the fact that male and female sperm act in completely different ways; male sperm swim faster than females, although females are much more resilient and should live for longer.

Step 1:

On the morning of the expected ovulation, the couple will go to a medical facility and the male will provide a semen sample. If the couple has chosen to have a female sperm inseminated, the female will also take Clomid to aid the process of conceiving a female baby.

Step 2: Test tube separation of X and Y sperm

The sperm are placed into a test tube along with a substance called albumin in increasingly thickened layers. The sperm will then swim their way down through the different layers. Working on the principle that only the fastest sperm will make it to the bottom.

Step 3:

The selected sperm is then artificially inseminated into the female to await conception.

Success rate

The success rates of the Ericsson (albumin) method are more favourable for parents wanting to conceive a boy, with the success rate reaching around 65%. Whereas parents wanting a girl may find a success rate of around 60-62%.

Day of Insemination

The Ericsson method is carried out on the day that the mother is expected to ovulate and involves separating the X (female) and Y (male) sperm and then artificially inseminating the selected sperm into the female. Careful tracking of the monthly cycle is highly advised, and no in-vitro fertilization is needed.

It relies on the fact that male and female sperm act in completely different ways; male sperm swim faster than females, although females are much more resilient and should live for longer.

Step 1:

On the morning of the expected ovulation, the couple will go to a medical facility and the male will provide a semen sample. If the couple has chosen to have a female sperm inseminated, the female will also take Clomid to aid the process of conceiving a female baby.

Step 2: Test tube separation of X and Y sperm

The sperm are placed into a test tube along with a substance called albumin in increasingly thickened layers. The sperm will then swim their way down through the different layers. Working on the principle that only the fastest sperm will make it to the bottom.

Step 3:

The selected sperm is then artificially inseminated into the female to await conception.

Success rate

The success rates of the Ericsson (albumin) method are more favourable for parents wanting to conceive a boy, with the success rate reaching around 65%. Whereas parents wanting a girl may find a success rate of around 60-62%.

Day of Insemination

The Ericsson method is carried out on the day that the mother is expected to ovulate and involves separating the X (female) and Y (male) sperm and then artificially inseminating the selected sperm into the female. Careful tracking of the monthly cycle is highly advised, and no in-vitro fertilization is needed.

It relies on the fact that male and female sperm act in completely different ways; male sperm swim faster than females, although females are much more resilient and should live for longer.

Step 1:

On the morning of the expected ovulation, the couple will go to a medical facility and the male will provide a semen sample. If the couple has chosen to have a female sperm inseminated, the female will also take Clomid to aid the process of conceiving a female baby.

Step 2: Test tube separation of X and Y sperm

The sperm are placed into a test tube along with a substance called albumin in increasingly thickened layers. The sperm will then swim their way down through the different layers. Working on the principle that only the fastest sperm will make it to the bottom.

Step 3:

The selected sperm is then artificially inseminated into the female to await conception.

Success rate

The success rates of the Ericsson (albumin) method are more favourable for parents wanting to conceive a boy, with the success rate reaching around 65%. Whereas parents wanting a girl may find a success rate of around 60-62%.

Given a choice and medical assistance, some Couples seek to conceive a baby with their preferred gender, either a boy or a girl on social grounds for family balancing.

Occasionally gender selection with medical assistance is recommended on medical grounds to avoid certain genetic conditions that are predominantly seen either in male or female babies.

How gender is determined in natural pregnancies

The sex ratio for the entire world estimated in 2017 is 102 males to 100 females.

Gender is only determined by a sperm not an egg.

A healthy sperm that is carrying one Sex Chromosome called ‘Y’ plus 22 other critical chromosomes ( a total of 23 chromosomes) succeeds in fertilising a healthy egg that can only carry Sex Chromosome ‘X’ plus 22 other critical chromosomes (a total of 23 chromosomes) , results in male embryo that can subsequently develop to be a male child.

A healthy sperm that is carrying one Sex Chromosome called ‘X’ plus 22 other critical chromosomes (a total of 23 chromosomes) succeeds in fertilising a healthy egg that can only carry Sex Chromosome ‘X’ plus 22 other critical chromosomes ( a total of 23 chromosomes) , results in female embryo that can subsequently develop to be a female child.

Presence of all 46 chromosomes (as 23 pairs) including one X from egg and one Y from sperm is mandatory for male gender embryo to develop into a healthy foetus and one X from egg and one Y from is mandatory with their complete structure is essential

How gender can be determined before conception through Assisted Conception Techniques

Three Methods that are very reliable (close to 98-99%) for Gender identification of an embryo, from one to few cells biopsied, processed and genetically analysed, before it is transferred to women’s uterus, called Pre-implantation Genetic Tests (PGT).

This is relatively new technique and couple should be aware of:

– No guarantee of normal child being born despite genetic screening of embryos for gender,

– Costs and risks of IVF-ICSI and PGT including potential unknown risks yet to be identified.

– Risks of miscarriage

– Need for re-confirmatory gold standard tests recommended in pregnancy for chromosomal abnormalities (such as Chorion Villus Sampling, Amniocentesis) and detailed foetal anomaly ultrasound by licensed specialists.

THREE GENETIC SCREENING TESTS FOR GENDER IDENTIFICATION

1. Florescent in situ hybridization (FISH) accurately identifies the sex chromosome pair of XX (girl) or XY (boy) embryo and in addition can detect numerical problems of another 3 pairs of chromosomes; Chromosome Pairs 21, 18 and 13.

Merits:

Not only the gender of the embryo is accurately identified but this allows selection of embryos without any chromosomal abnormality in the specific 4 pairs of chromosomes, XX, XY, Chromosome pair 21, Chromosome pair 18, Chromosome pair 13). Consequently, there is a higher chance of a successful pregnancy, compared to those without embryo screening with FISH-PGT.

Similarly, deselection of embryos with abnormalities in any of the 4 pairs of chromosomes, example Down’s syndrome (chromosome pair 21) Edward’s syndrome (chromosome pair 18) Patau syndrome (chromosome pair 13) is expected to reduce the risk of miscarriage as most of the miscarriages are linked to chromosomal abnormalities.

In addition, it allows to couple to decide and avoid if they so wish, the risk of babies born with any of the above syndromes including those with sex chromosome abnormalities such as Turner Syndrome and Klinefelter’s syndrome associated with morbidity.

Relatively less expensive compared to aCGH and NGS

Demerits:

Incomplete genetic assessment as 19 out of 23 pairs of chromosomes are not tested for, therefore pregnancy may still not happen despite transfer of chosen gender embryos even of good grade.

• Array Comprehensive Genetic Hybridization (aCGH)

With this comprehensive genetic screening test, the Pair of Sex chromosomes (XX or XY) along with remaining 22 pairs of chromosomes are identified for their presence or absence and any structural abnormalities.

Merits: Complete genetic assessment of 23 pairs of chromosomes, therefore embryos with various numerical errors can be accurately identified allowing clinician and couple to select and deselect accordingly which embryos to transfer and which ones not to transfer.

Over and above the chosen gender, if present, much higher chance of success rates and less risk of miscarriage is as also expected as all 23 pairs are screened and only chromosomally normal embryos of preferred gender are utilised for embryo transfer.

Demerits: Relatively expensive compared to FISH

Detection Limits

1-2% false positive or false negative results

Limitations

Embryos with no results and the need for repeat biopsy.

Because of comprehensive screening of all 23 pairs, there is significantly higher risk of not having any suitable embryo to transfer despite finding embryos with chosen gender as these preferred gender embryos may carry abnormalities of any of the remaining 22 pairs, that precludes them from usage.

Limitations:

This popular test is gradually replaced with more advanced and sensitive genetic technique called Next Generation Sequencing (NGS)

• Next Generation Sequencing (NGS)

The Pair of Sex chromosomes (XX or XY) along with remaining 22 pairs of chromosomes are identified for their presence or absence and any structural abnormalities.

Merits: Complete genetic assessment of 23 pairs of chromosomes, therefore embryos with various numerical errors can be accurately identified allowing clinician and couple to select and deselect accordingly which embryos to transfer and which ones not to transfer.

Over and above the chosen gender, if present, much higher chance of success rates and less risk of miscarriage is as also expected as all 23 pairs are screened, and only chromosomally normal embryos of preferred gender are utilised for embryo transfer.

Demerits: Relatively expensive compared to FISH

Detection Limits

1-2% false positive or false negative results

Limitations

Embryos with no results and the need for repeat biopsy.

Methods that are less reliable and unavailable in UAE

There is a technique with limited evidence called Sperm Sorting Technique that will pool sperm sample with higher proportion of ‘Y’ chromosome containing sperm or ‘X’ containing sperm but there will always be mixture of both ‘Y’ and ‘X’ carrying sperm in the same sample therefore, false positive and false negative outcomes of Gender Identification.

Enriched mixed sample of both Y and X carrying Sperms but with higher proportion of either ‘Y’ or ‘X’ carrying sperm can then be used either for intrauterine insemination or in vitro fertilization or ICSI

Details of the procedure involved

Detailed Patient Information Sheet on IVF-ICSI, complications of IVF-ICSI and Pre-implantation Genetic Testing are available on request.

Given a choice and medical assistance, some Couples seek to conceive a baby with their preferred gender, either a boy or a girl on social grounds for family balancing.

Occasionally gender selection with medical assistance is recommended on medical grounds to avoid certain genetic conditions that are predominantly seen either in male or female babies.

How gender is determined in natural pregnancies

The sex ratio for the entire world estimated in 2017 is 102 males to 100 females.

Gender is only determined by a sperm not an egg.

