This Web page will review the various causes of male infertility, explain what to expect at the initial doctor visit, and discuss treatment options.

Approximately 15% of couples are unable to conceive a child; 1/3 of the cases are related to the male partner, 1/3 are related to the female partner, and 1/3 are a combination of both. Thus, a male fertility problem occurs in 50% of infertile couples. It is generally accepted that an evaluation of fertility problems should begin whenever a couple expresses concern and that the male and female should be evaluated simultaneously.

What Causes Male Infertility?

Varicoceles 

The most common cause of male infertility is a varicocele, which is found in forty percent of men evaluated for infertility. A varicocele is a dilation or swelling of the veins that drain the testicle. Varicoceles can occur on one or both sides, but are most common on the left side. It is felt that varicoceles cause male infertility by raising the temperature of the testicles thus affecting the testicle's ability to produce sperm. The treatment for varicoceles is surgical ligation of the affected veins, which allows the normal functioning veins to improve the drainage of the testicle. For most patients, an improvement in sperm production can be seen 4 months after surgery. Most studies show a 65% chance of improved sperm production with 45% of couples achieving pregnancy after varicocele ligation. The Varicoceles page contains additional information 

Absence of sperm (Azoospermia)

Another cause of male infertility is complete absence of sperm in the ejaculate, known as azoospermia, which occurs in approximately 10% of infertile males. There are two reasons that azoospermia happens. 

1. Failure of the testicles to produce adequate amounts of sperm (testicular failure or non-obstructive azoospermia). Testicular failure is typically irreversible but may be treated using In Vitro Fertilization (IVF) combined with Testicular Extraction of Sperm (TESE).
     
2. Obstruction of the reproductive tract (obstructive azoospermia). In obstructive azoospermia, the testicle is producing adequate amounts of sperm but the sperm are unable to get into the ejaculate because the tubes (epididymis, vas deferens or ejaculatory duct) are blocked or absent. Vasectomy is the most common reason for blockage of the tubes. Recurrent infection of the epididymis (epididymitis) leading to scarring can also result in blockage of the tubes. Bypass of the scarred area can be accomplished with a microsurgical procedure called a microscopic vasoepididymostomy, the same procedure that is performed during a vasectomy reversal. Congenital bilateral absence of the vas deferens (CBAVD) occurs in a small percentage of men and is associated with the lung disease called cystic fibrosis. CBAVD can be treated using TESE with IVF. Blockage of the ejaculatory duct is an unusual occurrence and is caused by cysts within the prostate gland. The cysts can be opened up using a cutting instrument equipped with a small telescope (resectoscope) which is passed down the urinary tube.

Hormone Abnormalities 

Abnormalities in hormone production may be a factor. Failure of the pituitary gland to produce adequate amounts of Follicle Stimulating Hormone (FSH) and Leutinizing Hormone (LH) (Hypogonadotropic hypogonadism) can lead to decreased sperm counts. A morning blood sample can detect this problem, which can then be treated with hormone replacement therapy.

Medications/Drugs 

A wide range of chemical substances can affect sperm quality and/or quantity, including medications. The medications listed below all have been associated with male infertility:

• Allopurinol 
• Anabolic steroids
• Antihypertensives 
• Chemotherapy 
• Cimetidine 
• Colchicines 
• Cyclosporine
• Dilantin 
• Erythromycin 
• Gentamycin
• Nitrofurantoin 
• Tetracycline

Other drugs associated with infertility include tobacco, marijuana, cocaine, heroin and methadone. Excessive alcohol and caffeine use may also affect sperm production.

Testicular Trauma/Torsion

Testicular trauma or torsion may affect fertility. Testicular torsion is a condition in which the testicle twists on the cord that attaches it to the body. Approximately 30 - 40% of men with a history of testicular torsion has an abnormal semen analysis.

What to Expect at the Initial Visit

A thorough history, physical exam, and two properly performed semen analyses are the cornerstones of the male fertility evaluation. The semen sample provides valuable information and is more than just the "sperm count." Multiple parameters are examined including the volume (amount) of the ejaculate, the sperm density (count), percent motility (the percent of sperm moving), and speed (forward progression). It is important to obtain two semen analyses because normal fluctuations in the semen analysis do occur. Men with persistently abnormal semen analyses should be evaluated.

