Male fertility is a real problem and there are indications based on reports from fertility treatment registers in several countries that this is increasing. There are many possible reasons for this increase and the most plausible cause could be the increasing exposure to environment factors that are an outcome of unregulated industrialization as well as lifestyle choices. While we are now constantly warned of the effects of the constant plundering of the environment with visuals of floods and crashing icebergs, we are often oblivious of the reproductive effects of environmental pollution. One example is the evidence that has accumulated over the years into the link between sperm defects and exposure to lead which is an ingredient of common chemicals such as paints that we are exposed to on a daily basis. There are also indications of the toxic effect of agricultural chemicals such as DDT which is widely available and used in India despite a government ban. What is not clear however is the exact mechanism of action of these toxicants on the male reproductive system and modern technology does not allow us to directly link a sperm defect in any individual to a particular substance in the environment. Similarly lifestyle choices and their effects on our health are not surprising. Research does point to the toxic effects of individual lifestyle choices such as tobacco chewing and the indirect effects of decreased physical activity leading to obesity and its possible associated impact on sperm production. But it is sometimes too early to come to a conclusion as the widely publicized and controversial American study on the effects of mobile telephone signals on sperm production in rats was not easily accepted by the wider scientific community.

However research into treatment of this challenging condition has been continuing and has resulted in revolutionary new possibilities. ICSI or intracytoplasmic sperm injection had revolutionized the treatment of male fertility with the ability to use the sperm from men who have had trouble conceiving due to poor quality sperm that had defects in movement, were too few in number or had other problems not detectable by conventional microscopy. In this technique sperm are picked up with a micro-needle and placed within the oocyte. The union of the egg and sperm take place and viable embryos grow out of this union. These embryos are then deposited in the uterus resulting in healthy births in a high percentage of patients. It is reported that thousands of cases have been performed since that path breaking moment in Brussels when sperm were first successfully injected into the center of a human egg. But it has never been entirely clear whether the entire natural sequence of events leading to fertilization is being repeated after ICSI is performed. However the results in terms of live births have been encouraging and as a result there is a definite trend towards increasing use of these techniques. The European society for human reproduction and embryology in its annual reports point to this trend and it is assumed that this increase is both due to an increasing incidence of male fertility as well as increasing confidence in the outcome of this technique.

Another remarkable extension of this technique was when the first successful pregnancies were reported after the use of sperm that were surgically removed from the testes of men who do not have sperm in the semen. Although there were initial concerns about the plausibility of gaining healthy live babies from sperm that are still developing in the testes, the results over the years have given immense confidence to the medical community. As a result thousands of males who could not have imagined having a child have undergone the testicular sperm extraction procedure followed by ICSI and have children of their own.

But sperm pathologies have continued to remain a challenge and ongoing research has yielded few answers to the reason why many men fail to conceive despite all these advanced techniques and seemingly normal partners. There is plenty of evidence to show that genetic defects in the sperm could result in a form of self selection such that these genetically abnormal sperm fail to initiate or complete the sequence of events leading to a healthy embryo. These gene defects are not visible in a normal microscope nor can any sperm that has been exposed to tests to determine the presence of these defects be used for ICSI as these techniques are destructive to the cells. The only test that has shown a relationship to potential is the structural appearance of the sperm cells. These defects can be of numerous types with defects observed in the head, neck or tail of these cells. This simple test of observation is used during the ICSI technique while trying to select out sperm from among the millions of cells. As mentioned above, the most normal looking sperm are selected out using a microscopic size needle at a magnification level 200 times normal. But the power of this selection method is impeded by the magnification level that is achievable by the equipment that is designed for ICSI. This has led to researchers trying to more efficiently perform ICSI by discerning the various structural abnormalities that would not be visible with conventional technology.

A group of researchers in Israel first published their work on the IMSI (Intra-cytoplasmic morphologically selected sperm injection) technique in 2005 and this study was subsequently supported by clinical studies showing its efficacy in groups of patients with extremely severe sperm defects. In this advancement over ICSI, the sperm can be more closely examined reaching magnification levels more than 7000 times. Looking at sperm at this magnification shows defects in sperm head that cannot be seen in conventional microscopes used for ICSI. This has been an exciting new development and numerous births have been reported from extreme cases of male infertility.

Research into male fertility continues with some researchers taking up the challenge of finding methods of treatment in males whose testes do not have capacity to produce any sperm. There have been attempts in other species to create sperm cells from embryo stem cells but modern science is a long way from achieving this successfully with human cells. Until then ICSI and its more advanced version IMSI will be the answer to thousands of couples frequenting fertility clinics for treatment of sperm related problems that are not amenable to medicines or surgery.

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IMSI write up by Dr. Sawas Thotathil
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