Male Infertility

Causes of Male Infertility

Male infertility is a significant aspect of reproductive health that deserves attention and understanding. It’s essential to recognize that infertility is not solely a female concern. In fact, infertility is caused by a male factor in approximately 30%-40% of cases. An additional 20% of infertile couples are found to have both male and female factors. By acknowledging the role of male fertility in the broader fertility landscape, we can ensure that both partners receive the comprehensive care they need on their journey towards parenthood.

Most cases of male infertility (90%) can be attributed to sperm production.

• Sperm production abnormalities
• Sperm transport disorders
• Erectile dysfunction
• Ejaculation disorders
• Abnormalities resulting in low sperm count and/or poor motility (i.e. the number of sperm which are viable and moving) 
• Abnormal morphology (i.e. malformed sperm) 

While there are many theories about what causes these conditions, it is not always possible for the fertility specialist to identify the cause. Possible causes of male infertility may include:

• Infection: Sometimes an infection may be discerned by finding inflammatory or white cells in the semen. Antibiotics can be prescribed to resolve the problem. 
• Genetic or environmentally-caused abnormalities: Sometimes the cause of sperm abnormality can be traced to genetic abnormalities, past testicular infection, environmental causes (such as smoking, hot tubs and marijuana use), hormonal deficiency (Hypogonadism), or genetic defects (cystic fibrosis). 
• Steroid or excessive testosterone use: It is becoming more common to see men with low sperm count as a result of steroids or testosterone shots given to help them bulk up. The presence of a varicocele or distended testicular veins may result in temperature elevation in the testes resulting in abnormal sperm production.
• Sperm transport disorders: Obstructions in sperm transport may be caused by infection or congenital absence of the vas or epididymis. 
• Stress, depression, alcohol or drug abuse: Sometimes, stress, depression, alcohol, certain medications and low testosterone levels may cause temporary erectile problems which may affect the couple’s ability to have sexual intercourse. 
• Retrograde ejaculation: At other times, the problem may be attributed to retrograde ejaculation or ejaculation into the bladder. This can happen after bladder or abdominal surgery, with certain medications or stricture (narrowing) of the urethra.
• Aging: As males get older, they may experience a decline in the count, motility and genetic quality of the sperm.

Diagnosing Male Infertility

Unlike female infertility, which requires numerous tests to diagnose, male infertility is a relatively simple evaluation consisting of medical history, physical examination and a semen analysis. If it is normal, usually, no other testing of the male partner is required.

Of course, the couple should ensure that the laboratory performing the semen analysis is highly experienced in this procedure and that the lab performs a complete evaluation. At Boca Fertility, our IVF laboratory is known for excellence in diagnostics and outcomes in fertility testing and treatment. 

If the semen analysis shows that there is a problem, an evaluation by an urologist (ideally one who specializes in infertility) is necessary. The male partner can expect to undergo a careful examination, blood tests and an ultrasound to try to pinpoint the cause.

Male Infertility Testing

Medical History

During your first appointment, we will start by reviewing your medical history including:

• Duration of infertility/sexual frequency
• Testicular surgery or injury
• Childhood illnesses
• Heat exposure
• Pesticide exposure
• Medications
• Smoking, alcohol and drug abuse
• Sexually transmitted diseases

Physical Examination

A physical examination may also be performed, which may reveal abnormalities of the penis or testicles, or the presence of a varicocele (abnormal enlargement of the veins in the scrotum).

Semen Analysis

In this test, freshly ejaculated semen is examined under the microscope to evaluate the number and quality of sperm and several other characteristics of the semen.

