Male Infertility

DEFINITION

Inability to procreate touches at the heart of the emotions of most individuals. Men and women may suffer a feeling of low self-esteem and depression. Many feel a loss of virility. When a couple is infertile, they carry a heavy, often self-induced, emotional burden. Couples often deal with the matter very privately. This often isolates them from friends and family. They are made to feel that they have a rare problem while the reality is quite different. Infertility is the impairment in the ability to achieve pregnancy. Other definitions state that infertility is the inability to conceive after one year of unprotected intercourse in females less than 35 years old. There are multiple causes for infertility including male and female factors. In the United States there are about 6 million women and men affected by infertility. About 15 % - 30 % of all couples suffer from infertility. If a couple is having a problem conceiving, 35% -40% of the time the male has a problem with his sperm. Tubal and pelvic problems account for 35 %, 10% is idiopathic, 5% cervical and 15% Ovulatory in nature. The exact evaluation and treatment will vary among individuals. Infertility programs have different approaches to the way testing and treatment is done. There is no "best way" to treat infertility patients. Being informed about your treatment is important in helping to determine what is the right choice for your care. When should a couple seek help with infertility? If you and your partner have had unprotected intercourse without conception or if you suspect infertility problems due to an abnormal medical history you should seek help.

The etiology of male infertility is either congenital or acquired due to environmental toxins or disease processes.

INITIAL EVALUATION

Both partners should be evaluated preferably at the same time. Women often seek infertility evaluation before their partner and usually choose their obstetrician /gynecologist. A male needs his own doctor to render appropriate counseling, advice and therapy. For men, this usually means a urologist with an interest in male reproduction. In the male, sperm contains the genetic material that must ultimately mix with the oocyte (egg) to initiate pregnancy. Sperm are produced in the testis. Each step in the process of sperm production and transport is important for functional sperm that can fertilize the egg. Any alteration in the process may result in male infertility. Since there are many potential causes of male infertility, male assessment must go beyond a semen analysis. Of course, the most important part of the evaluation is a careful history and physical examination by a physician. This section attempts to summarize the different types of evaluation that are involved with diagnosing the cause of infertility.

• The age of the patient, the age of his partner, whether or not either one have prior proven fertility.

• Possible events in the patient's life that might have attributed to his fertility including but not limited to mumps orchitis, history of prior testicular trauma or malignancy.

• Environmental effects including use of alcohol and tobacco, use of anabolic steroids for bodybuilding or other purposes, frequent use of a hot tub, and type of underwear worn.

• Routine medications.

• Family history with special attention to the presence of cystic fibrosis in the family. Men who have cystic fibrosis or who are carriers of the cystic fibrosis gene may also have a genetic cause for infertility. The gene for cystic fibrosis can hinder the development of the vas deferens. Ascertain if there is any history of ambiguous genitalia in the family.

• History of any surgery to the genitourinary tract including orchiopexy, herniorrhaphy, or any transurethral surgery.

• Coital history including the length of time the couple has been trying unsuccessfully to conceive, the timing of intercourse, and the use of any lubricant or other material during intercourse that could be potentially spermicidal.

• History of a recent febrile illness that may have affected semen analysis parameters.

PHYSICAL EXAMINATION

A complete physical exam should be done. This will include:

• Assessment of sexual maturity, i.e. adult male growth hair pattern?

• Investigation of inguinal or scrotal incisions

• Evaluation of penis for any signs of hypospadias or epispadias or Cordee.

• Examination of testicles for consistency and size (the testicle is made up primarily of sperm so if the testicle is small, it may not be making much sperm). An irregular epididymis may indicate infection or obstruction.

• Palpation of the epididymis bilaterally (an irregular eididymis may indicate infection or obstruction).

• Palpatation of the vas deferens.

• Evaluation for inguinal hernias.

• Examination of the scrotum for possible varicocele with the patient in a standing and supine position, employing the Valsalva maneuver.

