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Male Infertility and You
Likelihood of Occurrence
A male factor is involved in 60% infertility cases. Forty percent are primarily male and 20% are combined male and female. Thus, when a couple is having trouble conceiving, it makes sense to evaluate the man as well as the woman. It is recommended that a comprehensive and accurate semen analysis be scheduled at the outset to evaluate the male partner before scheduling expensive and invasive tests for the female.
Varicoceles are dilated veins in the scrotum, causing a negative effect on sperm production. Varicoceles are extremely common. Approximately 40% of men with infertility will have varicoceles. Interestingly, 80% of men with secondary infertility (they are not able to initiate an additional pregnancy) will have varicoceles. Varicoceles may be easily corrected through outpatient surgery performed by a male infertility specialist. This is done with a local and sedation, through a small incision where the pubic hair is (so no muscle is involved), and with the use of an operating microscope. Multiple studies have shown that this technique causes more improvement, and leads to significantly fewer complications and much less post operative pain.
Seminal Fluid Abnormalities
If the seminal fluid is very thick, it may be difficult for the sperm to move into the woman’s reproductive tract. Often, in cases of seminal fluid abnormalities, the sperm can be placed directly inside the uterus with intrauterine insemination (IUI).
Ductal System Problems
Ducts that carry sperm may be missing or blocked. In some situations, the ducts may be repaired or unblocked. If this is not possible, the sperm may be harvested and then injected directly into a woman’s eggs.
Men can develop an immunological response (antibodies) to their own sperm. The causes for this may include testicular trauma, testicular infection, large varicoceles, or testicular surgery. The treatment for anti-sperm antibodies is somewhat controversial. Men may be treated with corticosteroids. However, this can lead to significant morbidity in the man. The most significant is aseptic necrosis of the hip (noninfectious destruction of the joint), requiring hip replacement.
Most of the time, the first level of intervention includes intrauterine insemination. If the couple is planning in-vitro fertilization (IVF), the presence of anti-sperm antibodies is usually an indication to inject the sperm directly into the egg (ICSI) instead of conventional IVF.
Impotence: Difficulties with Erections and Ejaculations
This includes the inability to obtain or maintain an erection, premature ejaculation, lack of ejaculation, retrograde (backwards) ejaculation, lack of appropriate timing of intercourse, and excessive masturbation.
This generally refers to the inability of the sperm-producing part of the testicles to make adequate numbers of mature sperm. The testicle may completely lack the cells that divide to become sperm, sperm may be made in low numbers or there may be an inability of the sperm to complete their development. This situation may be caused by genetic abnormalities, hormonal factors or varicoceles. Even in the case where the testes are only producing low numbers of sperm, the sperm may be harvested and used with advanced reproductive techniques.
When a baby boy is born without the testes having fully descended into the scrotum, the condition is known as cryptorchidism. The current recommendation is that at approximately one year of age, if the testes have not descended by themselves, they be brought down surgically. Cryptorchidism may be a cause of testicular failure. Fifty per cent of men who have both testes undescended at birth, will have no sperm in the ejaculate even if they were surgically brought down.
There are a number of fairly common drugs that may have a negative effect on sperm production and/or function. They include:
- Ketoconazole (an anti-fungal)
- Sulfasalazine (for inflammatory bowel disease)
- Spironolactone (an anti-hypertensive)
- Calcium Channel Blockers (anti-hypertensives)
- Allopurinol, Colchicine (for gout)
- Antibiotics: Nitrofurantoin, Erythromycin, Gentamicin
- Methotrexate (cancer, psoriasis, arthritis)
- Cimetidine (for ulcer or reflux)
- The following drugs can cause ejaculatory dysfunction:
- Antipsychotics: Chlorpromazine, Haloperidol, Thioridazine
- Antidepressants: Amitripltyline, Imipramine, Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft)
- Anti-hypertensives: Guanethidine, Prazosin, Phenoxibenzamine, Phentolamine, Reserpine, Thazides
The testicles are stimulated to make sperm by pituitary hormones. If these are absent or severely decreased, the testes will not maximally produce sperm. Importantly, men who take androgens (steroids) for body building shut down the production of hormones for sperm production.