A healthy sperm that is carrying one Sex Chromosome called ‘Y’ plus 22 other critical chromosomes ( a total of 23 chromosomes) succeeds in fertilising a healthy egg that can only carry Sex Chromosome ‘X’ plus 22 other critical chromosomes (a total of 23 chromosomes) , results in male embryo that can subsequently develop to be a male child.

A healthy sperm that is carrying one Sex Chromosome called ‘X’ plus 22 other critical chromosomes (a total of 23 chromosomes) succeeds in fertilising a healthy egg that can only carry Sex Chromosome ‘X’ plus 22 other critical chromosomes ( a total of 23 chromosomes) , results in female embryo that can subsequently develop to be a female child.

Presence of all 46 chromosomes (as 23 pairs) including one X from egg and one Y from sperm is mandatory for male gender embryo to develop into a healthy foetus and one X from egg and one Y from is mandatory with their complete structure is essential

How gender can be determined before conception through Assisted Conception Techniques

Three Methods that are very reliable (close to 98-99%) for Gender identification of an embryo, from one to few cells biopsied, processed and genetically analysed, before it is transferred to women’s uterus, called Pre-implantation Genetic Tests (PGT).

This is relatively new technique and couple should be aware of:

– No guarantee of normal child being born despite genetic screening of embryos for gender,

– Costs and risks of IVF-ICSI and PGT including potential unknown risks yet to be identified.

– Risks of miscarriage

– Need for re-confirmatory gold standard tests recommended in pregnancy for chromosomal abnormalities (such as Chorion Villus Sampling, Amniocentesis) and detailed foetal anomaly ultrasound by licensed specialists.

THREE GENETIC SCREENING TESTS FOR GENDER IDENTIFICATION

1. Florescent in situ hybridization (FISH) accurately identifies the sex chromosome pair of XX (girl) or XY (boy) embryo and in addition can detect numerical problems of another 3 pairs of chromosomes; Chromosome Pairs 21, 18 and 13.

Merits:

Not only the gender of the embryo is accurately identified but this allows selection of embryos without any chromosomal abnormality in the specific 4 pairs of chromosomes, XX, XY, Chromosome pair 21, Chromosome pair 18, Chromosome pair 13). Consequently, there is a higher chance of a successful pregnancy, compared to those without embryo screening with FISH-PGT.

Similarly, deselection of embryos with abnormalities in any of the 4 pairs of chromosomes, example Down’s syndrome (chromosome pair 21) Edward’s syndrome (chromosome pair 18) Patau syndrome (chromosome pair 13) is expected to reduce the risk of miscarriage as most of the miscarriages are linked to chromosomal abnormalities.

In addition, it allows to couple to decide and avoid if they so wish, the risk of babies born with any of the above syndromes including those with sex chromosome abnormalities such as Turner Syndrome and Klinefelter’s syndrome associated with morbidity.

Relatively less expensive compared to aCGH and NGS

Demerits:

Incomplete genetic assessment as 19 out of 23 pairs of chromosomes are not tested for, therefore pregnancy may still not happen despite transfer of chosen gender embryos even of good grade.

• Array Comprehensive Genetic Hybridization (aCGH)

With this comprehensive genetic screening test, the Pair of Sex chromosomes (XX or XY) along with remaining 22 pairs of chromosomes are identified for their presence or absence and any structural abnormalities.

Merits: Complete genetic assessment of 23 pairs of chromosomes, therefore embryos with various numerical errors can be accurately identified allowing clinician and couple to select and deselect accordingly which embryos to transfer and which ones not to transfer.

Over and above the chosen gender, if present, much higher chance of success rates and less risk of miscarriage is as also expected as all 23 pairs are screened and only chromosomally normal embryos of preferred gender are utilised for embryo transfer.

Demerits: Relatively expensive compared to FISH

Detection Limits

1-2% false positive or false negative results

Limitations

Embryos with no results and the need for repeat biopsy.

Because of comprehensive screening of all 23 pairs, there is significantly higher risk of not having any suitable embryo to transfer despite finding embryos with chosen gender as these preferred gender embryos may carry abnormalities of any of the remaining 22 pairs, that precludes them from usage.

Limitations:

This popular test is gradually replaced with more advanced and sensitive genetic technique called Next Generation Sequencing (NGS)

• Next Generation Sequencing (NGS)

The Pair of Sex chromosomes (XX or XY) along with remaining 22 pairs of chromosomes are identified for their presence or absence and any structural abnormalities.

Merits: Complete genetic assessment of 23 pairs of chromosomes, therefore embryos with various numerical errors can be accurately identified allowing clinician and couple to select and deselect accordingly which embryos to transfer and which ones not to transfer.

Over and above the chosen gender, if present, much higher chance of success rates and less risk of miscarriage is as also expected as all 23 pairs are screened, and only chromosomally normal embryos of preferred gender are utilised for embryo transfer.

Demerits: Relatively expensive compared to FISH

Detection Limits

1-2% false positive or false negative results

Limitations

Embryos with no results and the need for repeat biopsy.

Methods that are less reliable and unavailable in UAE

There is a technique with limited evidence called Sperm Sorting Technique that will pool sperm sample with higher proportion of ‘Y’ chromosome containing sperm or ‘X’ containing sperm but there will always be mixture of both ‘Y’ and ‘X’ carrying sperm in the same sample therefore, false positive and false negative outcomes of Gender Identification.

Enriched mixed sample of both Y and X carrying Sperms but with higher proportion of either ‘Y’ or ‘X’ carrying sperm can then be used either for intrauterine insemination or in vitro fertilization or ICSI

Details of the procedure involved

Detailed Patient Information Sheet on IVF-ICSI, complications of IVF-ICSI and Pre-implantation Genetic Testing are available on request.

Given a choice and medical assistance, some Couples seek to conceive a baby with their preferred gender, either a boy or a girl on social grounds for family balancing.

Occasionally gender selection with medical assistance is recommended on medical grounds to avoid certain genetic conditions that are predominantly seen either in male or female babies.

How gender is determined in natural pregnancies

The sex ratio for the entire world estimated in 2017 is 102 males to 100 females.

Gender is only determined by a sperm not an egg.

A healthy sperm that is carrying one Sex Chromosome called ‘Y’ plus 22 other critical chromosomes ( a total of 23 chromosomes) succeeds in fertilising a healthy egg that can only carry Sex Chromosome ‘X’ plus 22 other critical chromosomes (a total of 23 chromosomes) , results in male embryo that can subsequently develop to be a male child.

A healthy sperm that is carrying one Sex Chromosome called ‘X’ plus 22 other critical chromosomes (a total of 23 chromosomes) succeeds in fertilising a healthy egg that can only carry Sex Chromosome ‘X’ plus 22 other critical chromosomes ( a total of 23 chromosomes) , results in female embryo that can subsequently develop to be a female child.

Presence of all 46 chromosomes (as 23 pairs) including one X from egg and one Y from sperm is mandatory for male gender embryo to develop into a healthy foetus and one X from egg and one Y from is mandatory with their complete structure is essential

How gender can be determined before conception through Assisted Conception Techniques

Three Methods that are very reliable (close to 98-99%) for Gender identification of an embryo, from one to few cells biopsied, processed and genetically analysed, before it is transferred to women’s uterus, called Pre-implantation Genetic Tests (PGT).

This is relatively new technique and couple should be aware of:

– No guarantee of normal child being born despite genetic screening of embryos for gender,

– Costs and risks of IVF-ICSI and PGT including potential unknown risks yet to be identified.

– Risks of miscarriage

– Need for re-confirmatory gold standard tests recommended in pregnancy for chromosomal abnormalities (such as Chorion Villus Sampling, Amniocentesis) and detailed foetal anomaly ultrasound by licensed specialists.

THREE GENETIC SCREENING TESTS FOR GENDER IDENTIFICATION

1. Florescent in situ hybridization (FISH) accurately identifies the sex chromosome pair of XX (girl) or XY (boy) embryo and in addition can detect numerical problems of another 3 pairs of chromosomes; Chromosome Pairs 21, 18 and 13.

Merits:

Not only the gender of the embryo is accurately identified but this allows selection of embryos without any chromosomal abnormality in the specific 4 pairs of chromosomes, XX, XY, Chromosome pair 21, Chromosome pair 18, Chromosome pair 13). Consequently, there is a higher chance of a successful pregnancy, compared to those without embryo screening with FISH-PGT.

Similarly, deselection of embryos with abnormalities in any of the 4 pairs of chromosomes, example Down’s syndrome (chromosome pair 21) Edward’s syndrome (chromosome pair 18) Patau syndrome (chromosome pair 13) is expected to reduce the risk of miscarriage as most of the miscarriages are linked to chromosomal abnormalities.

In addition, it allows to couple to decide and avoid if they so wish, the risk of babies born with any of the above syndromes including those with sex chromosome abnormalities such as Turner Syndrome and Klinefelter’s syndrome associated with morbidity.

Relatively less expensive compared to aCGH and NGS

Demerits:

Incomplete genetic assessment as 19 out of 23 pairs of chromosomes are not tested for, therefore pregnancy may still not happen despite transfer of chosen gender embryos even of good grade.

• Array Comprehensive Genetic Hybridization (aCGH)

With this comprehensive genetic screening test, the Pair of Sex chromosomes (XX or XY) along with remaining 22 pairs of chromosomes are identified for their presence or absence and any structural abnormalities.

Merits: Complete genetic assessment of 23 pairs of chromosomes, therefore embryos with various numerical errors can be accurately identified allowing clinician and couple to select and deselect accordingly which embryos to transfer and which ones not to transfer.