• Examination of the prostate to rule-out prostatitis. Transrectal ultrasound to rule-out ejaculatory duct cyst.

• Physical examination to rule out any chronic or unsuspected systemic diseases that may impair testicular function.

• Vasography (an x-ray that looks for blockage of the vas deferens) to evaluate for vasal obstruction within the inguinal vas deferens.

• Testis biopsy can be performed percutaneously or in an open fashion as an outpatient procedure. A needle aspiration can also be performed upon the the testicle. .

• Genetic testing for the evaluation of infertility. It is certainly advisable should the couple be considering intracytoplasmic sperm injection.

LABORATORY TESTING

Laboratory testing should include:

• The cornerstone of the male evaluation is the semen analysis. Two semen analyses (SA) spaced at least three months apart. These should be collected for analysis after 48-72 hours of abstinence from ejaculation. The lab should examine the sample within one hour of collection. The semen is analyzed for volume, sperm density, sperm motility, sperm morphology and forward progression. The sample is also analyzed for an increased number of found cells that could represent either white blood cells or immature sperm cells. Several semen analyses should be performed to assess if a particular problem is consistently present. If semen testing appears to fall into the average range, and a couple is still not achieving a pregnancy, more sophisticated testing may be necessary to better evaluate sperm function.

• Basic hormonal evaluation including FSH (follicle stimulating hormone), LH (luteinizing hormone), testosterone, and prolactin.

TREATMENT

Treatment, of course, is aimed at the presumed cause of the infertility. Treatment of male factor infertility can be divided into two basic categories of therapy:

1. Specific therapy to improve the semen quality:

• Should a varicocele (a dilated vein in the scrotum that allows blood to pool and impair semen quality) be present and the semen analyses pattern is consistent with presence of a varicocele, varicocelectomy may improve semen quality. Most specialists believe varicoceles disrupt the cooling mechanism of the testes, causing the testicles to overheat. This in turn decreases sperm production or interferes with sperm function. A correction of a varicocele has shown enhanced semen parameter and pregnancy rates. Varicoceles (more commonly found on the left side) are the most common and treatable diagnosis in our experience. Following correcting of varicoceles, approximately 70% will show improvement in semen quality. Many men have varicoceles, yet they are not the cause of infertility in many cases. It takes a knowledgeable clinician and quality laboratory testing to determine when it is appropriate to correct a varicocele, and at what point after correction there has been sufficient improvement to justify continued efforts at natural conception, or when the level of improvement has only been sufficient to allow conception through medically assisted methods.

• Some men will have no sperm in the ejaculate but will have normal sperm production. This is usually the result of a blockage in the sperm transport system. History, physical examination and a diagnostic biopsy of the testis may determine this. Obstruction at the epididymis can be congenital (developed at birth) or caused by infection, trauma, or vasectomy (epididymal blowout). In many cases, obstructions are treatable. A TRUS (transrectal ultrasound) can be performed to determine where the blockage lies. Because of the excellent visualization of the seminal vesicles, prostate, and ejaculatory duct, TRUS has become an important diagnostic technique in the evaluation process. If the ultrasound is normal, the next step may be to biopsy the testicle. If the testicular biopsy is normal, then a blockage is present either in the epididymis or vas deferens. If azoospermia (no sperm) is present in a man who has had a vasectomy, vasovasostomy (Vasectomy Reversal) may be an option. In the current era of infertility treatment for male factors, sperm duct microsurgery has been increasing in frequency. Experience and technical expertise of the surgeon are critical. The most common reason to perform sperm duct microsurgery is to reverse the vasectomy. Another option is the microscopic epididymal sperm aspiration or (MESA) procedure for procurement of sperm for intracytoplasmic sperm injection (ICSI) discussed below.

