Male infertility was overlooked for decades as female factors were seen as paramount, male biology was relatively poorly understood and interventions limited. However, everything has changed in one lifetime; we now recognize male factor infertility as the sole, or part, cause for half of couples, and fatherhood is possible for many previously considered sterile. Australia has taken a leading role in these scientific, bioengineering, clinical practice and cultural advances.
In 1974, the Prince Henry’s Reproductive Medicine Clinic provided the first integrated clinic involving endocrinologists, urologists, gynaecologists, nurses and counsellors. It had a specialised reproductive laboratory and a donor sperm service, and was run after-hours to suit working couples.
Knowledge of sperm ultrastructure and motility, sperm-egg interactions, reproductive hormone assay and regulation of hypothalamo-pituitary-testicular function and spermatogenesis, and life table analyses of male subfertility informed evaluation, the use of gonadotrophin therapy and clinical decision-making.
In the 1980s, ART allowed real time ‘sperm function testing’, revealing key determinants such as zona binding and acrosome reactivity. Conventional IVF was successful in milder male factor, even allowing the first pregnancy with surgically recovered epididymal sperm.
Success rates improved dramatically using ICSI, especially using testicular sperm retrieval in obstructive azoospermia (diminishing the role of surgery) and spermatogenic failure e.g. Klinefelter’s syndrome (reducing need for donor sperm). Identification of genetic associations (aneuploidies, Y microdeletions, point mutations) along with embryo selection provided a degree of safety for offspring. Further genetic revelations are certain.
Overall data on the health of ART-conceived offspring is reassuring however; data specifically for ICSI/male infertility is extremely limited.
Culturally, male infertility is now widely discussed and consumers have access to excellent materials. Sadly, while all guidelines and RTAC evaluation criteria require evaluation of the male partner, this is not widely practiced nor are clinics audited. Even the national ART database (once NPSU now ANZARD) does not yet record male aetiologies or provide male factor specific outcomes.