Over and above the chosen gender, if present, much higher chance of success rates and less risk of miscarriage is as also expected as all 23 pairs are screened and only chromosomally normal embryos of preferred gender are utilised for embryo transfer.

Demerits: Relatively expensive compared to FISH

Detection Limits

1-2% false positive or false negative results

Limitations

Embryos with no results and the need for repeat biopsy.

Because of comprehensive screening of all 23 pairs, there is significantly higher risk of not having any suitable embryo to transfer despite finding embryos with chosen gender as these preferred gender embryos may carry abnormalities of any of the remaining 22 pairs, that precludes them from usage.

Limitations:

This popular test is gradually replaced with more advanced and sensitive genetic technique called Next Generation Sequencing (NGS)

• Next Generation Sequencing (NGS)

The Pair of Sex chromosomes (XX or XY) along with remaining 22 pairs of chromosomes are identified for their presence or absence and any structural abnormalities.

Merits: Complete genetic assessment of 23 pairs of chromosomes, therefore embryos with various numerical errors can be accurately identified allowing clinician and couple to select and deselect accordingly which embryos to transfer and which ones not to transfer.

Over and above the chosen gender, if present, much higher chance of success rates and less risk of miscarriage is as also expected as all 23 pairs are screened, and only chromosomally normal embryos of preferred gender are utilised for embryo transfer.

Demerits: Relatively expensive compared to FISH

Detection Limits

1-2% false positive or false negative results

Limitations

Embryos with no results and the need for repeat biopsy.

Methods that are less reliable and unavailable in UAE

There is a technique with limited evidence called Sperm Sorting Technique that will pool sperm sample with higher proportion of ‘Y’ chromosome containing sperm or ‘X’ containing sperm but there will always be mixture of both ‘Y’ and ‘X’ carrying sperm in the same sample therefore, false positive and false negative outcomes of Gender Identification.

Enriched mixed sample of both Y and X carrying Sperms but with higher proportion of either ‘Y’ or ‘X’ carrying sperm can then be used either for intrauterine insemination or in vitro fertilization or ICSI

Details of the procedure involved

Detailed Patient Information Sheet on IVF-ICSI, complications of IVF-ICSI and Pre-implantation Genetic Testing are available on request.

CAUSES

Pretesticular (1%):

Gonadotrophin deficiency (Hypothalamic/ Pituitary disease) examples; Kallman syndrome, tumours, radiation, surgery,

Hyperprolactinaemia, hyper‐or hypothyroidism, Hormones Intake (anabolic steroids, glucocorticoid excess).

Most of these can be treated with hormone manipulation

Testicular (Majority of Causes):

Idiopathic: (almost 50%)

Congenital: Chromosomal (Kleinfelter syndrome 47, XXY), Y chromosome microdeletions, Noonan syndrome (male Turner syndrome 45, XO), Undescended Tests (Cryptorchidism)

Acquired: Infection/Injury (orchitis, torsion, trauma), Varicocele*, Severe systemic disease (renal failure, liver failure), Testicular tumours, Chemotherapy, radiotherapy

*Varicoceles, a collection of dilated refluxing veins in the spermatic cord, are found twice commonly in men with abnormal semen compared to those with normal semen. (25% vs 12%). It is believed that increased scrotal heating and altered testicular steroidogenesis affects semen quality, but the evidence is limited.

These conditions are largely irreversible but can be treated with assisted reproductive technology (ART), if sperm is retrievable. The diagnosis is based on reduction in testicular size and elevation of serum FSH levels and in the majority of cases (66%) the cause is unknown.

Post‐testicular (anatomical or functional obstruction):

Excluding Vasectomy, 40% of azospermia cases are due to obstruction, and with ART these men can achieve pregnancy after sperm retrieval.

Congenital: Cystic fibrosis, congenital absence of the vas deferens (CAVD), Young’s syndrome

Acquired: Infection (chlamydia, gonorrhoea), Vasectomy, Iatrogenic vasal injury

Disorders of sperm function or motility: Globozoospermia (100% round heads), Maturation defects, Immunological infertility, Immotile cilia syndrome

The diagnosis is based on normal serum FSH levels, normal testicular volume and evidence of complete spermatogenesis on biopsy.

These conditions can be treated with microsurgery or with ART

Sexual dysfunction:

Erectile/ ejaculatory dysfunction, Inappropriate timing and frequency of intercourse. Diabetes mellitus, multiple sclerosis, spinal cord/pelvic injuries.

DETAILED HISTORY

Male age

A UK study has shown that paternal age of >35 years halves the chance of achieving a pregnancy compared with a paternal age of <25 years and drop in fertility is worse after the age of 50. There are also studies showing increase in adverse outcome in the offspring.

Environmental, occupational and lifestyle factors: Obesity, Alcohol, Tobacco, Oxidative stress,

Obesity

Through an imbalance of reproductive hormone (reduced sex hormone binding globulin and elevated oestrogen levels), amongst others, obesity is associated with poor semen quality. In addition, sexual dysfunction is also more common in obese men possibly from altered metabolism of environmental toxins, and sedentary lifestyle.

Alcohol

Heavy alcohol consumption affects sexual and reproductive performance in a reversible fashion.

Tobacco

Tobacco smoking and cannabis consumption have been shown to reduce semen parameters and men with suboptimal semen quality may benefit from quitting smoking and this should be strongly encouraged. Other recreational drugs such as cocaine, amphetamines and opiates may adversely affect reproductive performance due to decreased libido and erectile dysfunction.

Oxidative Stress

There is limited evidence for, sperm DNA damage secondary to oxidative stress may be the cause of between 30% and 80% of male subfertility cases. Recent evidence suggests that antioxidant supplementation in subfertile males, including carnitines, vitamin C, vitamin E, selenium, zinc and coenzyme Q10, improves semen quality and live birth rates in couples undergoing fertility treatment.

More than 104 000 such chemicals and physical agents (environmental, occupational) have been identified that can affect semen quality; heat, X‐rays, heavy metals (lead, mercury), glycol ethers (highly volatile compounds used as solvents) and pesticides. The level of environmental estrogens would not appear to be a threat to male reproductive health.

Recent observational studies support a dose‐dependent decrease in semen parameters related to exposure to electromagnetic waves emitted from mobile phones, but there is still no clear clinical significance of this.

There is evidence that a sedentary lifestyle, Testicular hyperthermia, can affect sperm production and semen quality, but no clear proof that wearing loose‐fitting underwear improves fertility.

Abuse

Usage of Anabolic‐androgenic steroids severely affects sperm quality and testosterone production and therefore can lead to azoospermia and erectile dysfunction, by interfering with the hypothalamic‐pituitary‐gonadal (HPG) axis. Azoospermia may be reversed by conservative management when the drugs are discontinued for 4-12 months and in some cases by administration of human chorionic gonadotrophin and human menopausal gonadotrophin.

A lot of ‘steroid‐free’ dietary supplements have been reported to be contaminated with traces of hormones.

EVALUATION

History, physical examination together with the semen analysis is standard initial evaluation of most men, followed by special tests in selected cases.

Fertility history: Previous pregnancies – with current and previous partners, Duration of infertility, Previous infertility treatments

Sexual history: Erection or ejaculation problems & Frequency and timings of intercourse

Social history: Alcohol, smoking, usage of anabolic steroids, recreational drugs, Exposure to ionising radiation (X-Rays), Chronic heat exposure, Aniline dyes, Pesticides and Lead exposure

Medical history: Recent pyrexia/ illness, Systemic illness – diabetes mellitus, cancer, infection. Genetic disorders – cystic fibrosis, Klinefelter syndrome

Surgical history: Undescended testes, orchidopexy, Hernia repair, Testicular trauma, torsion, Pelvic, bladder or retroperitoneal surgery

Medication: Nitrofurantoin, cimetidine, sulfasalazine, spironolactone, α‐blockers, methotrexate, colchicine, amiodarone, antidepressants, phenothiazines, chemotherapy

Physical examination

Signs of decreased body hair or gynaecomastia, the height, weight, BMI and blood pressure should be noted.

Scrotal examination in the standing position should establish presence of normal, size (mean volume of 20 ml) and firm consistency testes on both sides, with non- tender and un-distended epididymis, and presence of vas difference, and absence of “bag of worms” suggestive of varicoceles during Valsalva manoeuvre.

Micro Penis, hypospadias should be looked for. And a rectal examination will provide clues on prostate abnormalities or seminal vesicle enlargement.

INVESTIGATIONS

Semen analysis is the most important investigation of male and is a guide for minimal standards of adequacy fertility (5^th percentile of semen characteristics of men initiating natural conception within 12 months of unprotected intercourse: WHO 2010). These minimum values do not imply proof of male fertility.

Semen analysis must be done at a qualified lab after 3-5 days abstinence and if an abnormality is detected a repeat semen analysis should be performed after 3 months, or sooner if the initial test shows azoospermia. The entire ejaculate should be collected, and the sample should be analysed within an hour of collection because sperm motility decreases after ejaculation. If produced at home, the sample should be kept at body temperature during transport.

Fresh semen is coagulated and liquefies 15–30 minutes after ejaculation. Low ejaculate volumes of <1.5 ml may not buffer against vaginal acidity sufficiently and may indicate retrograde ejaculation, obstruction, androgen deficiency, incomplete collection or anejaculation.