• Since hormones are necessary for the production and maintenance of sperm, hormonal problems can cause infertility. Medical treatment of male factor infertility is limited. The pituitary gland in the middle of the brain secretes follicle stimulating hormone and luteinizing hormone, which affect the testicle. FSH stimulates Sertoli cells in the testicles, which supports and nurture sperm. LH stimulates cells that make testosterone, which is necessary for sperm production. Problems with either or both can create fertility problems. These substances are easily measured in blood and imbalance is treatable. The most successful uses of medication have been with gonadotropic hormones (LH and FSH) to treat patients with hypogonadism (low levels of LH and FSH. A trial of Clomiphene may be indicated. Although only one in five men will respond to Clomiphene, there are occasional cases in which oligospermia (a low sperm count) is the only problem, and in these cases a therapeutic trial is a reasonable treatment option. Other medications may improve sperm motility i.e. a dietary supplement called Proxeed.

• Obviously, the cessation of gonadotoxic drugs and substances such as alcohol, tobacco, and recreational drugs should be recommended. Many substances in the environment, in the food we eat, in the medicines we take, and the in activities we pursue affect sperm production. Smoking, drinking alcohol excessively and exposure to certain chemicals such as pesticides and insecticides or fumes from a factory can affect sperm. Some of the substances cannot be avoided yet others can. It takes about three months to see if removing that substance will alter sperm production.

• If prostatitis or pyospermia is present, antibiotics should be used. If retrograde ejaculation is present, steps should be taken to try to ensure antegrade ejaculation or the semen could be obtained from a post-ejaculatory void and used for artificial insemination.

• Antisperm antibodies can cause infertility. Sperm is like a foreign cell to the rest of the mans body. This occurs because the sperm take on many new proteins during maturation that the immune system has not seen before. The sperm hide from the immune system in the testicle, where a barrier keeps blood and white blood cells away from them. This prevents a man's allergic reaction to his own sperm. Sometimes however the immune system does see sperm and makes antibodies to attack them. These antisperm antibodies (ASA) may affect the mobility or function of the sperm. If antisperm antibodies are present, a course of steroids may be effective. Steroids such as prednisone will reduce sperm antibody levels and thereby increase sperm movement and function in nearly half of cases. However, the literature now supports using microscopic epididymal sperm aspiration as a first line therapy in this case.

• Some men will have disorders that affect the ability for a man to ejaculate normally. This includes the cases of retrograde ejaculation (sperm is ejaculated into the bladder instead of through the penis) or an ejaculation (inability to ejaculate at all). These usually result from medical problems that affect the ejaculatory mechanism. He should have a retrograde semen analysis to determine if there is sperm in the urine. Dr. Richard Chopp, Dr. Stephen Hardeman, Dr. Elizabeth Houser, Dr. Bryan Kansas, Dr. Melody Denson and Dr. Randy Fagin are equally qualified to evaluate your general infertility questions.

Some couples complete their testing without any abnormalities identified. While this may be frustrating to be diagnosed as unexplained infertility, all hope is not lost. This simply means you have reached a point in your evaluation that the more common causes of infertility have been ruled out and the best course of action is to begin coordinated attempt at pregnancy rather than continue to look for reasons why the woman is not pregnant.

2. Assisted Reproductive Technologies (ART) are techniques which bring the sperm closer to the egg.

In many cases, a treatable cause of male infertility has not been identified or treatment has not resulted in pregnancy. ART or assisted reproductive technologies may be sued to bring and place the sperm closer to the egg with the hope that this will achieve a pregnancy. Procedures that may be performed include:

• MESA or microepididymal sperm aspiration.
• TESE or testicular sperm extraction
• ICSI or Intracytoplasmic sperm injection

Male factor fertility disorders may be caused by a wide spectrum of medical problems. A team approach is necessary to help support the couple in their emotional and medical course of therapy. Evaluation and treatment from a urologist with expertise in the field of male fertility disorder is crucial.

You may also contact the Urology Team or schedule an appointment.

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