Infertility:Men

How can male infertility be diagnosed and treated?

Causes of infertility in men
Cancer treatment: Chemotherapy and radiation can cause abnormal sperm or sterility.

DES (diethylstilbestrol) exposure: Synthetic estrogen used in the 50s and 60s used by women to prevent miscarriage. Can cause low sperm counts, decreased sperm motility, and abnormal sperm forms, small penises, undescended testicles (risk factor for testicular cancer), abnormal testicles.

Hormonal imbalances: Hormone problems affecting sperm count include thyroid problems, low testosterone levels, elevated FSH, and excess prolactin (see next entry).

Hyperprolactinemia (excess prolactin): can inhibit GnRH, resulting in lower LH and testosterone. Also low FSH.

Idiopathic oligospermia: A fancy way of saying, 'You don't have much sperm, and we have no idea why.'

Immune problems: Both men and women can have immune reactions to sperm. There is a lot of controversy about how prevalent this is. Immune reactions to sperm in the man (autoimmune) can be a problem post-vasectomy, but may also have other causes. Anti-sperm antibodies in the male are often indicated by hyperviscosity which may inhibit forward progression. In mild cases, anti-sperm antibodies in the male or female (alloimmune) may be overcome by IUIs, for which the man will be asked to ejaculate into a cup with a special preparation in it. If IUI does not work, or if the problem is considered too severe, IVF may be necessary, with ICSI likely for male anti-sperm antibodies. Predisone, a steroid, may be given to the party producing the antibodies.

Impotence: One of the less common causes. Note: impotence is a *medical* problem. There are a variety of medical causes that can contribute, including diabetes mellitus, certain required medications such as antidepressants, etc. Sexual advice from friends is generally *not* welcome. Some useful advice on impotence can be found at impotence.org. The drug Viagra, according to the manufacturer, does not appear to have any negative impact on sperm.

Infection: Postpubertal mumps, and, occasionally, venereal diseases such as gonorrhea and chlamydia can harm male fertility. Also, recurrent infections such as prostatitis can lower sperm count and motility.

Klinefelter's Syndrome: Men with Klinefelter's syndrome have two X chromosomes and one Y chromosome, rather than the normal one X and one Y. They are generally tall and thin, with small testicles. More information can be found at globalwebsol.com/vv and genetic.org.

Lifestyle factors: These include factors which raise the temperature of the scrotum (such as the use of hot tubs or long baths), or harm sperm production. A variety of medicines and recreational drugs can decrease male fertility. These include alcohol, marijuana, cocaine, cigarettes, anabolic steroids, sulfasalazine, cimetidine (Tagamet, used for ulcers), nitrofurantoin (used for UTIs), anti-hypertensive drugs (specifically calcium channel blockers), aspirin, Dilantin (for epilepsy), colchicine, and antidepressants (note that some of these drugs should *not* be simply discontinued, because they may be required for other serious medical problems). Exposure to certain chemicals, such as lead and arsenic, and many types of paints or varnishes, can also adversely affect male fertility.

Obstruction: Can occur at various points, blocking sperm from getting out. Treated surgically. Often may be easier to work around obstruction by doing MESA or TESA instead of trying to repair surgically.

Prior surgery: The vas may be damaged during surgery fo hernia repair, orchiopexy, and even during varicocelectomy.

Retrograde ejaculation: Can be caused by certain medications, surgeries, and nerve damage (for example, from diabetes mellitus). Sperm goes in the wrong direction and can be found in the urine.

Sexual Dysfunction: Reported in up to 20% of infertile men. May include decreased sexual desire, inability to maintain an erection, and premature ejaculation. This could result from low testosterone or performance anxiety.

Trauma to testicles: Injury to testicles, such as from being hit, followed by atrophy. May also be the result of having the mumps and develop bi-lateral orchitis.

Undescended testicle: If the testicles do not descend during puberty, their body temperature may be too high, reducing quality and quantity of sperm production. Rare.

Varicocele: An enlarged vein in the scrotum, which causes pooling of blood and an elevated temperature. This one is controversial. According to some, it is one of the most common and readily treatable causes of male infertility. Others say that varicocele is also common among fertile men, and question the connection with infertility and the need for treatment. Large varicoceles that go untreated can cause permanent damage to the testicles. This can lead to testicular failure or atrophy. Testicular failure is indicated by an elevated FSH and means that the testicles are starting to stop producing sperm. Testicular atrophy is indicated by small testicle size and often leads to lower testosterone levels. This affects sperm counts and can also lead to the need for testosterone replacement therapy as the man ages. Note: Testosterone replacement _should not_ be used while pursuing fertility treatments as it will make the brain think it doesn't need to make testosterone and sperm counts will diminish even further. Description of surgery with graphics is available at maleinfertility.org

Vasectomy reversal: Though vasectomies are meant as a permanent means of birth control, it turns out that they can often be reversed. However, it is easier to reverse them if not too much time has passed since the vasectomy. The more time has passed, the more likely it is that the man will have an immune reaction to his own sperm.