A hormonal profile must be performed on all men with male factor infertility. This will help rule out serious medical conditions, give more information on the sperm-producing ability of the testes and may reveal situations where hormonal treatment is indicated.
Men may have infections of their reproductive tract. These may include infections of the prostate (prostatitis), of the epididymis (epididymitis), or of the testes (orchitis).
Post-pubertal viral infections of the testes may cause significant damage (atrophy) of the testes and may cause absolute and irreversible infertility. Bacterial infections or sexually transmitted diseases may cause blockages of the sperm ducts.
Active bacterial or viral infections may have a negative effect on sperm production or sperm function. White blood cells, which are the body’s response to infection, may also have a negative effect on sperm membranes, making them less hearty.
If excessive white blood cells or bacteria are seen in a semen specimen, a general genital culture should be done as well as cultures for commonly asymptomatic, sexually-transmitted diseases including mycoplasma, ureaplasma, and chlamydia.
Men whose total number of moving sperm in the ejaculate (calculated by multiplying the volume of the ejaculate, by the concentration of sperm, by the percent that are moving) of less than 5 million must have genetic testing done. Sometimes, this production of low numbers of sperm is the result of genetic abnormalities that could have significant implications for children.
Cigarette smoking has been shown to significantly affect semen quality. If a man smokes, he decreases the chances of achieving a pregnancy, and increases the chances that his partner will have a miscarriage or an abnormal baby even if she is able to conceive.
Marijuana often causes a decreased average sperm count, motility, and normal morphology.
Even infrequent cocaine use causes decreased sperm count, motility, and normal morphology.
Anabolic Steroids (male hormones)
Anabolic androgenic steroids may cause severely diminished spermatogenesis or complete absence of sperm. When taken, these steroids cause a persistent depression of the hypothalamus and pituitary, which may be irreversible even when the steroids are stopped.
Moderate alcohol use does not affect male fertility. Excessive alcohol use affects the hormonal axis and is a direct gonadotoxin.
Most vaginal lubricants, including K-Y Jelly, Surgilube, and Lubifax, are toxic to sperm. The one most often recommended is Pro-Seed.
Moderate amounts of exercise can only be helpful. However, long-distance runners and distance cyclers have decreased spermatogenesis. These activities should be moderated when a sub-fertile man is attempting conception.
The general purpose of a man’s evaluation (semen analysis and, if appropriate, a consultation) is to identify any problems in order to maximize the quality of the man’s semen. This may reduce the need for more complicated interventions for the female partner. It is also important to rule out significant medical problems that may contribute to a poor semen analysis. The most important first step in any man’s evaluation is the semen analysis.
Semen is the fluid that a man ejaculates. The sperm within the semen are the cells that actually fertilize the egg and are therefore the most important to assess. However, the sperm account for only 1% to 2% of the semen volume. Problems with the surrounding fluid may also interfere with the movement and function of the sperm. Therefore, both the sperm and the fluid must be tested.
The semen analysis will help determine whether there is a male factor involved in the couple’s sub-fertility. A thorough evaluation helps determine the cause of an abnormal semen analysis and rules out medical problems.
Standard Semen Analysis Tests
Almost all laboratories will conduct tests and report on the following information, using values established by the World Health Organization:
- Concentration (count): This is a measurement of how many million sperm there are in each milliliter of fluid. Average sperm concentration is more than 60 million per milliliter. Counts of less than 20 million per milliliter are considered sub-fertile.
- Motility (mobility): This is the percentage of sperm that are moving. Fifty percent or more of the sperm should be moving.
- Morphology: This is the count of the number of normally shaped sperm. The sperm are examined under a microscope and must meet specific sets of criteria in order to be considered normal. Most commercial laboratories will use WHO morphology. Thirty percent of the sperm should be normal by these criteria.
- Volume: This is the volume of the ejaculate. Normal is two milliliters or greater.
- Total Motile Count: This is the number of moving sperm in the entire ejaculate. There should be more than 40 million motile sperm in the ejaculate.
- Standard Semen Fluid Tests: Color, viscosity, and the time until the specimen liquefies should also be measured. Abnormalities in the seminal fluid may adversely affect the sperm, or the way they get out of the fluid and move through a woman’s reproductive tract.
