Infertility is a condition affecting both partners and each should be thoroughly evaluated. In fact, no treatment of the female should begin until the semen analysis has been completed. There is some degree of male factor infertility in 47% of infertile couples. Treatment of the female will not result in pregnancy if sperm are not capable of reaching and fertilizing an egg.
Sperm must be ejaculated into the vagina, swim through the cervical mucus, enter the uterus, and fertilize an egg at the end of the fallopian tube. There are many measures of sperm quality including the number ejaculated, their shape, their ability to swim in a straight line and others.
Sperm are produced in the testicles under the influence of the hormones testosterone, FSH and LH and low levels of these hormones impair sperm function. Rarely, there are diseases of the pituitary gland that cause reduced levels of FSH and LH. LH stimulates the Leydig cells to produce testosterone and low levels impair sperm production.
One cause of male subfertility is prolonged elevated scrotal temperature. The scrotum expands and contracts adjusting the testicles proximity to the body thus regulating temperature. Tight clothing or prolonged sitting, as seen in long distance truck drivers, can interfere with the scrotums cooling functions. Regular prolonged sitting in hot tubes may also negatively effect sperm production.
A varicocele is an abnormal mass of varicose veins in the scrotum which causes an increase in testicular temperature and can cause pain and wasting of the testicles. It most often occurs on the left side and can usually be repaired by surgery. Improvements in sperm count and function will not be seen for three months since this is the time required for sperm production. It is unclear whether varicocele surgery leads to an increase in pregnancy rates.
A man may produce antisperm antibodies which can incapacitate his sperm. The body naturally produces antibodies to foreign bodies such as bacteria, viruses, or allergens. These antibodies are essential to protect the body from infection. Antisperm antibodies usually result because the immune system has been sensitized by contact between blood cells and sperm. This can occur as a result of testicular trauma.
Retrograde ejaculation is when sperm are ejaculated “backwards” into the bladder rather than through the urethra and men with this condition have reduced semen volume. Normally the muscle around the bladder contracts to cause the sperm to enter the urethra and be propelled out the penis. Retrograde ejaculation can be caused by diabetes, some medications, and as a side effect of prostate surgery.
Sperm quantity can also be diminished by a blockage of the vas deferens, which is the tube that transports the sperm from the testicles to the urethra. If the blockage cannot be repaired surgically, IVF/ICSI is the treatment of choice.
Other factors that affect sperm “quality” are smoking, certain medications, infection, excessive alcohol, exposure to toxins such as heavy metals, heredity, and others. Changing negative behaviors can often improve sperm counts within three months.
Infections can be effectively treated with antibiotic therapy and specific hormonal disorders, such as hypogonadotropic hypogonadism (rare 5%) can be treated with injectable hormones. Other medications, such as Clomid and hCG have been tried with little success. One limitation is that medications must be given for three months and they are very expensive.
Intrauterine insemination is a first line treatment for mild male factor infertility. Sperm are provided by masturbation, washed and concentrated in special solutions, and inserted directly into the uterus. This procedure is also effective when cervical mucus problems are present.
Moderate to severe male factor infertility requires in vitro fertilization with intracytoplasmic sperm injection (ICSI), if the couple desires a child genetically related to both parents. Special procedures such as testicular sperm aspiration can be used to obtain sperm directly from the reproductive tract when there is none in the ejaculate. Otherwise, a sperm donor can be used.
We often recommend an evaluation by one of our urologists who is specially trained in male factor infertility.