Male Infertility
Male infertility is any health issue in a man that lowers the chances of his female partner getting pregnant.
About 13 out of 100 couples can’t get pregnant with unprotected sex. There are many causes for infertility in men and women. In over a third of infertility cases, the problem is with the man. This is most often due to problems with his sperm production or with sperm delivery.
What Happens Under Normal Conditions?
The man’s body makes tiny cells called sperm. During sex, ejaculation normally delivers the sperm into the woman’s body.
The male reproductive system makes, stores, and transports sperm. Chemicals in your body called hormones control this. Sperm and male sex hormone (testosterone) are made in the 2 testicles. The testicles are in the scrotum, a sac of skin below the penis. When the sperm leave the testicles, they go into a tube behind each testicle. This tube is called the epididymis.
Just before ejaculation, the sperm go from the epididymis into another set of tubes. These tubes are called the vas deferens. Each vas deferens leads from the epididymis to behind your bladder in the pelvis. There each vas deferens joins the ejaculatory duct from the seminal vesicle. When you ejaculate, the sperm mix with fluid from the prostate and seminal vesicles. This forms semen. Semen then travels through the urethra and out of the penis.
Male fertility depends on your body making normal sperm and delivering them. The sperm go into the female partner’s vagina. The sperm travel through her cervix into her uterus to her fallopian tubes. There, if a sperm and egg meet, fertilization happens.
The system only works when genes, hormone levels and environmental conditions are right.
WHAT CAUSES MALE INFERTILITY?
Making mature, healthy sperm that can travel depends on many things. Problems can stop cells from growing into sperm. Problems can keep the sperm from reaching the egg. Even the temperature of the scrotum may affect fertility. These are the main causes of male infertility:
Sperm Disorders
The most common problems are with making and growing sperm. Sperm may:
- not grow fully
- be oddly shaped
- not move the right way
- be made in very low numbers (oligospermia)
- not be made at all (azoospermia)
Sperm problems can be from traits you’re born with. Lifestyle choices can lower sperm numbers. Smoking, drinking alcohol, and taking certain medications can lower sperm numbers. Other causes of low sperm numbers include long-term sickness (such as kidney failure), childhood infections (such as mumps), and chromosome or hormone problems (such as low testosterone).
Damage to the reproductive system can cause low or no sperm. About 4 out of
every 10 men with total lack of sperm (azoospermia) have an obstruction (blockage).
A birth defect or a problem such as an infection can cause a blockage.
Varicoceles
Varicoceles are swollen veins in the scrotum. They’re found in 16 out of 100 of all men. They are more common in infertile men (40 out of 100). They harm sperm growth by blocking proper blood drainage. It may be that varicoceles cause blood to flow back into your scrotum from your belly. The testicles are then too warm for making sperm. This can cause low sperm numbers.
Retrograde Ejaculation
Retrograde ejaculation is when semen goes backwards in the body. They go into your bladder instead of out the penis. This happens when nerves and muscles in your bladder don’t close during orgasm (climax). Semen may have normal sperm, but the semen cannot reach the vagina.
Retrograde ejaculation can be caused by surgery, medications or health problems of the nervous system. Signs are cloudy urine after ejaculation and less fluid or “dry” ejaculation.
Immunologic Infertility
Sometimes a man’s body makes antibodies that attack his own sperm. Antibodies are most often made because of injury, surgery or infection. They keep sperm from moving and working normally. We don’t know yet exactly how antibodies lower fertility. We do know they can make it hard for sperm to swim to the fallopian tube and enter an egg. This is not a common cause of male infertility.
Obstruction
Sometimes sperm can be blocked. Repeated infections, surgery (such as vasectomy), swelling or developmental defects can cause blockage. Any part of the male reproductive tract can be blocked. With a blockage, sperm from the testicles can’t leave the body during ejaculation.
Hormones
Hormones made by the pituitary gland tell the testicles to make sperm. Very low hormone levels cause poor sperm growth.
Chromosomes
Sperm carry half of the DNA to the egg. Changes in the number and structure of chromosomes can affect fertility. For example, the male Y chromosome may be missing parts.
Medication
Certain medications can change sperm production, function and delivery. These medications are most often given to treat health problems like:
- arthritis
- depression
- digestive problems
- infections
- high blood pressure
- cancer
HOW IS MALE INFERTILITY DIAGNOSED?
