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Male Infertility

Infertility is caused by a male factor in approximately 30%-40% of cases. An additional 20% of couples are found to have a combination of male and female factors contributing to their infertility.

About three quarters of cases of male infertility are related to either low sperm count, poor motility (i.e.: the number of sperm which are viable and moving), or abnormal morphology (i.e.: malformed sperm). While there are many theories about what causes these conditions, it is not always possible for the fertility specialist to identify the cause. Sometimes an infection may be indicated by finding white cells in the semen and can be effectively treated by a Urologist. At other times, stress can cause temporary erectile or ejaculatory problems.

The remaining one-quarter of male infertility results from obstructions in the testes, environmental causes (such as smoking and hot tubs), hormonal deficiency, or auto-immune factors.

Unlike female infertility, which requires a battery of tests to diagnose, male infertility is a relatively simpler evaluation consisting of medical history, physical examination and a semen analysis. If it is normal, ususally, no other testing of the male partner is required.

Of course, the couple should ensure that the laboratory performing the semen analysis is highly experienced in this procedure and that they check the motility and morphology as well as the count.

If the semen analysis shows that there is a problem, an evaluation by a urologist- ideally one who specializes in infertility is necessary. Your partner can expect to undergo a careful examination, blood tests and an ultrasound to try to pinpoint the cause.

The semen analysis evaluation is considered normal if the sperm concentration is over 20 million/ml; motility (percentage of forward moving sperm) is over 50%; morphology(normal shape sperm) is over 14% and semen volume is greater than 2 ml. in addition, the semen is evaluated for the presence of white cells which may indicate that an infection is present. Semen culture can identify the bacteria responsible for the infection so that appropriate antibiotics can be prescribed by the physician.

The Urologist may ask the husband about history of surgery such hernia repair, mumps, injury to the testicles or exposure to heat which may adversely affect both sperm count and motility. The urologist will probably inquire about marijuana, cocaine and alcohol use as they may decrease testosterone level or sperm production. Anabolic steroids for body building should be avoided because of severe and potentially irreversible suppression of sperm production.

Absence of sperm in the semen may be caused by ejaculation of the sperm into the bladder (retrograde ejaculation), congenital absence of the vas deferens (sperm transport ejaculatory duct), scarring of the ejaculatory duct or testicular failure.

Testicular failure can be distinguished from sperm transport abnormalities by measuring the husband’s hormonal profile; these include Follicle Stimulating Hormone (FSH), Luteinizing Hormone (LH), Inhibin, Testosterone, Prolactin and Thyroid stimulating Hormone (TSH).

When testicular sperm production is normal, sperm can be retrieved directly from the testicle by needle biopsy(TESA) and utilized to achieve pregnancy by In Vitro Fertilization (IVF) and injection of a single sperm into the egg or Intracytoplasmic Sperm Injection (ICSI).

In some men, low or absent sperm may be attributed to deletion of very small regions in their Y chromosome (DAZ) and can be detected by genetic studies.

Varicocele (abnormal dilatation of the testicular veins) can be found in about 30% of infertile males. Varicocele is thought to cause sperm abnormalities by increasing blood flow to the testicles and raising testicular temperature. Some urologists advocate surgery to remove the dilated veins (varicocelectomy) but the benefits of the surgery have not been conclusive.

Many tools are available to the fertility specialist for treating male infertility.

In mild cases, super-ovulation (a procedure in which the wife is given fertility drugs (below) to stimulate formation of several eggs (right) , thus increasing the possibility that any one will fertilize) after Intrauterine Insemination (IUI). With IUI, the husband's semen is washed, capacitated and concentrated and then injected directly into the uterus. Follistim Injection

When auto-immune factors are present, the sperm are first purified in a technique called "sperm washing."

In Vitro Fertilization (IVF) is also frequently utilized to treat severe male factor infertility or in cases where superovulation and insemination has not been successful.

Recently, two high-tech breakthroughs have increased the odds significantly for couples with severe male infertility undergoing IVF:

Utilizing "ICSI" (pronounced "icksy"), which stands for IntraCytoplasmic Sperm Injection, a single sperm is all that is needed. It can be injected, using microscopic techniques (micromanipulation), directlys into an egg. In this procedure, the wife undergoes a normal IVF cycle. However, when it is time to fertilize the egg, a single sperm is drawn into a very thin-tipped pipette. The tip of the pipette is inserted into the egg and the sperm is then released directly into the egg. This process can be repeated for each egg.

Or, if a man has no sperm whatsoever in the ejaculate, it is now possible to remove a few sperm cells directly from testicular tissue, utilizing a procedure called "TESA" (Testicular Sperm Aspiration). These cells can then be injected into an egg using the ICSI procedure described above.

For couples who do not want to undergo IVF, artificial insemination by donor sperm (AID) can be used. Modern sperm banks use very careful screening procedures before accepting a man as a donor. The couple never meets the donor or knows his identity, but they are provided with a description and medical history. AID has been used for many years by fertility specialists with much success.

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