Additional Semen Analysis Tests
- Forward Progression: This describes how well the moving sperm are making progress. Only when the motility (percent moving) is combined with the forward progression is an accurate picture of sperm movement obtained. A man’s motility may be normal and the fact that the sperm are moving sluggishly or almost not at all will be overlooked if the forward progression is not recorded separately.
- Kruger Morphology: This is a more detailed evaluation of the morphology. A Kruger test helps determine which of the available advanced reproductive techniques may be most appropriate and successful.
- Anti-Sperm Antibodies: Some men may produce antibodies to their own sperm, which may decrease fertility rates. Semen should be routinely tested for these antibodies, as more than 10% of men whose other sperm parameters are normal will have abnormal amounts of antibodies.
- White Blood Cells: The semen may contain a high number of white blood cells (wbc’s), which may be an indication of either infection or inflammation. WBC’s cannot be differentiated from other round cells normally found in the semen (debris and immature sperm) without special staining. If more than one-million round cells are found in the ejaculate, a portion of the ejaculate should be specially stained to look for an increased number of wbc’s. If the wbc count is elevated, semen cultures (for bacterial and sexually transmitted diseases) should be performed on a subsequent specimen. The wbc’s can represent infection or inflammation. They have a negative effect on the sperm themselves. Often a course of anti-inflammatories is used. Antibiotics should only rarely be used and then should be appropriately selected based on culture results. Most men will have some bacteria in the ejaculate, which does not mean it has to be treated!
- In certain situations, specialized tests are needed. These depend on the findings at the time of the analysis and can often be performed on the same specimen.
- Spun Specimen: Even if no sperm are seen on the test slide, the sperm count may still not be zero (there may be very low numbers of sperm in the ejaculate). This has important implications as it may determine if the couple can conceive using advanced reproductive techniques. This must be assessed by spinning down the specimen so all of the sperm are concentrated in a pellet which is then examined under a microscope.
- Viability: Sperm may be alive, but not moving. A specialized staining technique is used to determine what percentage of the sperm is alive. This test is indicated when the motility (percent moving) is less that thirty percent.
- Fructose: In men with no sperm or very low numbers of sperm in the ejaculate, it is important to determine whether the sperm are not being produced at all, or whether they are being produced but are blocked from “getting into” the semen. A fructose test can help differentiate between these two problems.
- Post-Ejaculatory Urinalysis (PEU): Some men ejaculate all or part of the sperm backward into the bladder. This can be detected by having a man ejaculate and immediately afterward urinate into a separate cup. The post-ejaculatory urine is then centrifuged to see if any sperm are present.
- Expertise: Semen testing is a sophisticated and technical field. An improperly or incompletely performed semen analysis may miss significant problems. Unrecognized problems may unnecessarily delay a man’s treatment. Unlike many other lab tests, a semen analysis relies completely on the expertise of those performing it. Make sure the lab has sophisticated protocols and well-trained, specialized technicians.
- Timing: In order to get accurate results, the specimen must be processed within one hour of collection. If not, the measurement of the movement of the sperm may be extremely inaccurate. With any lab you use, make sure that the analysis is performed on site and not shipped elsewhere for evaluation.
- Thoroughness: You should use a laboratory that has the capability to do complete initial testing as well as the flexibility to do the appropriate follow-up testing on the same specimen.
- Comfort and Convenience: In order to maximize your results, it is important that you are as relaxed as possible. Ideally, the specimen should be collected at the laboratory itself in a comfortable room that is meant specifically for that purpose.
More that 50% of men will have a treatable cause of male factor infertility. When these conditions are treated, either through medication or surgery, a man will often see a significant improvement in his semen analysis. This will increase his chances of achieving a conception with a partner, either through natural intercourse or through less invasive means.
Those men whose conditions are not treatable may still have the option of using advanced reproductive techniques to achieve a pregnancy. Even those men with no sperm in the ejaculate may be able to have some living sperm procured from them through other methods and achieve a pregnancy using advanced reproductive techniques. Those few men who produce absolutely no sperm at all will have this information so that they can explore other options.
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