- Causes of male fertility can be hard to diagnose. The problems are most often with sperm production or delivery. Diagnosis starts with a full history and physical exam. Your health care provider may also want to do blood work and semen tests.
History and Physical Exam
- Your health care provider will take your health and surgical histories. Your provider will want to know about anything that might lower your fertility. These might include defects in your reproductive system, low hormone levels, sickness or accidents.
- Your provider will ask about childhood illnesses, current health problems, or medications that might harm sperm production. Such things as mumps, diabetes and steroids may affect fertility. Your provider will also ask about your use of alcohol, tobacco, marijuana and other recreational drugs. He or she will ask if you’ve been exposed to ionizing radiation, heavy metals or pesticides. Heavy metals are an exposure issue (e.g. mercury, lead arsenic). All of these can affect fertility.
- Your health care provider will learn how your body works during sex. He or she will want to know about you and your partner’s efforts to get pregnant. For example, your healthcare provider may ask if you’ve had trouble with erections.
- The physical exam will look for problems in your penis, epididymis, vas deferens, and testicles. Your doctor will look for varicoceles. They can be found easily with a physical exam.
Semen Analysis
- Semen analysis is a routine lab test. It helps show the cause of male infertility. The test is most often done twice. Semen is collected by having you masturbate into a sterile cup. The semen sample is studied. It can be checked for things that help or hurt conception (fertilization).
- Your health care provider will study your sperm volume, count, concentration, movement (“motility”), and structure. The quality of your sperm tells much about your ability to conceive (start a pregnancy). For instance, semen is normal if it turns from a pearly gel into a liquid within 20 minutes. If not, there may be a problem with the seminal vesicles, your male sex glands. Lack of fructose (sugar) in a sperm-free sample may mean there are no seminal vesicles. Or it may mean there is a blocked ejaculatory duct.
- Even if the semen test shows low sperm numbers or no sperm, it may not mean you are permanently infertile. It may just show there’s a problem with the growth or delivery of sperm. More test may be needed.
Transrectal Ultrasound and/or Scrotal Ultrasound
- Your health care provider may order a transrectal ultrasound. Ultrasound uses sound waves bouncing off an organ to get a picture of the organ. The health care provider can see if structures such as the ejaculatory duct or seminal vesicles are poorly formed or blocked.
Testicular Biopsy
- If a semen test shows a very low number of sperm or no sperm you may need a testicular biopsy. This test can be done in an operating room with general or local anesthesia. A small cut is made in the scrotum. It can also be done in a clinic using, a needle through the numbed scrotal skin. In either case, a small piece of tissue from each testicle is removed and studied under a microscope. The biopsy serves 2 purposes. It helps find the cause of infertility. And it can collect sperm for use in assisted reproduction.
Hormonal Profile
- The health care provider may check your hormones. This is to learn how well your testicles make sperm. It can also rule out major health problems. For example, follicle-stimulating hormone (FSH) is the pituitary hormone that tells the testicles to make sperm. High levels may mean your pituitary gland is trying to get the testicles to make sperm, but they won’t.
HOW IS MALE INFERTILITY TREATED?
Treatment depends on what’s causing infertility. Many problems can be fixed with drugs or surgery. This would allow conception through normal sex. The treatments below are broken into 3 categories:
- Non-surgical therapy for Male Infertility
- Surgical Therapy for Male Infertility
- Treatment for Unknown Causes of Male Infertility
Non-Surgical Treatment for Specific Male Infertility Conditions
Many male infertility problems can be treated without surgery.
Hyperprolactinemia
Hyperprolactinemia is when the pituitary gland makes too much of the hormone prolactin. It’s a factor in infertility and erectile dysfunction. Treatment depends on what’s causing the increase. If medications are the cause, your health care provider may stop them. Drugs may be given to bring prolactin levels to normal. If a growth in the pituitary gland is found, you may be referred to
a neurosurgeon.
Hypogonadotropic Hypogonadism
Hypogonadotropic hypogonadism is when the testicles don’t make sperm due to poor stimulation by the pituitary hormones. This is due to a problem in the pituitary or hypothalamus. It’s the cause of a small percentage of infertility in men. It can exist at birth (“congenital”). Or it can show up later (“acquired”).
The congenital form, known also as Kallmann’s syndrome, is caused by lower amounts of gonadotropin-releasing hormone (GnRH). GnRH is a hormone made by the hypothalamus. The acquired form can be triggered by other health issues such as:
- pituitary tumors
- head trauma
- anabolic steroid use.
