IVF, ICSI, IUI & Male Factor Infertility

Male factor infertility contributes to nearly 40–50% of all infertility cases, either as a sole cause or a contributing factor. Fortunately, modern reproductive technologies give fertility specialists powerful tools to overcome these challenges.

Reproductive endocrinologists (REs) and embryologists collaborate closely with urologists and andrologists to select the most effective treatment pathway. The tools primarily used in managing male factor infertility include Intrauterine Insemination (IUI), In Vitro Fertilization (IVF), and Intracytoplasmic Sperm Injection (ICSI). Each approach has its own role depending on the severity and cause of the male factor.

1. Intrauterine Insemination (IUI)

Purpose: IUI is often the first-line treatment for mild male factor infertility.

Process:

• A semen sample is collected and “washed” in the laboratory to concentrate motile, healthy sperm.

• These sperm are then directly introduced into the uterus around the time of ovulation to increase the chances of fertilization.

When It’s Considered:

• Sperm concentration and motility are mildly reduced, but at least 5–10 million total motile sperm are available after washing.

• The female partner has open fallopian tubes and normal ovulation.

• There are no significant sperm morphology or DNA integrity issues.

Limitations:

• Success rates per cycle are generally 10–15%, depending on age and sperm quality.

• Not effective in cases of severe oligospermia (low sperm count), asthenozoospermia (poor motility), or teratozoospermia (abnormal shape).

2. In Vitro Fertilization (IVF)

Purpose: IVF allows fertilization to occur outside the body and is useful when sperm parameters are moderately to severely abnormal.

Process:

• Eggs are retrieved from the ovaries after controlled ovarian stimulation.

• Sperm are combined with eggs in a laboratory dish to allow natural fertilization.

• Resulting embryos are monitored and cultured for several days before transfer into the uterus.

When It’s Considered:

• Sperm count, motility, or morphology are too poor for IUI success.

• Previous IUIs have failed (typically after 3–4 attempts).

• Female partner’s age or egg quality necessitates a more controlled and higher-success approach.

• There are additional female factors, such as tubal disease or endometriosis.

Limitations:

• Standard IVF may fail when sperm cannot naturally penetrate the egg membrane — which is why ICSI is often added for male factor cases.

3. Intracytoplasmic Sperm Injection (ICSI)

Purpose: ICSI was developed to address severe male infertility by bypassing natural barriers to fertilization.

Process:

• A single, morphologically normal sperm is selected and injected directly into a mature egg using a fine microneedle under microscopic guidance.

• The fertilized egg (zygote) is then cultured into an embryo for transfer.

When It’s Considered:

• Severe oligospermia: very low sperm count (<5 million/mL).

• Asthenozoospermia: very poor motility.

• Azoospermia: sperm retrieved surgically from the testis (TESE, micro-TESE, or PESA).

• Previous IVF failure due to failed fertilization.

• Use of cryopreserved or surgically retrieved sperm, which are often fragile.

Advantages:

• Dramatically increases fertilization rates in male factor cases.

• Enables use of sperm that would otherwise not be viable for natural or IUI conception.

Limitations:

• ICSI does not improve embryo quality if underlying sperm DNA damage is significant.

• Requires highly skilled embryologists and advanced lab infrastructure.