Infertility is a major medical problem in the United States affecting approximately 2-3 million, or 1 in 6 couples. Infertility is defined as the inability to conceive after 1 year of unprotected, adequately timed intercourse. Approximately 1/3 of the cases are related to a male factor, 1/3 are due to a female cause, and 1/3 are related to a combination of a male and female factor. In other words, in almost 67% of the infertility cases a male fertility problem can be found. Overall, an evaluation should begin whenever the couple expresses concern and both the male and female should be evaluated simultaneously.
Causes of Male Infertility
The most common cause for male infertility is a varicocele, which is found in 40% of men being evaluated for infertility. If a couple has a child and is having difficulty having a second child (secondary infertility), a varicocele can be found in 80% of male patients. A varicocele is an abnormal dilation of the veins which drain the testicle in the scrotum. Varicoceles can occur on one or both sides, but typically occurs on the left side. One thought is that the pooling of blood around the testicle and the excess heat provided can create problems with the ability to produce normal sperm by the testicle. The treatment for varicoceles is surgery to tie off the abnormal veins, which then allows for an improved sperm production in approximately 67% of patients at 4 months time from the surgery.
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, and smoking can result in infertility.
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. Other sites of infection and possible obstruction include the testicle, seminal vesicle, and prostate gland.
Any medication or drug can potentially have serious adverse effects on sperm production, temporary or permanent. These include, but are not limited to the following:
- Anabolic steroids
- Calcium-channel blockers
- Chemotherapy Agents
- Chemicals (pesticides)
- Valproic Acid
Other drugs including alcohol, tobacco, excessive caffeine, marijuana, heroin, cocaine, and methadone.
Although not common, abnormalities in hormone production can be a cause of male infertility. There may be a tumor or indeterminate failure of the pituitary gland to produce adequate levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which can lead to low sperm counts and testosterone levels. Analyzing hormone levels can detect these problems, which then may be treated by medication, hormone replacement therapy, or surgery.
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. Through surgical techniques sperm may be found by testicular sperm extraction (TESE) in 50% of males and used with assisted reproductive technology 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. 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. Blockage of the ejaculatory ducts can often be opened by surgery using a small telescope. 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), and used with assisted reproductive technology to have a child.
What to expect at the Initial Visit
A thorough history and physical examination are an essential part of the evaluation. 2-3 semen analyses (sperm counts) will be obtained during subsequent visits as well as hormonal and genetic blood tests if deemed a necessary part of the evaluation. There is always a fluctuation of the sperm count which is the reason for obtaining multiple semen analyses. The patient is asked to abstain from ejaculation for 2 days prior to giving a sample for analysis. Each analysis will contain several values which are evaluated: volume, sperm density (count), motility (the percent of sperm moving), and forward progression (how well the sperm move).
Normal Semen Analysis
- PH 7.2-7.8
- Volume 1.5-5ml
- Sperm Density > 20 million/ml
- Motility >50%
- Forward Progression >2 (scale 0-4)
- Morphology >4% normal
When the sperm count is <20 million/ml this is termed oligospermia, whereas a complete lack of sperm is termed azoospermia. The volume and ph values are critical in determining whether or not a blockage in the male reproductive tract exists. It is important to remember that these numbers are just guidelines and that strict adherence is not necessary. Couples may be able to become pregnant with numbers below the given values whereas others may not be able to achieve pregnancy with superior numbers. Again, the issue of whether a male, female, or a combination of factors are involved in infertility is an important issue.
At the initial visit the history is extremely important, not only from the male patient but also from the spouse in order to provide a clue to the reason for the infertility. The medical and surgical history, trauma, infections, childhood diseases, medications, alcohol, tobacco, drug, and career are all pertinent. Also, a full sexual history including previous pregnancies with the same or different partner, timing and frequency of ejaculation, use of lubricants, libido, potency and a family history are necessary questions.
A physical examination of the patient will be performed as well. Various potential factors as a cause for the infertility, including the presence of previous surgeries, testicle size and texture, body habitus, hair distribution, presence/absence of the vas deferens, varicocele, cysts, and evidence of blockage in the reproductive tract will be searched for.
If a hormonal imbalance is suspected based on history, physical examination, and semen analyses, then blood hormone levels will be drawn.
Considerable discussion will occur during the initial office visit. The physician and the couple will discuss all potential factors involved in their infertility, decide on an appropriate treatment plan, and answer all questions if possible.
The treatment plan begins with counseling the couple concerning sexual practices. Intercourse should take place every 48 hours during the time of ovulation, which may be determined with ovulation prediction kits. Lubricants such as K-Y jelly, Lubifax, Surgilube, petroleum jelly, and saliva can impair sperm activity, whereas vegetable oil and raw egg whites do not.
Lifestyle changes such as eating a healthy diet, exercising, and maintaining an appropriate body weight are essential. Tobacco, alcohol, and drugs must be eliminated, not only because they delay conception but also can damage the baby.
Active infections are treated with the appropriate antibiotics. Hormone replacement therapy is utilized if the correct hormonal abnormality is detected. Surgery is indicated to treat a varicocele, if needed.
Spinal cord injury patients often are unable to ejaculate and thus need specific treatment. This may include stimulating ejaculation with a special vibrator, electroejaculation (an electrical probe), or surgically extracting sperm from the testicle (MicroTESE).
Vasectomy Reversal/Microreconstruction is performed in situations where a blockage exists either from a previous vasectomy, infection, previous surgery, or a condition the patient was just born with. Success of these procedures is based on microsurgical expertise and patients should research their surgeon prior to undergoing such a procedure.
Assisted Reproductive Technology (ART) has revolutionized infertility. In situations where natural pregnancy is not possible after medical, hormonal, and surgical therapy then ART may be an appropriate next step for the couple. These procedures include:
- IUI (Intrauterine Insemination): involves placing processed sperm into the uterus during the period of ovulation.
- IVF (In Vitro Fertilization): harvesting eggs from the female partner and placing them into a petri dish where the male’s sperm have been placed. The embryo is then transferred into the female for a pregnancy to occur.
- ICSI (Intracytoplasmic Sperm Injection): a highly specialized technique which involves injecting a single sperm into a single egg cell. The embryo is then transferred into the female for a pregnancy to occur.
These techniques can improve the chances of pregnancy by 5-10% with IUI up to 40-50% with IVF/ICSI. Of course, the latter comes at significant expense (approx. $20,000) to the couple, which is not covered by insurance companies. As always, if there are conditions which can be treated either with medications or surgery and allow for natural pregnancy, this is usually preferred.
The diagnosis and treatment of infertility in the couple involves many emotional, mental, psychological, and physical responses. It is important to remember that infertility is not uncommon, it is treatable and that knowledgeable, expert health care professionals can assist the couple in achieving their goal.