Endocrine tests

In men with Oligospermia (sperm counts of <5 × 10⁶ ml) and or impaired sexual function (erectile dysfunction, reduced libido, symptomatic hypothyroid, endocrine evaluation should include, FSH, LH, testosterone and prolactin in an early morning blood sample to assess normality of Hypothalamic-pituitary-gonadal (HPG). FSH reflects sperm production. Low testosterone levels with high FSH and LH indicate primary testicular failure whereas low testosterone levels in combination with low LH and FSH levels indicate a central defect with secondary hypogonadism. Azoospermia in combination with normal hormone levels suggests an obstructive cause.

Genetic evaluation

A karyotype is indicated in cases of severe oligospermia (<1 × 10⁶ ml) or azoospermia to identify Klinefelter syndrome (47, XXY) microdeletions on the long arm of the Y chromosome (Yq). This region includes the Azoospermia Factor (AZF) locus, which contains three subregions: AZFa, AZFb, and AZFc. AZFc micro‐deletions have a good prognosis for surgical sperm recovery whereas the prognostic value for sperm recovery in AZFa and AZFb micro‐deletions is poor. All men with idiopathic obstructive azoospermia and those with non‐palpable vas deferens (CBAVD) should be tested for mutations in the cystic fibrosis gene as they can be associated with cystic fibrosis carrier status.

Imaging

Scrotal ultrasound should be performed if an abnormality such as a testicular tumour is detected on physical examination. Ultrasound can also be useful in the clinical diagnosis of varicocele, especially with the use of colour flow Doppler and demonstration of retrograde blood flow with a Valsalva manoeuvre. If an absent vas is detected on examination, a renal ultrasound scan is recommended, as up to 30% of such men may have a renal abnormality.

Testicular biopsy

Testicular biopsy can aid the diagnosis of azoospermia and facilitate sperm recovery for intracytoplasmic sperm injection (ICSI) use. Biopsy can be done by an open/microscopic or percutaneous needle approach and is used to obtain a small piece of testicular tissue for histological examination and if sperm found for ICSI or cryopreservation. Testicular biopsy specimens can be classified histologically:

• normal (appropriate number of cells with complete spermatogenesis)
• hypo-spermatogenesis (all cell types present and in correct ratio but at reduced cell numbers)
• maturation arrest (failure of spermatogenesis beyond a certain stage; can be ‘early’ or ‘late’)
• sertoli cell‐only (del Castillo) syndrome (no germ cells).

In some cases, complex mixtures of pathological patterns may be present.

Other sperm function tests

Routine semen analysis provides information about spermatogenesis and sperm delivery, but the functional ability of sperm is difficult to ascertain. Sperm DNA fragmentation has been shown to be a robust predictor of assisted reproductive outcomes. Sperm DNA tests such as the sperm chromatin structure assay (SCSA), the comet assay and the TUNEL (terminal deoxynucleotidyl transferase‐mediated dUTP nick end‐labelling) assay, which assess sperm DNA integrity, show promise both as diagnostic tests for male infertility and prognostic tests for the outcome of assisted reproductive technologies. Their clinical application, however, needs further evaluation and improvement.

TREATMENT OPTIONS

Medical treatment

Specific hormonal treatments are effective for hyperprolactinaemia, hypothyroidism and congenital adrenal hyperplasia. Hypo-gonadotrophic hypogonadism can be treated successfully with GnRH or exogenous gonadotrophins. However medical treatments have a limited role in idiopathic male infertility as there is no treatable cause in over 50% of these cases.

Primary testicular failure

There is no effective treatment to restore fertility in primary testicular failure. Men undergoing treatments that contribute to infertility, such as chemotherapy, should be offered the opportunity to cryopreserve semen. Alternatively, surgical sperm retrieval with assisted reproduction can be attempted and the prognosis depends on the underlying pathology and the quality of sperm that can be found even with microscopic sperm retrieval.

Urological surgery

Reversal of vasectomy

The success rates for vasectomy reversal depend on the skill of the operating surgeon, surgical technique and the time from the initial surgery. Patency rates seem to decline with increasing time due to the increasing rates of anti‐sperm antibody development and secondary epididymal obstruction.

Surgical sperm retrieval

Techniques for sperm retrieval from the testes include testicular sperm aspiration (TESA), testicular sperm extraction (TESE) and microsurgical TESE (micro‐TESE) performed under local combined with regional or general anaesthesia. The results of a single biopsy may not be indicative of the spermatogenic process in the whole of the testis and multiple biopsies may be necessary both to find treatment suitable sperm and or to diagnose testicular pathology.

Sperm from the epididymis can be retrieved by microsurgical (MESA) or percutaneous (PESA) epididymal sperm aspiration under local anaesthetic.

Sperm can be retrieved from the testes or the epididymis for use in IVF/ICSI. Common indications include obstructive causes, severe male factor infertility or ejaculatory failure (sperm retrieval by Rectal Electro Ejaculation). Testicular biopsy should be done in a tertiary centre with facilities for sperm cryopreservation.

Success rates for surgical sperm retrieval of almost 100% have been reported in obstructive cases, with lower rates of approximately 50% in non‐obstructive cases. A meta‐analysis of the use of surgical sperm retrieval in azoospermic men, showed the outcome of ICSI cycles in terms of fertilisation rates and clinical pregnancy rates to be significantly higher with the use of sperm from men with obstructive azoospermia as compared with non‐obstructive azoospermia.

Varicocele repair

Recent evidence from a randomised control trial indicates that varicocelectomy in infertile men with impaired semen quality and palpable varicoceles (clinically evident bilateral), significantly improves semen characteristics and the chances of pregnancy within 1 year of follow‐up. Varicocelectomy may also correct the serum testosterone deficit in men with varicocele and low testosterone levels.

Assisted reproduction

Intrauterine insemination (IUI)

IUI involves the placement of a washed pellet of ejaculated sperm within the uterine cavity, thus bypassing the cervical barrier. It can be performed with or without ovarian stimulation. Indications include mild male factor infertility, immunologic infertility and mechanical problems of sperm delivery such as erectile dysfunction or hypospadias.

National Institute for Clinical Excellence (NICE), United Kingdom recommends that IUI is used in mild forms of oligozoospermia (reduced number of sperms) usually no less than 5 million motile sperm. Monthly conception rates of 8–16% have been reported for IUI and therefore, NICE currently recommends the use of up to six cycles of unstimulated IUI in mild cases of male factor infertility to optimize chances of successful pregnancy and reduce the risk of multiple pregnancies.

In vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI)

Although IVF can be used to treat milder forms of sperm abnormalities, more severe forms require ICSI. ICSI was originally described in 1988 and has since revolutionised the treatment of male factor infertility. It involves the micromanipulation and injection of a single human sperm into the cytoplasm of the oocyte. ICSI requires ovarian stimulation, oocyte retrieval and sperm preparation as for IVF. It is used for un‐correctable severe forms of male factor infertility including oligospermia and asthenoteratozoospermia (OATS), or following fertilisation failure in a previous IVF cycle. Average pregnancy rates of 33.0% per embryo transfer have been reported after ICSI.

Ethical issues

Recent data suggest that offspring born to infertile couples using ICSI have a higher incidence of chromosomal anomalies than do children who are naturally conceived.

Possible mechanism for this could be that ICSI bypasses the natural barriers to fertilisation and therefore there is the potential risk of propagation of genetic defects that may re‐surface in the male offspring of treatable infertile men. This could potentially lead to the creation of a population of subfertile men and couple are to be fully counselled on this concern.

‘Artificial’ haploid gametes have been successfully created in vitro from embryonic stem cells in animal models. These gametes have been used to create live offspring in mice. Human trials is unlikely to progress due to strong ethical reasons.

Conclusion

Male infertility is a common problem that requires appropriate specialist referral. Assessment should include full clinical history and careful examination. Semen analysis remains the main initial investigation that guides further assessment of the infertile male. Advances in research have increased the treatment options available for male infertility. The potential for ICSI to propagate genetic abnormalities warrants thorough counselling for couples regarding the possible implications of its use, prior to treatment starting. The health and wellbeing of children following ICSI requires long‐term follow‐up.

In the future, a better understanding of the causes of male infertility and new reproductive technologies may offer the possibility of novel treatments, but these need to be carried out within the appropriate ethical framework.

CAUSES

Pretesticular (1%):

Gonadotrophin deficiency (Hypothalamic/ Pituitary disease) examples; Kallman syndrome, tumours, radiation, surgery,

Hyperprolactinaemia, hyper‐or hypothyroidism, Hormones Intake (anabolic steroids, glucocorticoid excess).

Most of these can be treated with hormone manipulation

Testicular (Majority of Causes):

Idiopathic: (almost 50%)

Congenital: Chromosomal (Kleinfelter syndrome 47, XXY), Y chromosome microdeletions, Noonan syndrome (male Turner syndrome 45, XO), Undescended Tests (Cryptorchidism)

Acquired: Infection/Injury (orchitis, torsion, trauma), Varicocele*, Severe systemic disease (renal failure, liver failure), Testicular tumours, Chemotherapy, radiotherapy

*Varicoceles, a collection of dilated refluxing veins in the spermatic cord, are found twice commonly in men with abnormal semen compared to those with normal semen. (25% vs 12%). It is believed that increased scrotal heating and altered testicular steroidogenesis affects semen quality, but the evidence is limited.

These conditions are largely irreversible but can be treated with assisted reproductive technology (ART), if sperm is retrievable. The diagnosis is based on reduction in testicular size and elevation of serum FSH levels and in the majority of cases (66%) the cause is unknown.

Post‐testicular (anatomical or functional obstruction):

Excluding Vasectomy, 40% of azospermia cases are due to obstruction, and with ART these men can achieve pregnancy after sperm retrieval.