Evaluation process for men
Discussion of medical and surgical history. This includes a history of systemic diseases, such as viral infections (particularly postpubertal mumps and venereal disease), fevers, and diabetes mellitus, previous surgery, especially in the genitourinary area, duration of infertility, previous pregnancies, and sexual history. Many men had a hernia repair as babies and this occasionally causes a blockage of the vas due to scar tissue or to just bad surgical practices.

Physical exam: This includes an examination of testicle position in the scrotum (if the testicles haven't descended properly, the sperm will not be cool enough), an examination of the scrotum for varicoceles (varicose veins of the testicles), and an examination of the prostate and prostatic fluid for signs of infection. Also, fat and hair distribution is examined, for signs of hormone imbalance.

Urinalysis: Looks for signs of a urinary tract infection, presence of sperm in the urine (which, in conjunction with a low sperm count, may indicate retrograde ejaculation), and signs of systemic disorders such as kidney problems or diabetes mellitus.

Semen analysis: This is done at least three times, since sperm count varies, and a 2-3 day abstinence is required before each analysis. Normal values follow:
• ejaculatory volume: 1.5-5.0 cc
• sperm density: > 20 million/ml
• motility: > 60%
• forward progression: > 2, on a scale of 1-4
• morphology: > 60% normal forms (should have oval head and long tail)
1) no significant microscopic sperm clumping,
2) no significant white or red blood cells,
3) no increased thickening of the seminal fluid (hyperviscosity).

Endocrine tests: Blood tests to check levels of testosterone, FSH (follicle stimulating hormone), LH (luteinizing hormone), prolactin, estradiol, and the thyroid hormones T-4 and T-3. Usually FSH levels are measured first for men with low sperm counts, and others are measured as indicated. Some patterns of hormone abnormalities are more amenable to treatment than others. An elevated FSH is an indicator of testicular failure or the beginnings of testicular failure. If this is the case, there is little that can make a large difference in the count. Low normal or low levels of testosterone often indicate testicular atrophy (usually due to varicoceles). There is also little that can be done to change the sperm count if the levels of testosterone are low. Thyroid is an often overlooked or forgotten cause of sperm problems and is easy to check and easy to remedy. A link to general thyroid disease info is thyroid.miningco.com.

Postcoital: Checks cervical mucus for presence of sperm after coitus. If a sperm count is low, generally it is just as easy to move on to intra-uterine insemination (IUI)rather than waste a cycle or more trying to do a postcoital. The sperm of men with low counts are more delicate and have more trouble surviving in mucus than do normal men's sperm.

Sperm Penetration Assay (SPA), or Hamster test (HEPA): This tests the ability of the sperm to penetrate a specially prepared hamster egg. This test is controversial and there is no clear evidence that the results are worthwhile. (FWIW, a little hamster has to die to donate the egg.)

Testicular biopsy: Takes a small piece of testicular tissue, and checks sperm-producing tubules and cells between the tubules. Possible patterns include: Normal (the tubules and the sperm in them are normal, so the problem is likely a blockage elsewhere), maturation arrest patterns, hypospermatogenesis (elements are there, but sperm isn't), and germinal cell aplasia (there just isn't any sperm there, and the only options for parenthood are donor insemination or adoption). This test is usually done as a last resort. It is often done in conjunction with an IVF cycle where donor sperm are ready as a backup in case there are no sperm in the biopsy.

Ultrasound of seminal vesicles to show their size, development, and whether they are emptying and storing sperm properly.

Vasogram: An x-ray using a dye to outline the ducts and look for obstructions.

Comments: Infertility - Men

Comments 1 to 6 of about 6.

kim715 - 1357 days ago.
2 months of donor sperm, drugs and about 3000 dollars we are not pregnat...waiting for IVF

RaychelDavey - 1540 days ago.
We've been doing a lot of fertility tests, the doctors have said my husband has a low sperm count. They were thinking about skipping over an IUI and doing invetro, but thats very expensive. Is there a way to make the sperm stronger? obviously not smoking/drinking/drugs and stuff but anything else?

kerijade - 1546 days ago.
My hubby did a sperm sample on Monday (after only waiting 2 days, not 3-5 like they said) and today our clinic wants him to come in and do an ultrasound...but didn't say why. Has anyone else's hubby done this?Is it usual practice or is it because something is wrong? He conceived with his ex 4 years ago so I don't think he's infertile. He is diabetic though so perhaps that's why the test. Someone help please!

LANNiE - 1626 days ago.
ReadyAndWaiting - I just looked through my human biology book from high school, and it says that a man normally ejaculates about a teaspoon of semen (which is about 3mL, and that contains between 250 - 300 million sperm), so you have nothing to worry about. =]. Hope I helped.

kim715 - 1634 days ago.
me and my DH have been ttc7yrs and just found out he has low count,morph and motility. probably due to his weight and past use of drugs.....they want us to do IVF with ICSI but we cannot afford it...thinking about donor sperm

precious1299 - 1660 days ago.
You are so lucky that the reversal worked because most doctors will not do it past the five year marker. My husband had a reversal in April after only 2.5 years and we are still trying.