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