Medically Assisted Procreation (MAP): techniques, levels and the male role

Medically Assisted Procreation (MAP), or assisted reproduction, is the set of medical techniques that help a couple with fertility problems to achieve a pregnancy. It ranges from the simplest methods, such as intrauterine insemination, to more complex ones such as in vitro fertilisation, up to surgical techniques for retrieving sperm in cases of azoospermia. In couple infertility the man is the cause of the problem in at least 50% of cases : this is why andrological assessment is an integral part of the process.

What couple infertility is

According to the World Health Organization (WHO), couple infertility is defined when, with a woman under 35, after one year of regular unprotected intercourse no conception has occurred. Above 35 years of age in the woman, the time to wait before seeing a specialist is reduced to six months .

It is worth knowing that the human species does not have a high reproductive capacity: the probability of pregnancy in a single act of intercourse coinciding with ovulation is about 25% . Overall, about one couple of reproductive age in six (15-17%) faces fertility problems.

The male role

In couple infertility the male factor accounts for at least 50% of cases. Among the most frequent andrological causes that reduce the fertilising capacity of the semen are varicocele , undescended testicle (cryptorchidism) and orchi-epididymitis. This is why, alongside investigations in the woman, the fundamental test for the man is semen analysis (spermiogram) . More on the dedicated male infertility page.

How the diagnosis is reached

To identify the cause of infertility, beyond a careful clinical history and an examination of both partners, some targeted investigations are needed:

• In the woman : basal hormone study, ultrasound and hysterosalpingography
• In the man : the spermiogram (semen analysis) is the basic test

MAP techniques, by level

When natural conception is not achieved, medicine offers progressively more complex techniques, organised by level.

Level I: Intrauterine Insemination (IUI)

This is the simplest method. It consists of placing a semen sample, already prepared in the laboratory, directly inside the woman's uterus, to shorten the distance between sperm and egg and favour their meeting, increasing the chances of fertilisation.

Level II: In Vitro Fertilisation (IVF and ICSI)

If insemination does not succeed, the next step is In Vitro Fertilisation with Embryo Transfer (IVF) : after retrieving the oocytes from the woman, egg and sperm are brought together in the laboratory ( in vitro ), to obtain already-fertilised embryos to transfer into the uterus. Fertilisation can be by conventional IVF or by Intracytoplasmic Sperm Injection (ICSI) , in which the best sperm is selected in the laboratory and injected directly into the oocyte.

Surgical sperm retrieval: TEFNA and TESE

When the man produces no sperm in the ejaculate (azoospermia) , MAP techniques in the woman are combined with surgical procedures to retrieve sperm directly from the testicles. Depending on the clinical situation these may be:

• TEFNA : percutaneous retrieval (with a needle, less invasive)
• TESE : open surgical retrieval

The law in Italy

In Italy, MAP is governed by Law 40 of 19 February 2004 and its subsequent amendments. Over time the framework has changed significantly, largely through rulings of the Constitutional Court: in particular judgment no. 162 of 9 April 2014 removed the ban on heterologous fertilisation (using donor gametes) in cases of otherwise untreatable sterility. The legal framework is complex and continues to evolve: for the current situation and for one's own specific case, it is always advisable to consult an authorised centre and the specialist.

The National MAP Registry , established by the Ministry of Health, is managed by the Italian National Institute of Health (ISS) and collects data on authorised facilities, embryos formed and children born through these techniques.

Frequently asked questions about MAP

After how long is it called couple infertility?

According to the WHO, after one year of regular unprotected intercourse without conception, with a woman under 35. Above 35 the period is reduced to six months, because female fertility declines with age. Beyond these times, it is advisable to see a specialist for investigations in both partners.

What is the male role in couple infertility?

The man is the cause of the problem in at least 50% of cases. The most common andrological causes are varicocele, cryptorchidism and orchi-epididymitis, which reduce semen quality. The basic test for the man is the spermiogram. This is why the couple should always be assessed as a whole, not just the woman.

What is the difference between IVF and ICSI?

Both are in vitro fertilisation techniques. In conventional IVF, egg and sperm are placed together in the laboratory and fertilisation occurs spontaneously. In ICSI, a single selected sperm is injected directly into the oocyte: this is especially useful when sperm quality or number is reduced.

What are TEFNA and TESE?

They are surgical techniques to retrieve sperm directly from the testis when the man produces none in the ejaculate (azoospermia). TEFNA is a percutaneous needle retrieval, less invasive; TESE is an open surgical retrieval. The retrieved sperm is then used for in vitro fertilisation.

Is heterologous fertilisation permitted in Italy?

Yes. The ban contained in Law 40/2004 was removed by Constitutional Court judgment no. 162 of 2014, which made it possible to use donor gametes in cases of otherwise untreatable sterility. Because the matter is also regulated at regional level and is evolving, for one's own case it is best to seek information from an authorised centre.

Do you have a couple fertility problem and want to assess the male factor? Ask Prof. Natali for a consultation or book an appointment at his practices in Florence and Empoli, Italy.

The information on this page is provided for general educational purposes and does not replace a medical examination, which remains the only diagnostic tool for correct and effective treatment.