Congenital: Cystic fibrosis, congenital absence of the vas deferens (CAVD), Young’s syndrome

Acquired: Infection (chlamydia, gonorrhoea), Vasectomy, Iatrogenic vasal injury

Disorders of sperm function or motility: Globozoospermia (100% round heads), Maturation defects, Immunological infertility, Immotile cilia syndrome

The diagnosis is based on normal serum FSH levels, normal testicular volume and evidence of complete spermatogenesis on biopsy.

These conditions can be treated with microsurgery or with ART

Sexual dysfunction:

Erectile/ ejaculatory dysfunction, Inappropriate timing and frequency of intercourse. Diabetes mellitus, multiple sclerosis, spinal cord/pelvic injuries.

DETAILED HISTORY

Male age

A UK study has shown that paternal age of >35 years halves the chance of achieving a pregnancy compared with a paternal age of <25 years and drop in fertility is worse after the age of 50. There are also studies showing increase in adverse outcome in the offspring.

Environmental, occupational and lifestyle factors: Obesity, Alcohol, Tobacco, Oxidative stress,

Obesity

Through an imbalance of reproductive hormone (reduced sex hormone binding globulin and elevated oestrogen levels), amongst others, obesity is associated with poor semen quality. In addition, sexual dysfunction is also more common in obese men possibly from altered metabolism of environmental toxins, and sedentary lifestyle.

Alcohol

Heavy alcohol consumption affects sexual and reproductive performance in a reversible fashion.

Tobacco

Tobacco smoking and cannabis consumption have been shown to reduce semen parameters and men with suboptimal semen quality may benefit from quitting smoking and this should be strongly encouraged. Other recreational drugs such as cocaine, amphetamines and opiates may adversely affect reproductive performance due to decreased libido and erectile dysfunction.

Oxidative Stress

There is limited evidence for, sperm DNA damage secondary to oxidative stress may be the cause of between 30% and 80% of male subfertility cases. Recent evidence suggests that antioxidant supplementation in subfertile males, including carnitines, vitamin C, vitamin E, selenium, zinc and coenzyme Q10, improves semen quality and live birth rates in couples undergoing fertility treatment.

More than 104 000 such chemicals and physical agents (environmental, occupational) have been identified that can affect semen quality; heat, X‐rays, heavy metals (lead, mercury), glycol ethers (highly volatile compounds used as solvents) and pesticides. The level of environmental estrogens would not appear to be a threat to male reproductive health.

Recent observational studies support a dose‐dependent decrease in semen parameters related to exposure to electromagnetic waves emitted from mobile phones, but there is still no clear clinical significance of this.

There is evidence that a sedentary lifestyle, Testicular hyperthermia, can affect sperm production and semen quality, but no clear proof that wearing loose‐fitting underwear improves fertility.

Abuse

Usage of Anabolic‐androgenic steroids severely affects sperm quality and testosterone production and therefore can lead to azoospermia and erectile dysfunction, by interfering with the hypothalamic‐pituitary‐gonadal (HPG) axis. Azoospermia may be reversed by conservative management when the drugs are discontinued for 4-12 months and in some cases by administration of human chorionic gonadotrophin and human menopausal gonadotrophin.

A lot of ‘steroid‐free’ dietary supplements have been reported to be contaminated with traces of hormones.

EVALUATION

History, physical examination together with the semen analysis is standard initial evaluation of most men, followed by special tests in selected cases.

Fertility history: Previous pregnancies – with current and previous partners, Duration of infertility, Previous infertility treatments

Sexual history: Erection or ejaculation problems & Frequency and timings of intercourse

Social history: Alcohol, smoking, usage of anabolic steroids, recreational drugs, Exposure to ionising radiation (X-Rays), Chronic heat exposure, Aniline dyes, Pesticides and Lead exposure

Medical history: Recent pyrexia/ illness, Systemic illness – diabetes mellitus, cancer, infection. Genetic disorders – cystic fibrosis, Klinefelter syndrome

Surgical history: Undescended testes, orchidopexy, Hernia repair, Testicular trauma, torsion, Pelvic, bladder or retroperitoneal surgery

Medication: Nitrofurantoin, cimetidine, sulfasalazine, spironolactone, α‐blockers, methotrexate, colchicine, amiodarone, antidepressants, phenothiazines, chemotherapy

Physical examination

Signs of decreased body hair or gynaecomastia, the height, weight, BMI and blood pressure should be noted.

Scrotal examination in the standing position should establish presence of normal, size (mean volume of 20 ml) and firm consistency testes on both sides, with non- tender and un-distended epididymis, and presence of vas difference, and absence of “bag of worms” suggestive of varicoceles during Valsalva manoeuvre.

Micro Penis, hypospadias should be looked for. And a rectal examination will provide clues on prostate abnormalities or seminal vesicle enlargement.

INVESTIGATIONS

Semen analysis is the most important investigation of male and is a guide for minimal standards of adequacy fertility (5^th percentile of semen characteristics of men initiating natural conception within 12 months of unprotected intercourse: WHO 2010). These minimum values do not imply proof of male fertility.

Semen analysis must be done at a qualified lab after 3-5 days abstinence and if an abnormality is detected a repeat semen analysis should be performed after 3 months, or sooner if the initial test shows azoospermia. The entire ejaculate should be collected, and the sample should be analysed within an hour of collection because sperm motility decreases after ejaculation. If produced at home, the sample should be kept at body temperature during transport.

Fresh semen is coagulated and liquefies 15–30 minutes after ejaculation. Low ejaculate volumes of <1.5 ml may not buffer against vaginal acidity sufficiently and may indicate retrograde ejaculation, obstruction, androgen deficiency, incomplete collection or anejaculation.

Endocrine tests

In men with Oligospermia (sperm counts of <5 × 10⁶ ml) and or impaired sexual function (erectile dysfunction, reduced libido, symptomatic hypothyroid, endocrine evaluation should include, FSH, LH, testosterone and prolactin in an early morning blood sample to assess normality of Hypothalamic-pituitary-gonadal (HPG). FSH reflects sperm production. Low testosterone levels with high FSH and LH indicate primary testicular failure whereas low testosterone levels in combination with low LH and FSH levels indicate a central defect with secondary hypogonadism. Azoospermia in combination with normal hormone levels suggests an obstructive cause.

Genetic evaluation

A karyotype is indicated in cases of severe oligospermia (<1 × 10⁶ ml) or azoospermia to identify Klinefelter syndrome (47, XXY) microdeletions on the long arm of the Y chromosome (Yq). This region includes the Azoospermia Factor (AZF) locus, which contains three subregions: AZFa, AZFb, and AZFc. AZFc micro‐deletions have a good prognosis for surgical sperm recovery whereas the prognostic value for sperm recovery in AZFa and AZFb micro‐deletions is poor. All men with idiopathic obstructive azoospermia and those with non‐palpable vas deferens (CBAVD) should be tested for mutations in the cystic fibrosis gene as they can be associated with cystic fibrosis carrier status.

Imaging

Scrotal ultrasound should be performed if an abnormality such as a testicular tumour is detected on physical examination. Ultrasound can also be useful in the clinical diagnosis of varicocele, especially with the use of colour flow Doppler and demonstration of retrograde blood flow with a Valsalva manoeuvre. If an absent vas is detected on examination, a renal ultrasound scan is recommended, as up to 30% of such men may have a renal abnormality.

Testicular biopsy

Testicular biopsy can aid the diagnosis of azoospermia and facilitate sperm recovery for intracytoplasmic sperm injection (ICSI) use. Biopsy can be done by an open/microscopic or percutaneous needle approach and is used to obtain a small piece of testicular tissue for histological examination and if sperm found for ICSI or cryopreservation. Testicular biopsy specimens can be classified histologically:

• normal (appropriate number of cells with complete spermatogenesis)
• hypo-spermatogenesis (all cell types present and in correct ratio but at reduced cell numbers)
• maturation arrest (failure of spermatogenesis beyond a certain stage; can be ‘early’ or ‘late’)
• sertoli cell‐only (del Castillo) syndrome (no germ cells).

In some cases, complex mixtures of pathological patterns may be present.

Other sperm function tests

Routine semen analysis provides information about spermatogenesis and sperm delivery, but the functional ability of sperm is difficult to ascertain. Sperm DNA fragmentation has been shown to be a robust predictor of assisted reproductive outcomes. Sperm DNA tests such as the sperm chromatin structure assay (SCSA), the comet assay and the TUNEL (terminal deoxynucleotidyl transferase‐mediated dUTP nick end‐labelling) assay, which assess sperm DNA integrity, show promise both as diagnostic tests for male infertility and prognostic tests for the outcome of assisted reproductive technologies. Their clinical application, however, needs further evaluation and improvement.

TREATMENT OPTIONS

Medical treatment

Specific hormonal treatments are effective for hyperprolactinaemia, hypothyroidism and congenital adrenal hyperplasia. Hypo-gonadotrophic hypogonadism can be treated successfully with GnRH or exogenous gonadotrophins. However medical treatments have a limited role in idiopathic male infertility as there is no treatable cause in over 50% of these cases.

Primary testicular failure

There is no effective treatment to restore fertility in primary testicular failure. Men undergoing treatments that contribute to infertility, such as chemotherapy, should be offered the opportunity to cryopreserve semen. Alternatively, surgical sperm retrieval with assisted reproduction can be attempted and the prognosis depends on the underlying pathology and the quality of sperm that can be found even with microscopic sperm retrieval.

Urological surgery

Reversal of vasectomy

The success rates for vasectomy reversal depend on the skill of the operating surgeon, surgical technique and the time from the initial surgery. Patency rates seem to decline with increasing time due to the increasing rates of anti‐sperm antibody development and secondary epididymal obstruction.