Table 1 - Minimal Standards of Adequacy

• Volume:      1.5 - 5.0 milliliters
• Sperm:        20 million per milliliter 
• Motility:       over 60%
• Speed:        Grade 3 or 4
• Morphology: Greater than 14% are normal shape (strict criteria)
• Fructose:     Present

Although the minimal standard sperm count is 20 million sperm per milliliter of semen, the "normal' sperm count for healthy males is typically 60 - 80 million per milliliter or higher. Men with sperm counts less than 60 million per milliliter should be further evaluated for male factor infertility. Another important aspect of the semen analysis is sperm motility. That is, the sperm's ability to move. Between 50 - 60% of the sperm cells should be motile. They are also "graded" on the quality of their movement, on a scale from zero to four. The semen analysis also reports the sperm's shape, or morphology. To be considered normal, a sperm must have an oval head, a normal mid-piece, and a tail. An abnormal sperm could have a tapered head, or two tails. The sperm head contains enzymes that break down the egg's protective coating and allow the sperm to penetrate the egg. High numbers of abnormal shaped sperm can lower the fertilization rate of the sperm. The normal value for sperm morphology is reported in two ways. The World Health Organization reports the percent of normal shaped sperm as greater than 60%. Another method is the Kruger classification (strict criteria) which more selectively evaluates sperm shape. The percentage of normal shaped sperm by the strict criteria is greater than 14%. The Kruger classification is used by some fertility clinics because it can more accurately predict the level of sperm fertilization. The semen analysis also reports the presence or absence of fructose. A nutrient for sperm, fructose is normally present in the semen. The volume of the ejaculate is also measured and reported. A normal amount is 1.5 - 5.0 milliliters.

At the initial visit, in addition to the semen analysis, a health history will be obtained. A simple way to obtain the health history is through use of a male infertility questionnaire. This questionnaire may be sent to you prior to the initial visit so that you can complete it at your leisure. Questions regarding past urological history, past surgical procedures, alcohol and tobacco use, medication use, and past testicular trauma will be asked. Questions regarding conditions of the work environment, such as exposures to chemicals and high temperatures, will also be asked.

A physical exam will be performed as well. During the physical you will be examined for factors that may contribute to infertility, including a varicocele.

If Dr. Schow suspects a hormone imbalance, hormone levels will be ordered.

At the initial physician visit, Dr. Schow will discuss the possible causes of the infertility as well as decide on a treatment plan. Dr. Schow will answer all of your questions, if possible, as well as provide appropriate educational materials regarding your situation.

Treatment Options

If a varicocele is detected, Dr. Schow will provide information on the treatment of varicoceles. Men with azoospermia will be treated according to the cause of the azoospermia.

If hormonal abnormalities are found to be the cause of the infertility, hormonal replacement therapy is prescribed. This may be either in the form of a tablet taken every day (Clomid), or an injection self-administered periodically throughout the week.

Counseling regarding sexual practices may occur if the questionnaire uncovers problems. Couples may be reminded that the optimal timing for intercourse is every 48 hours during the time when ovulation is most likely. They are cautioned to avoid lubricants, or use them very sparingly, as lubricants can impair sperm survival. Even saliva can impair sperm survival.

Lifestyle changes may be a part of the treatment plan. Alcohol, tobacco, and marijuana are all considered toxic to sperm. If indicated, decreasing the consumption of these drugs or eliminating them altogether will be recommended.

Assisted Reproductive Techniques (ART)

Assisted Reproductive Techniques have revolutionized male infertility care. These procedures manipulate sperm in a controlled manner and have greatly facilitated pregnancy. The procedures are typically provided by a female infertility specialist and include:

• IUI - Intrauterine insemination - involves depositing a large number of specially processed sperm into the uterus at the optimal point in the menstrual cycle.
   
• IVF - In vitro fertilization - involves harvesting eggs from the female partner and combining them with sperm in a carefully controlled laboratory procedure.
   
• ICSI - Intracytoplasmic sperm injection - a type of IVF that involves microscopically injecting a single sperm into an egg. This revolutionary procedure allows physicians to fertilize eggs even when very few sperm are available. 

Procedures provided by a male infertility specialist include:

• TESE - Testicular extraction of sperm is a procedure used to acquire sperm for IVF in the setting of azoospermia (absent sperm). Dr. Schow will remove samples of testicular tissue and give them to the embryologist. Under the microscope the embryologist will identify and collect live sperm from the testicular samples. Typically only small numbers of sperm are collected and require the use of ICSI to fertilize the egg. This technique is used for men with azoospermia as a result of testicular failure and is also indicated for men who have uncorrectable obstructive azoospermia. It should be noted that very few sperm are able to be collected using TESE and intrauterine insemination (IUI) is not possible with TESE.

These new technologies have added an entirely new dimension to male infertility treatment.  One important consideration in the use of these “high tech” treatments is the cost. Unfortunately, these forms of treatment may not be covered by insurance plans.

Conclusion

Male infertility can be a very emotional problem for couples. Misinformation and frustration with delays in diagnosis and/or treatment can occur when patients have not been properly evaluated. It is important that all couples suffering from infertility should have an evaluation by an expert in male infertility. Many infertility problems are treatable and a physician who specializes in male infertility can provide valuable assistance for couples wanting to have children.
 

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