Definition of Male Infertility
Infertility is a major medical issue in the United States. It affects approximately two to three million, or one in six, couples. Infertility is defined as the inability to conceive after one year of unprotected, adequately timed intercourse.
Approximately one third of the cases are related issues with the male, one third are due to issues with the female, and one third are related to a combination of issues in both the male and female. That means that, in almost 67% of infertility cases, a male fertility problem can be identified. Overall, an evaluation should begin as soon as the couple expresses concern. Ideally, both the male and female should both be evaluated simultaneously.
Symptoms of Male Infertility
The most common male fertility problems involve issues with making and growing sperm. Sperm may:
- Not grow fully
- Not move a particular way
- Lack of sperm (azoospermia)
- Be made in very low numbers (oligospermia)
Causes of Male Infertility
The most common cause for male infertility is a varicocele. A varicocele is an abnormal dilation of the veins which drains the testicle inside the scrotum. Varicoceles account for 40% of men being evaluated for infertility. However, if a couple has already had a child and is having difficulty having a second (secondary infertility), that number jumps to 80% of male patients. Varicoceles can occur on one side or both sides but typically occurs on the left side.
It is thought that the pooling of blood around the testicle and the excess heat provided may create problems with the ability for the testicle to produce normal sperm. The treatment for varicoceles is a microsurgery in which the abnormal veins are tied off, which then allows for improved sperm production in approximately 50% of patients in after 4 months of having the surgery performed.
Other causes for male infertility are a history and/or treatment of testicular cancer, undescended testicles, trauma, or torsion (twisting) of the testicle. Any previous surgery to the abdomen, back, pelvis, scrotum, testicle, prostate, and even a hernia repair can also be related to male infertility.
A history of diabetes mellitus, multiple sclerosis, cystic fibrosis, chemotherapy, radiation treatment, excessive alcohol, drug use, and smoking can result in infertility, temporary or permanent.
Any febrile infection can potentially affect male fertility. Mumps if contracted after puberty can cause damage to the testicles and sperm production in about 30% of patients. Sexually transmitted diseases or other bacterial infections can also affect semen quality and potentially cause obstruction in the reproductive tract, especially at the epididymis. Abnormal lubrication use can also be an issue.
Lack of Sperm (Azoospermia)
The complete lack of sperm in the ejaculate, azoospermia, occurs in approximately 10% of patients with male infertility. There are two main reasons for azoospermia:
1. Non-obstructive azoospermia: failure of the testicles to produce sperm. The patient’s hormone levels may be abnormal and a genetic cause can often be detected, which is important since this may be passed on to future children or cause a birth defect. Through surgical techniques, sperm may be found by Microsurgical Testicular Sperm Extraction (microTESE) in 65% of males and used with advanced reproductive technology IVF/ICSI ( in vitro fertilization/intracytoplasmic sperm injection) to obtain a pregnancy.
2. Obstructive azoospermia: blockage of the reproductive tract. In obstructive azoospermia, sperm is prevented from getting into the ejaculate because of a blockage in the tubal system, i.e. at the level of the testicle, epididymis, vas deferens, or ejaculatory duct. The most common cause is from a previous vasectomy which can then be undone (Vasectomy reversal). Previous infection or a genetic cause may result in a blockage of the epididymis, which may be reconstructed or bypassed through a similar procedure as a vasectomy reversal. Sometimes the vas deferens is missing, which is called Congenital Bilateral Absence of the Vas Deferens (CBAVD). Since this condition is associated with cystic fibrosis, these men and their partners must be evaluated with genetic testing. The couple may then elect to have sperm retrieved by surgery, Microsurgical Epididymal Sperm Aspiration (MESA)/ Microsurgical Testicular Sperm Extraction (microTESE), and used with advanced reproductive technology IVF/ICSI ( in vitro fertilization/intracytoplasmic sperm injection) to obtain a pregnancy.
Approximately, 600,000 vasectomies are performed each year for birth control in the United States, of which 5-10% of men choose to have a vasectomy reversal performed in the future. Reversals are performed for several reasons: new partner, change of mind, change in religious beliefs, persistent pain after a vasectomy, psychological reasons, or loss of a child. This should only be done by a fellowship trained experienced microsurgeon, such as Dr. Damani.
The microsurgical reversal is usually performed in light of a prior vasectomy, however, it may be performed because of a blockage resulting from infection, trauma, previous surgery, or genetic anomaly. There are two types of reversal or reconstruction which are performed, depending on the site of previous blockage. The two types include vasovasostomy which involves reconnecting the two ends of the vas deferens together, whereas a vasoepididymostomy involves connecting the vas deferens to the epididymis. The decision on which procedure is to be performed depends on what is seen at the time of the operation and should only be done by a fellowship trained experienced microsurgeon, such as Dr. Damani.
Dr. Damani’s success rates with Microsurgical Vasectomy Reversals are shown below:
*Success rates are based on how long ago the vasectomy was performed/allowing for recovery of sperm into the semen following surgery.
Since this procedure is not covered by insurance companies, we have fixed the rates so that the charge to the patient remains as low as possible. We are happy to answer any questions you may have.
Meet Your Doctor Manish N. Damani, M.D.