Surgical sperm retrieval

Techniques for sperm retrieval from the testes include testicular sperm aspiration (TESA), testicular sperm extraction (TESE) and microsurgical TESE (micro‐TESE) performed under local combined with regional or general anaesthesia. The results of a single biopsy may not be indicative of the spermatogenic process in the whole of the testis and multiple biopsies may be necessary both to find treatment suitable sperm and or to diagnose testicular pathology.

Sperm from the epididymis can be retrieved by microsurgical (MESA) or percutaneous (PESA) epididymal sperm aspiration under local anaesthetic.

Sperm can be retrieved from the testes or the epididymis for use in IVF/ICSI. Common indications include obstructive causes, severe male factor infertility or ejaculatory failure (sperm retrieval by Rectal Electro Ejaculation). Testicular biopsy should be done in a tertiary centre with facilities for sperm cryopreservation.

Success rates for surgical sperm retrieval of almost 100% have been reported in obstructive cases, with lower rates of approximately 50% in non‐obstructive cases. A meta‐analysis of the use of surgical sperm retrieval in azoospermic men, showed the outcome of ICSI cycles in terms of fertilisation rates and clinical pregnancy rates to be significantly higher with the use of sperm from men with obstructive azoospermia as compared with non‐obstructive azoospermia.

Varicocele repair

Recent evidence from a randomised control trial indicates that varicocelectomy in infertile men with impaired semen quality and palpable varicoceles (clinically evident bilateral), significantly improves semen characteristics and the chances of pregnancy within 1 year of follow‐up. Varicocelectomy may also correct the serum testosterone deficit in men with varicocele and low testosterone levels.

Assisted reproduction

Intrauterine insemination (IUI)

IUI involves the placement of a washed pellet of ejaculated sperm within the uterine cavity, thus bypassing the cervical barrier. It can be performed with or without ovarian stimulation. Indications include mild male factor infertility, immunologic infertility and mechanical problems of sperm delivery such as erectile dysfunction or hypospadias.

National Institute for Clinical Excellence (NICE), United Kingdom recommends that IUI is used in mild forms of oligozoospermia (reduced number of sperms) usually no less than 5 million motile sperm. Monthly conception rates of 8–16% have been reported for IUI and therefore, NICE currently recommends the use of up to six cycles of unstimulated IUI in mild cases of male factor infertility to optimize chances of successful pregnancy and reduce the risk of multiple pregnancies.

In vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI)

Although IVF can be used to treat milder forms of sperm abnormalities, more severe forms require ICSI. ICSI was originally described in 1988 and has since revolutionised the treatment of male factor infertility. It involves the micromanipulation and injection of a single human sperm into the cytoplasm of the oocyte. ICSI requires ovarian stimulation, oocyte retrieval and sperm preparation as for IVF. It is used for un‐correctable severe forms of male factor infertility including oligospermia and asthenoteratozoospermia (OATS), or following fertilisation failure in a previous IVF cycle. Average pregnancy rates of 33.0% per embryo transfer have been reported after ICSI.

Ethical issues

Recent data suggest that offspring born to infertile couples using ICSI have a higher incidence of chromosomal anomalies than do children who are naturally conceived.

Possible mechanism for this could be that ICSI bypasses the natural barriers to fertilisation and therefore there is the potential risk of propagation of genetic defects that may re‐surface in the male offspring of treatable infertile men. This could potentially lead to the creation of a population of subfertile men and couple are to be fully counselled on this concern.

‘Artificial’ haploid gametes have been successfully created in vitro from embryonic stem cells in animal models. These gametes have been used to create live offspring in mice. Human trials is unlikely to progress due to strong ethical reasons.

Conclusion

Male infertility is a common problem that requires appropriate specialist referral. Assessment should include full clinical history and careful examination. Semen analysis remains the main initial investigation that guides further assessment of the infertile male. Advances in research have increased the treatment options available for male infertility. The potential for ICSI to propagate genetic abnormalities warrants thorough counselling for couples regarding the possible implications of its use, prior to treatment starting. The health and wellbeing of children following ICSI requires long‐term follow‐up.

In the future, a better understanding of the causes of male infertility and new reproductive technologies may offer the possibility of novel treatments, but these need to be carried out within the appropriate ethical framework.

CAUSES

Pretesticular (1%):

Gonadotrophin deficiency (Hypothalamic/ Pituitary disease) examples; Kallman syndrome, tumours, radiation, surgery,

Hyperprolactinaemia, hyper‐or hypothyroidism, Hormones Intake (anabolic steroids, glucocorticoid excess).

Most of these can be treated with hormone manipulation

Testicular (Majority of Causes):

Idiopathic: (almost 50%)

Congenital: Chromosomal (Kleinfelter syndrome 47, XXY), Y chromosome microdeletions, Noonan syndrome (male Turner syndrome 45, XO), Undescended Tests (Cryptorchidism)

Acquired: Infection/Injury (orchitis, torsion, trauma), Varicocele*, Severe systemic disease (renal failure, liver failure), Testicular tumours, Chemotherapy, radiotherapy

*Varicoceles, a collection of dilated refluxing veins in the spermatic cord, are found twice commonly in men with abnormal semen compared to those with normal semen. (25% vs 12%). It is believed that increased scrotal heating and altered testicular steroidogenesis affects semen quality, but the evidence is limited.

These conditions are largely irreversible but can be treated with assisted reproductive technology (ART), if sperm is retrievable. The diagnosis is based on reduction in testicular size and elevation of serum FSH levels and in the majority of cases (66%) the cause is unknown.

Post‐testicular (anatomical or functional obstruction):

Excluding Vasectomy, 40% of azospermia cases are due to obstruction, and with ART these men can achieve pregnancy after sperm retrieval.

Congenital: Cystic fibrosis, congenital absence of the vas deferens (CAVD), Young’s syndrome

Acquired: Infection (chlamydia, gonorrhoea), Vasectomy, Iatrogenic vasal injury

Disorders of sperm function or motility: Globozoospermia (100% round heads), Maturation defects, Immunological infertility, Immotile cilia syndrome

The diagnosis is based on normal serum FSH levels, normal testicular volume and evidence of complete spermatogenesis on biopsy.

These conditions can be treated with microsurgery or with ART

Sexual dysfunction:

Erectile/ ejaculatory dysfunction, Inappropriate timing and frequency of intercourse. Diabetes mellitus, multiple sclerosis, spinal cord/pelvic injuries.

DETAILED HISTORY

Male age

A UK study has shown that paternal age of >35 years halves the chance of achieving a pregnancy compared with a paternal age of <25 years and drop in fertility is worse after the age of 50. There are also studies showing increase in adverse outcome in the offspring.

Environmental, occupational and lifestyle factors: Obesity, Alcohol, Tobacco, Oxidative stress,

Obesity

Through an imbalance of reproductive hormone (reduced sex hormone binding globulin and elevated oestrogen levels), amongst others, obesity is associated with poor semen quality. In addition, sexual dysfunction is also more common in obese men possibly from altered metabolism of environmental toxins, and sedentary lifestyle.

Alcohol

Heavy alcohol consumption affects sexual and reproductive performance in a reversible fashion.

Tobacco

Tobacco smoking and cannabis consumption have been shown to reduce semen parameters and men with suboptimal semen quality may benefit from quitting smoking and this should be strongly encouraged. Other recreational drugs such as cocaine, amphetamines and opiates may adversely affect reproductive performance due to decreased libido and erectile dysfunction.

Oxidative Stress

There is limited evidence for, sperm DNA damage secondary to oxidative stress may be the cause of between 30% and 80% of male subfertility cases. Recent evidence suggests that antioxidant supplementation in subfertile males, including carnitines, vitamin C, vitamin E, selenium, zinc and coenzyme Q10, improves semen quality and live birth rates in couples undergoing fertility treatment.

More than 104 000 such chemicals and physical agents (environmental, occupational) have been identified that can affect semen quality; heat, X‐rays, heavy metals (lead, mercury), glycol ethers (highly volatile compounds used as solvents) and pesticides. The level of environmental estrogens would not appear to be a threat to male reproductive health.

Recent observational studies support a dose‐dependent decrease in semen parameters related to exposure to electromagnetic waves emitted from mobile phones, but there is still no clear clinical significance of this.

There is evidence that a sedentary lifestyle, Testicular hyperthermia, can affect sperm production and semen quality, but no clear proof that wearing loose‐fitting underwear improves fertility.

Abuse

Usage of Anabolic‐androgenic steroids severely affects sperm quality and testosterone production and therefore can lead to azoospermia and erectile dysfunction, by interfering with the hypothalamic‐pituitary‐gonadal (HPG) axis. Azoospermia may be reversed by conservative management when the drugs are discontinued for 4-12 months and in some cases by administration of human chorionic gonadotrophin and human menopausal gonadotrophin.

A lot of ‘steroid‐free’ dietary supplements have been reported to be contaminated with traces of hormones.

EVALUATION

History, physical examination together with the semen analysis is standard initial evaluation of most men, followed by special tests in selected cases.

Fertility history: Previous pregnancies – with current and previous partners, Duration of infertility, Previous infertility treatments

Sexual history: Erection or ejaculation problems & Frequency and timings of intercourse

Social history: Alcohol, smoking, usage of anabolic steroids, recreational drugs, Exposure to ionising radiation (X-Rays), Chronic heat exposure, Aniline dyes, Pesticides and Lead exposure

Medical history: Recent pyrexia/ illness, Systemic illness – diabetes mellitus, cancer, infection. Genetic disorders – cystic fibrosis, Klinefelter syndrome

Surgical history: Undescended testes, orchidopexy, Hernia repair, Testicular trauma, torsion, Pelvic, bladder or retroperitoneal surgery

Medication: Nitrofurantoin, cimetidine, sulfasalazine, spironolactone, α‐blockers, methotrexate, colchicine, amiodarone, antidepressants, phenothiazines, chemotherapy

Physical examination

Signs of decreased body hair or gynaecomastia, the height, weight, BMI and blood pressure should be noted.

