Male Factor Infertility and When ICSI is Needed
Male factor infertility accounts for approximately 40-50% of all infertility cases. ICSI overcomes most barriers to fertilisation when sufficient motile sperm exist. For men without sperm in the ejaculate, surgical retrieval techniques are required.
Complete semen analysis - WHO 2021 reference values:
- Volume: ?1.4 mL
- Total motility: ?42%
- Progressive motility: ?30%
- Morphology (Kruger strict): ?4% normal forms
- Total sperm count: ?39 million per ejaculate
Abnormalities below these thresholds indicate:
- Oligospermia: Low sperm count - mild (<15M/mL), moderate (<5M/mL), severe (<1M/mL)
- Asthenospermia: Poor motility
- Teratospermia: Abnormal morphology
- OAT syndrome: Combined oligo-astheno-teratospermia
- Azoospermia: No sperm in ejaculate - obstructive (normal spermatogenesis; blocked outflow) vs. non-obstructive (impaired spermatogenesis)
Sperm DNA Fragmentation (SDF): Standard semen analysis does not assess sperm nuclear DNA integrity. SDF >25% correlates with reduced IVF/ICSI fertilisation rates, poor embryo development, recurrent miscarriage, and recurrent IVF failure. SDF testing (TUNEL or SCD assay) is recommended for:
- Recurrent (?2) miscarriage
- Previous failed IVF/ICSI cycles (?2) with good embryo quality
- Varicocele
- Significant lifestyle factors (obesity, smoking, heat exposure)
Indications for ICSI (rather than standard IVF):
- Severe oligospermia or OAT syndrome
- Any surgically retrieved sperm (TESE/PESA)
- Previous poor fertilisation (<25%) with standard IVF
- High SDF
- Frozen-thawed sperm
- PGT-A cycles (to avoid contamination from binding sperm)
TESE and PESA - Surgical Sperm Retrieval
Obstructive azoospermia (OA): Normal sperm production but blocked or absent vas deferens/epididymis (e.g., post-vasectomy, congenital bilateral absence of vas deferens [CBAVD], prior infection). High sperm retrieval rates - PESA or conventional TESE almost always successful.
PESA (Percutaneous Epididymal Sperm Aspiration):
- Fine needle inserted into the epididymis under local anaesthesia
- Sperm aspirated; best suited to obstructive azoospermia
- 15-30 minute procedure; discharge same day
- Multiple attempts can be made; samples cryopreserved for future ICSI cycles
- Success: >90% in obstructive azoospermia
Conventional TESE (Testicular Sperm Extraction):
- Small incision in testis under local anaesthesia + sedation; small biopsy segments taken from different areas
- Sperm identified by embryologist in lab; cryopreserved if found
- Success: >90% in obstructive; 30-50% in non-obstructive azoospermia
micro-TESE (Microsurgical TESE):
- Gold standard for NOA (non-obstructive azoospermia) - Sertoli cell-only syndrome, hypospermatogenesis, maturation arrest
- Performed under operating microscope at 20- magnification - identifies tubules likely to contain sperm (appear larger/more opaque)
- Overall NOA success: 40-60% (vs. 30-45% conventional TESE in NOA); significantly higher yield in Sertoli cell-only syndrome
- Requires general/spinal anaesthesia; 1-night hospital stay; recovery 5-7 days
- Available at select partner hospitals with microsurgery-trained urologist/andrologist
Sperm cryopreservation: All surgically retrieved sperm can be vitrified and stored for future ICSI cycles - avoiding the need to coordinate retrieval with oocyte collection. Men with confirmed NOA may consider sperm banking from a successful micro-TESE before their partner undergoes ovarian stimulation.
IMSI (Intracytoplasmic Morphologically Selected Sperm Injection): High-magnification (6,600- vs. 400- standard) sperm selection before ICSI injection - identifies and avoids sperm with nuclear vacuoles (associated with DNA fragmentation and poor embryo quality). Recommended for:
- Recurrent IVF failure
- Severe teratospermia (all or nearly all abnormal forms)
- High SDF
ICSI Outcomes and Costs
ICSI fertilisation and embryo development:
- Normal fertilisation rate (2PN): 65-80% of mature (MII) oocytes injected
- Blastocyst development (Day 5/6): 40-55% of fertilised eggs progress to blastocyst
- Usable blastocyst rate: approximately 30-50% of mature oocytes injected - depends on age, ovarian reserve, and underlying diagnosis
ICSI success rates (own sperm + own eggs):
| Age | Fresh/FET blastocyst SET | With PGT-A |
|---|---|---|
| <35 | 45-55% | 60-70% |
| 35-37 | 35-45% | 55-65% |
| 38-40 | 22-35% | 48-58% |
| >40 | 12-25% | 42-52% |
ICSI with TESE (day of retrieval sperm vs. frozen): Fresh TESE sperm on day of egg collection is preferred when reliably available - frozen TESE samples give equivalent outcomes for obstructive azoospermia; data for NOA is slightly lower with frozen vs. fresh in some studies.
Cost comparison Turkey vs. UK:
| Service | Turkey | UK Private |
|---|---|---|
| ICSI (included in IVF package) | +-400-600 | +-1,000-1,500 |
| PESA | -600-1,000 | -1,500-2,500 |
| Conventional TESE | -800-1,500 | -2,000-3,500 |
| micro-TESE | -2,500-4,000 | -5,000-10,000 |
| IMSI (per cycle) | +-400-600 | +-800-1,200 |
| Sperm DNA fragmentation test | -150-250 | -300-500 |
Complete IVF-ICSI cycle (own eggs, own sperm) Turkey: -3,000-5,000; UK: -6,000-10,000
Lifestyle optimisation before ICSI: Sperm DNA fragmentation is modifiable: antioxidant supplementation (CoQ10 600mg/day, Vitamins C/E, Lycopene, Selenium) for at least 3 months before cycle; smoking cessation; weight loss if BMI >30; avoid testicular heat; treat varicocele if Grade 2-3 before stimulation.