If hypogonadotropic hypogonadism is suspected, your health care provider may want you to have an MRI. This will show a picture of your pituitary gland. You will also have a blood test to check prolactin levels. Together, an MRI and blood test can rule out pituitary tumors. If there are high levels of prolactin but no tumor on the pituitary gland, your provider may try to lower your prolactin first. Gonadotropin replacement therapy would be the next step. During treatment, blood testosterone levels and semen will be checked. Chances for pregnancy are very good. The sperm resulting from this treatment are normal.
Retrograde Ejaculation
Retrograde ejaculation, semen flowing back instead of going out the penis, has many causes. It can be caused by:
- prostate or bladder surgeries
- diabetes
- spinal cord injury
- anti-depressants
- certain anti-hypertensives
- medications used to treat prostate enlargement (BPH)
Retrograde ejaculation is found by checking your urine for sperm. This is done under a microscope right after ejaculation. Drugs can be used to correct retrograde ejaculation.
Surgical Therapy for Male Infertility
Varicocele Treatments
Varicoceles can be fixed with minor outpatient surgery called varicocelectomy. Fixing these swollen veins helps sperm movement, numbers, and structure.
Azoospermia Treatments
If your semen lacks sperm (azoospermia) because of a blockage, there are many surgical choices.
Microsurgical Vasovasostomy
Vasovasostomy is used to undo a vasectomy. It uses microsurgery to join the 2 cut parts of the vas deferens in each testicle.
Vasoepididymostomy
Vasoepididymostomy joins the upper end of the vas deferens to the epididymis. It’s the most common microsurgical method to treat epididymal blocks.
Treatment for Unknown Causes of Male Infertility
Sometimes it’s hard to tell the cause of male infertility. This is called “non-specific” or “idiopathic” male infertility. Your health care provider may uses experience to help figure out what works. This is called “empiric therapy.” Because infertility problems are often due to hormones, empiric therapy might balance hormone levels. It’s not easy to tell how well empiric treatments will work. Each case is different.
Assisted Reproductive Techniques
If infertility treatment fails or isn’t available, there are ways to get pregnant without sex. These methods are called assisted reproductive techniques (ARTs). Based on the specific type of infertility and the cause, your health care provider may suggest:
Intrauterine Insemination (IUI)
For IUI, your health care provider places the sperm into the female partner’s uterus through a tube. IUI is often good for low sperm count and movement problems, retrograde ejaculation, and other causes of infertility.
In Vitro Fertilization (IVF)
IVF is when the egg of a female partner or donor is joined with sperm in a lab Petri dish. For IVF, the ovaries must be overly stimulated. This is often done with drugs. It allows many mature eggs to be retrieved. After 3 to 5 days of growth, the fertilized egg (embryo) is put back into the uterus. IVF is used mostly for women with blocked fallopian tubes. But it’s being used more and more in cases where the man has very severe and untreatable oligospermia (low sperm count).
Intracytoplasmic Sperm Injection (ICSI)
ICSI is a variation of IVF. It has revolutionized treatment of severe male infertility. It lets couples thought infertile get pregnant. A single sperm is injected into the egg with a tiny needle. Once the egg is fertilized, it’s put in the female partner’s uterus. Your health care provider may use ICSI if you have very poor semen quality. It is also used if you have no sperm in the semen caused by a block or testicular failure that can’t be fixed. Sperm may also be taken from the testicles or epididymis by surgery for this method.
Sperm Retrieval for ART
Microsurgical methods can remove sperm blocked by obstructive azoospermia (no sperm). The goal is to get the best quality and number of cells. This is done while trying not to harm the reproductive tract. These methods include:
Testicular Sperm Extraction (TESE)
This is a common technique used to diagnose the cause of azoospermia. It also gets enough tissue for sperm extraction. The sperm taken from the testicle can be used fresh or frozen (“cryopreserved”). One or many small biopsies are done, often in the office.
Associated Treatments:
Varicocelectomy (Microsurgical, Sub-Inguinal, Laparoscopic)
Epididymal and/or Testicular (TESA) sperm retrieval for use with IVF and ICSI
Transurethral Resection of the Ejaculatory Ducts
Associated Conditions:
Disorders of the Testes and Scrotum
Assisted Reproductive Techniques