Scrotal examination in the standing position should establish presence of normal, size (mean volume of 20 ml) and firm consistency testes on both sides, with non- tender and un-distended epididymis, and presence of vas difference, and absence of “bag of worms” suggestive of varicoceles during Valsalva manoeuvre.

Micro Penis, hypospadias should be looked for. And a rectal examination will provide clues on prostate abnormalities or seminal vesicle enlargement.

INVESTIGATIONS

Semen analysis is the most important investigation of male and is a guide for minimal standards of adequacy fertility (5^th percentile of semen characteristics of men initiating natural conception within 12 months of unprotected intercourse: WHO 2010). These minimum values do not imply proof of male fertility.

Semen analysis must be done at a qualified lab after 3-5 days abstinence and if an abnormality is detected a repeat semen analysis should be performed after 3 months, or sooner if the initial test shows azoospermia. The entire ejaculate should be collected, and the sample should be analysed within an hour of collection because sperm motility decreases after ejaculation. If produced at home, the sample should be kept at body temperature during transport.

Fresh semen is coagulated and liquefies 15–30 minutes after ejaculation. Low ejaculate volumes of <1.5 ml may not buffer against vaginal acidity sufficiently and may indicate retrograde ejaculation, obstruction, androgen deficiency, incomplete collection or anejaculation.

Endocrine tests

In men with Oligospermia (sperm counts of <5 × 10⁶ ml) and or impaired sexual function (erectile dysfunction, reduced libido, symptomatic hypothyroid, endocrine evaluation should include, FSH, LH, testosterone and prolactin in an early morning blood sample to assess normality of Hypothalamic-pituitary-gonadal (HPG). FSH reflects sperm production. Low testosterone levels with high FSH and LH indicate primary testicular failure whereas low testosterone levels in combination with low LH and FSH levels indicate a central defect with secondary hypogonadism. Azoospermia in combination with normal hormone levels suggests an obstructive cause.

Genetic evaluation

A karyotype is indicated in cases of severe oligospermia (<1 × 10⁶ ml) or azoospermia to identify Klinefelter syndrome (47, XXY) microdeletions on the long arm of the Y chromosome (Yq). This region includes the Azoospermia Factor (AZF) locus, which contains three subregions: AZFa, AZFb, and AZFc. AZFc micro‐deletions have a good prognosis for surgical sperm recovery whereas the prognostic value for sperm recovery in AZFa and AZFb micro‐deletions is poor. All men with idiopathic obstructive azoospermia and those with non‐palpable vas deferens (CBAVD) should be tested for mutations in the cystic fibrosis gene as they can be associated with cystic fibrosis carrier status.

Imaging

Scrotal ultrasound should be performed if an abnormality such as a testicular tumour is detected on physical examination. Ultrasound can also be useful in the clinical diagnosis of varicocele, especially with the use of colour flow Doppler and demonstration of retrograde blood flow with a Valsalva manoeuvre. If an absent vas is detected on examination, a renal ultrasound scan is recommended, as up to 30% of such men may have a renal abnormality.

Testicular biopsy

Testicular biopsy can aid the diagnosis of azoospermia and facilitate sperm recovery for intracytoplasmic sperm injection (ICSI) use. Biopsy can be done by an open/microscopic or percutaneous needle approach and is used to obtain a small piece of testicular tissue for histological examination and if sperm found for ICSI or cryopreservation. Testicular biopsy specimens can be classified histologically:

• normal (appropriate number of cells with complete spermatogenesis)
• hypo-spermatogenesis (all cell types present and in correct ratio but at reduced cell numbers)
• maturation arrest (failure of spermatogenesis beyond a certain stage; can be ‘early’ or ‘late’)
• sertoli cell‐only (del Castillo) syndrome (no germ cells).

In some cases, complex mixtures of pathological patterns may be present.

Other sperm function tests

Routine semen analysis provides information about spermatogenesis and sperm delivery, but the functional ability of sperm is difficult to ascertain. Sperm DNA fragmentation has been shown to be a robust predictor of assisted reproductive outcomes. Sperm DNA tests such as the sperm chromatin structure assay (SCSA), the comet assay and the TUNEL (terminal deoxynucleotidyl transferase‐mediated dUTP nick end‐labelling) assay, which assess sperm DNA integrity, show promise both as diagnostic tests for male infertility and prognostic tests for the outcome of assisted reproductive technologies. Their clinical application, however, needs further evaluation and improvement.

TREATMENT OPTIONS

Medical treatment

Specific hormonal treatments are effective for hyperprolactinaemia, hypothyroidism and congenital adrenal hyperplasia. Hypo-gonadotrophic hypogonadism can be treated successfully with GnRH or exogenous gonadotrophins. However medical treatments have a limited role in idiopathic male infertility as there is no treatable cause in over 50% of these cases.

Primary testicular failure

There is no effective treatment to restore fertility in primary testicular failure. Men undergoing treatments that contribute to infertility, such as chemotherapy, should be offered the opportunity to cryopreserve semen. Alternatively, surgical sperm retrieval with assisted reproduction can be attempted and the prognosis depends on the underlying pathology and the quality of sperm that can be found even with microscopic sperm retrieval.

Urological surgery

Reversal of vasectomy

The success rates for vasectomy reversal depend on the skill of the operating surgeon, surgical technique and the time from the initial surgery. Patency rates seem to decline with increasing time due to the increasing rates of anti‐sperm antibody development and secondary epididymal obstruction.

Surgical sperm retrieval

Techniques for sperm retrieval from the testes include testicular sperm aspiration (TESA), testicular sperm extraction (TESE) and microsurgical TESE (micro‐TESE) performed under local combined with regional or general anaesthesia. The results of a single biopsy may not be indicative of the spermatogenic process in the whole of the testis and multiple biopsies may be necessary both to find treatment suitable sperm and or to diagnose testicular pathology.

Sperm from the epididymis can be retrieved by microsurgical (MESA) or percutaneous (PESA) epididymal sperm aspiration under local anaesthetic.

Sperm can be retrieved from the testes or the epididymis for use in IVF/ICSI. Common indications include obstructive causes, severe male factor infertility or ejaculatory failure (sperm retrieval by Rectal Electro Ejaculation). Testicular biopsy should be done in a tertiary centre with facilities for sperm cryopreservation.

Success rates for surgical sperm retrieval of almost 100% have been reported in obstructive cases, with lower rates of approximately 50% in non‐obstructive cases. A meta‐analysis of the use of surgical sperm retrieval in azoospermic men, showed the outcome of ICSI cycles in terms of fertilisation rates and clinical pregnancy rates to be significantly higher with the use of sperm from men with obstructive azoospermia as compared with non‐obstructive azoospermia.

Varicocele repair

Recent evidence from a randomised control trial indicates that varicocelectomy in infertile men with impaired semen quality and palpable varicoceles (clinically evident bilateral), significantly improves semen characteristics and the chances of pregnancy within 1 year of follow‐up. Varicocelectomy may also correct the serum testosterone deficit in men with varicocele and low testosterone levels.

Assisted reproduction

Intrauterine insemination (IUI)

IUI involves the placement of a washed pellet of ejaculated sperm within the uterine cavity, thus bypassing the cervical barrier. It can be performed with or without ovarian stimulation. Indications include mild male factor infertility, immunologic infertility and mechanical problems of sperm delivery such as erectile dysfunction or hypospadias.

National Institute for Clinical Excellence (NICE), United Kingdom recommends that IUI is used in mild forms of oligozoospermia (reduced number of sperms) usually no less than 5 million motile sperm. Monthly conception rates of 8–16% have been reported for IUI and therefore, NICE currently recommends the use of up to six cycles of unstimulated IUI in mild cases of male factor infertility to optimize chances of successful pregnancy and reduce the risk of multiple pregnancies.

In vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI)

Although IVF can be used to treat milder forms of sperm abnormalities, more severe forms require ICSI. ICSI was originally described in 1988 and has since revolutionised the treatment of male factor infertility. It involves the micromanipulation and injection of a single human sperm into the cytoplasm of the oocyte. ICSI requires ovarian stimulation, oocyte retrieval and sperm preparation as for IVF. It is used for un‐correctable severe forms of male factor infertility including oligospermia and asthenoteratozoospermia (OATS), or following fertilisation failure in a previous IVF cycle. Average pregnancy rates of 33.0% per embryo transfer have been reported after ICSI.

Ethical issues

Recent data suggest that offspring born to infertile couples using ICSI have a higher incidence of chromosomal anomalies than do children who are naturally conceived.

Possible mechanism for this could be that ICSI bypasses the natural barriers to fertilisation and therefore there is the potential risk of propagation of genetic defects that may re‐surface in the male offspring of treatable infertile men. This could potentially lead to the creation of a population of subfertile men and couple are to be fully counselled on this concern.

‘Artificial’ haploid gametes have been successfully created in vitro from embryonic stem cells in animal models. These gametes have been used to create live offspring in mice. Human trials is unlikely to progress due to strong ethical reasons.

