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Male Infertility Overview
The following information is for educational purposes only. We do not diagnose or treat the underlying cause of male infertility. This is typically done by an urologist. However, treatment such as inseminations or in vitro fertilization are often effective in couples.
Infertility was once considered a “female problem” but we now know that male infertility is common. Some degree of male infertility is present in up to half of infertile couples. While certain exceptions exist, no significant treatment of the female should begin until male infertility has been excluded.
The semen analysis is a basic fertility test that assesses sperm quality and quantity. Sperm require three months to develop so a sample taken today is reflective of conditions three months prior, which might have changed.
A normal semen analysis has the following characteristics:
- More than 20 million sperm per milliliter
- More than 50% actively motile (ability to swim or move in straight lines)
- Adequate volume of fluid in the ejaculate
- More than 5% highly normal forms (shape) suggesting excellent fertilizing capacity by Kruger strict criteria
- Less than one million white blood cells per one milliliter of semen
Unlike females whose fertility declines with age, most males retain fertility throughout their lifetimes. Male infertility occurs when quality sperm cannot be produced and ejaculated into the vagina, swim through the cervix into the uterus, and be present in sufficient quantity to initiate fertilization and subsequent pregnancy.
There are several causes of male infertility:
- Obstruction of the ability of the sperm to exit from the testicle: The vas deferens is the tube that transports sperm and blockages lead to infertility. The vas deferens may be congenitally deformed or there may be scar tissue as a result of infection or surgery. Microsurgery or needle aspiration procedures can be a useful way to obtain sperm for IVF. In some circumstances, such as a prior vasectomy, surgical repair can even lead to conceptions that occur naturally or with IUIs.
- Varicocoel: A varicocoel is a collection of dilated veins in the spermatic cord, which may impair the normal process for heat control of the testicle. It has been long speculated that this may affect the quality of the sperm. While surgical repair of a varicocoel is possible, it has been difficult to prove that it improves the ability to conceive.
- Environmental toxins: Smoking, excessive alcohol, marijuana, certain medications, anabolic steroids used for bodybuilding, and other environmental factors can definitely affect fertility. Every effort should be made to eliminate these factors from your lifestyle.
- Retrograde ejaculation: This is a condition where sperm are ejaculated “backward” into the bladder rather than” forward” into the urethra of the penis. Conditions such as diabetes, certain medications, or particular urologic surgeries can result in a loss of the normal muscle tone. As a result, the sperm ejaculate into the bladder. Sperm can often be retrieved from the bladder, however, and used for IUI or IVF.
- Hypogonadotropic hypogonadism: This rare hormonal condition results in reduced gonadotropin (FSH, LH) production from the brain. This is one of the few causes of male infertility that may respond to drug therapy (FSH). However, the response is not always good, the treatment course is at least three months, and it is expensive.
- Antisperm antibodies: A man can produce antibodies to his own sperm often as a result of previous testicular trauma or a vasectomy. When these antibodies are present, the sperm will crosslink with one another preventing the normal motility of the sperm necessary to reach the egg and initiate fertilization. These antisperm antibodies may also prevent fertilization by blocking the attachment of the sperm to the egg. IUI can sometimes overcome these obstacles, but many times IVF combined with ICSI is necessary.
- Unexplained or idiopathic infertility: Unfortunately, the most common cause of male infertility cannot be determined. For unknown reasons, some men simply do not produce many viable sperm.
When sperm counts are mild or moderately severe, simple infertility treatments such as IUI can be successful. IVF success rates are generally higher than those associated with an IUI, and are definitely a better choice when severe male infertility exists.
Unfortunately, there are no proven medical treatments for male infertility except in rare cases of hormonal deficiency. Even these cases require three months of therapy, which is expensive. Many male fertility enhancement products are promoted, especially on the Internet, but they lack a consensus of clinical studies documenting their effectiveness.
Some men who have had a vasectomy seek to have the procedure reversed. This is often due to a new relationship or simply regret of limiting his family size. A vasectomy reversal can be very effective, but works best when it is reversed in the first several years after the vasectomy.
The longer the duration of the vasectomy, the lower the expectations of seeing a return of sperm in the ejaculate that can result in a pregnancy. As a result, for couples contemplating a vasectomy, it may be a consideration to cryopreserve (freeze) some sperm in case a future prospective vasectomy reversal is unsuccessful.
When men have undergone a vasectomy reversal and sperm counts are extremely low, in vitro fertilization (IVF) can be very successful, especially when used in conjunction with intracytoplasmic sperm injection (ICSI).
This is a process where individual sperm are injected into individual eggs. It should be noted that an alternative to a vasectomy reversal exists whereby sperm are extracted from the male reproductive tract by a needle or operative procedure and frozen.
This allows the sperm to be utilized at a later time when the female partner undergoes an IVF procedure and the previously frozen sperm are used in an IVF cycle. When such techniques are utilized, extremely low sperm counts can still be highly successful.
Some circumstances exist where the sperm counts are too low to even consider IVF, or despite aggressive treatments a pregnancy does not occur. Under such circumstances, some couples will want to explore the use of donor sperm. We have worked with a number of excellent sperm banks through the years, which has helped us to achieve happy results for many couples.