Conclusion

Male infertility is a common problem that requires appropriate specialist referral. Assessment should include full clinical history and careful examination. Semen analysis remains the main initial investigation that guides further assessment of the infertile male. Advances in research have increased the treatment options available for male infertility. The potential for ICSI to propagate genetic abnormalities warrants thorough counselling for couples regarding the possible implications of its use, prior to treatment starting. The health and wellbeing of children following ICSI requires long‐term follow‐up.

In the future, a better understanding of the causes of male infertility and new reproductive technologies may offer the possibility of novel treatments, but these need to be carried out within the appropriate ethical framework.

We are proud to announce that our official Grand Opening Ceremony has commenced on Thursday, the 15th of February.

Our utmost gratitude and appreciation goes to Sheikh Mohammed bin Maktoum bin Juma Al Maktoum for taking part in this festive and important event for our center. Blessings and warm regards to him, his family, and to all those, who have placed their heart and effort in making this day pleasant and memorable!

Dr. Amal Alias, the founder and the owner of the Dr. Amal Alias brand, has, along with the other members of our team, given Sheikh Mohammed Al Maktoum a tour around the facility, showing some of the best and most advanced IVF industry equipment in the UAE.

With high hopes and brave dreams we take this crucial step to the new beginning.

We are proud to announce that our official Grand Opening Ceremony has commenced on Thursday, the 15th of February.

Our utmost gratitude and appreciation goes to Sheikh Mohammed bin Maktoum bin Juma Al Maktoum for taking part in this festive and important event for our center. Blessings and warm regards to him, his family, and to all those, who have placed their heart and effort in making this day pleasant and memorable!

Dr. Amal Alias, the founder and the owner of the Dr. Amal Alias brand, has, along with the other members of our team, given Sheikh Mohammed Al Maktoum a tour around the facility, showing some of the best and most advanced IVF industry equipment in the UAE.

With high hopes and brave dreams we take this crucial step to the new beginning.

Numerical Abnormalities

A person typically has 46 chromosomes/23 pairs of chromosomes, however, sometimes during embryo development a chromosome can be either gained or lost. For example, Down syndrome is a result of having one extra chromosome (47 instead of 46), and Turner’s syndrome is a result of having one less chromosome (45 instead of 46).

Structural Abnormalities

Structural chromosomal abnormalities occur when chromosomes are missing a part, have an extra part, or have switched places with another chromosome’s part. Structural abnormalities lead to either too much or too little chromosome material, which results in diseases such as Pallister Killian syndrome, and Cri du Chat syndrome.

Two Types of Genetic Testing Methods

1) Pre-implantation genetic diagnosis (PGD) is when an embryo is biopsied for the most common genetic conditions. This method is typically used when a wife, husband, or both may have a known genetic condition, a family history of a genetic condition, or may have a previous child with a genetic condition.

2) Pre-implantation genetic screening (PGS) / Next Generation Sequencing (NGS) is when an embryo is biopsied to determine the number of chromosomes it has. This method is typically used when a husband/wife have known infertility causes, previous miscarriages, and/or are older in age.

Testing for genetic diseases is used in conjunction with in‐vitro fertilization (IVF) to test embryos for chromosomal abnormalities prior to transfer. Some causes of infertility (recurrent abortion, etc) can be due to genetic abnormalities within the embryo. Therefore, testing the embryo for genetic abnormalities is a very important step to a successful IVF/ICSI cycle, and a healthy baby.

How it is performed?

In both PGS and PGD, one or more cells from the embryo are removed/biopsied on the 3rd or 5th day after fertilization and sent to an advanced genetic laboratory. The laboratory performs the respective genetic tests and sends us the detailed report. The doctor and embryologist will review the report, counsel the patient based on the report findings, and make the best plan to achieve the best outcome.

Numerical Abnormalities

A person typically has 46 chromosomes/23 pairs of chromosomes, however, sometimes during embryo development a chromosome can be either gained or lost. For example, Down syndrome is a result of having one extra chromosome (47 instead of 46), and Turner’s syndrome is a result of having one less chromosome (45 instead of 46).

Structural Abnormalities

Structural chromosomal abnormalities occur when chromosomes are missing a part, have an extra part, or have switched places with another chromosome’s part. Structural abnormalities lead to either too much or too little chromosome material, which results in diseases such as Pallister Killian syndrome, and Cri du Chat syndrome.

Two Types of Genetic Testing Methods

1) Pre-implantation genetic diagnosis (PGD) is when an embryo is biopsied for the most common genetic conditions. This method is typically used when a wife, husband, or both may have a known genetic condition, a family history of a genetic condition, or may have a previous child with a genetic condition.

2) Pre-implantation genetic screening (PGS) / Next Generation Sequencing (NGS) is when an embryo is biopsied to determine the number of chromosomes it has. This method is typically used when a husband/wife have known infertility causes, previous miscarriages, and/or are older in age.

Testing for genetic diseases is used in conjunction with in‐vitro fertilization (IVF) to test embryos for chromosomal abnormalities prior to transfer. Some causes of infertility (recurrent abortion, etc) can be due to genetic abnormalities within the embryo. Therefore, testing the embryo for genetic abnormalities is a very important step to a successful IVF/ICSI cycle, and a healthy baby.

How it is performed?

In both PGS and PGD, one or more cells from the embryo are removed/biopsied on the 3rd or 5th day after fertilization and sent to an advanced genetic laboratory. The laboratory performs the respective genetic tests and sends us the detailed report. The doctor and embryologist will review the report, counsel the patient based on the report findings, and make the best plan to achieve the best outcome.

Numerical Abnormalities

A person typically has 46 chromosomes/23 pairs of chromosomes, however, sometimes during embryo development a chromosome can be either gained or lost. For example, Down syndrome is a result of having one extra chromosome (47 instead of 46), and Turner’s syndrome is a result of having one less chromosome (45 instead of 46).

Structural Abnormalities

Structural chromosomal abnormalities occur when chromosomes are missing a part, have an extra part, or have switched places with another chromosome’s part. Structural abnormalities lead to either too much or too little chromosome material, which results in diseases such as Pallister Killian syndrome, and Cri du Chat syndrome.

Two Types of Genetic Testing Methods

1) Pre-implantation genetic diagnosis (PGD) is when an embryo is biopsied for the most common genetic conditions. This method is typically used when a wife, husband, or both may have a known genetic condition, a family history of a genetic condition, or may have a previous child with a genetic condition.

2) Pre-implantation genetic screening (PGS) / Next Generation Sequencing (NGS) is when an embryo is biopsied to determine the number of chromosomes it has. This method is typically used when a husband/wife have known infertility causes, previous miscarriages, and/or are older in age.

Testing for genetic diseases is used in conjunction with in‐vitro fertilization (IVF) to test embryos for chromosomal abnormalities prior to transfer. Some causes of infertility (recurrent abortion, etc) can be due to genetic abnormalities within the embryo. Therefore, testing the embryo for genetic abnormalities is a very important step to a successful IVF/ICSI cycle, and a healthy baby.

How it is performed?

In both PGS and PGD, one or more cells from the embryo are removed/biopsied on the 3rd or 5th day after fertilization and sent to an advanced genetic laboratory. The laboratory performs the respective genetic tests and sends us the detailed report. The doctor and embryologist will review the report, counsel the patient based on the report findings, and make the best plan to achieve the best outcome.

Holistic fertility health:

A state of mental and physical wellbeing can only be attained if one is contended with one’s inner self. There is stress in everybody’s life and knowing how to deal with it can ease a lot of problems. A fertile mind resides in a healthy body. Approaches like good food habits, exercise and lifestyle modifications, yoga, meditation, alternative therapies like acupressure and regular counseling sessions to deal with problems can help attain the achievable.

Endoscopy procedures:

Gynecological endoscopy procedures like hysteroscopy and laparoscopy forms an important part of any fertility and gynecological center. Fibroids, endometriosis (chocolate cyst), endometrial polyps, uterine abnormalities like uterine septum can be endoscopically corrected. Fertility enhancing procedures like tubal cannulation for blocked tubes, hysteroscopy metroplasty for thin endometrial lining can also enhance reproductive outcomes.

Holistic fertility health:

A state of mental and physical wellbeing can only be attained if one is contended with one’s inner self. There is stress in everybody’s life and knowing how to deal with it can ease a lot of problems. A fertile mind resides in a healthy body. Approaches like good food habits, exercise and lifestyle modifications, yoga, meditation, alternative therapies like acupressure and regular counseling sessions to deal with problems can help attain the achievable.

Endoscopy procedures:

Gynecological endoscopy procedures like hysteroscopy and laparoscopy forms an important part of any fertility and gynecological center. Fibroids, endometriosis (chocolate cyst), endometrial polyps, uterine abnormalities like uterine septum can be endoscopically corrected. Fertility enhancing procedures like tubal cannulation for blocked tubes, hysteroscopy metroplasty for thin endometrial lining can also enhance reproductive outcomes.

Holistic fertility health:

A state of mental and physical wellbeing can only be attained if one is contended with one’s inner self. There is stress in everybody’s life and knowing how to deal with it can ease a lot of problems. A fertile mind resides in a healthy body. Approaches like good food habits, exercise and lifestyle modifications, yoga, meditation, alternative therapies like acupressure and regular counseling sessions to deal with problems can help attain the achievable.

Endoscopy procedures:

Gynecological endoscopy procedures like hysteroscopy and laparoscopy forms an important part of any fertility and gynecological center. Fibroids, endometriosis (chocolate cyst), endometrial polyps, uterine abnormalities like uterine septum can be endoscopically corrected. Fertility enhancing procedures like tubal cannulation for blocked tubes, hysteroscopy metroplasty for thin endometrial lining can also enhance reproductive outcomes.