Tests for Sperm DNA Damage

Infertile men, with abnormal sperm count are more likely to have increased sperm DNA damage. The cause for this is not clear but it may occur as a result of heat exposure, radiation or chemotherapy, infection, cigarette smoking and varicocele. There are several tests for sperm DNA damage (SDD, SCSA). Their usefulness is questionable and The Practice Committee of the American Society for Reproductive Medicine issued the following statements:

• Existing data on the relationship between abnormal DNA integrity and reproductive outcomes are limited.
• Sperm DNA damage is more common in infertile men and may affect reproductive outcomes in selected couples, including those with recurrent spontaneous miscarriage or unexplained infertility
• At present, the results of sperm DNA integrity testing alone do not predict pregnancy rates achieved with intercourse, IUI, or IVF and ICSI.
• Currently, there is no proven role for routine DNA integrity testing in the evaluation of infertility.
• Treatments for abnormal DNA integrity have not been shown to have clinical value.

Treatment of Male Infertility

Once the cause for the infertility is identified, your fertility specialist will recommend the appropriate therapy. Some example treatments include:

• Antibiotic Treatment: Antibiotic medication is prescribed for 10-21 days if an infection is present.
• Lifestyle Changes: Discontinue smoking, drinking and drug use. Anabolic steroids for bodybuilding should be avoided because of severe and potentially irreversible suppression of sperm production. Avoid exposure to heat and environmental toxins.
• Hormonal Treatment with medications such as HCG and HMG (gonadotropins): injections is recommended for men with low pituitary FSH and LH levels. Clomiphene tablets 25-50mg every other day are sometimes advised in men with low sperm count and low testosterone levels. Men with an elevated prolactin level can be treated with a prolactin lowering medication (bromocriptine).
• Retrograde Ejaculation: Ejaculation of sperm into the bladder can be treated with medications such as pseudoephedrine which helps close the bladder neck, preventing sperm from entering the bladder. Another option is to recover sperm from the urine after ejaculation. In these cases, a single sperm is injected into each egg (ICSI) during In Vitro Fertilization (IVF).

Treating Varicocele

Abnormal dilatation of the testicular veins can be found in about 15 % of normal males and in 40% of infertile males. Almost all varicoceles occur on the left side. Varicocele is thought to cause sperm abnormalities by increasing blood flow to the testicles and raising testicular temperature. Varicocele can be reliably diagnosed by palpation of the scrotal sac and Doppler ultrasound. Whether or not varicocele causes infertility is controversial. Some urologists advocate surgery to remove the dilated veins (varicocelectomy), but the benefits of the surgery have not been conclusive. For an older couple with diminishing ovarian reserve, IVF and ICSI should be offered without delay. A non-surgical alternative to varicocelectomy is a radiological treatment called Embolization. The procedure is performed by an interventional radiologist who will be inserting a thin wire into the veins, draining the testis, and injecting small particles into the veins to close them off.

Conceiving with Male Infertility

Intrauterine Insemination (IUI)

IUI is indicated for mild to moderate sperm abnormalities. The semen is washed with special culture media to remove dead sperm, inflammatory cells and bacteria and is then injected into the uterus utilizing a soft catheter. The procedure is most effective when combined with ovulation induction therapy for the female partner. The woman is given gonadotropin hormone injections for about 10 days to stimulate the development of 2-4 eggs, improving the likelihood of fertilization after IUI. In Vitro Fertilization is often recommended after 3-6 unsuccessful IUI treatment cycles or for older female partners who are concerned about deterioration in the quality of their eggs.

In Vitro Fertilization (IVF)

IVF is often recommended for severe sperm abnormalities and failed IUI. IVF is a process of fertilizing an egg with a sperm in the laboratory (in vitro) to produce an embryo. The embryos are then transferred into the uterus to initiate a pregnancy.

ICSI (Intracytoplasmic Sperm Injection)

ICSI is a laboratory technique for injecting a single sperm into an egg using a high power manipulating microscope.

A single sperm is loaded into a thin glass needle, the needle is then advanced through the egg shell or zona pellucida and into the egg’s cytoplasm. The sperm is then injected into the egg and the process is repeated until all of the eggs are injected. The eggs are returned to the incubator and checked the following day to see how many are fertilized. About 80% of the injected eggs will fertilize normally to produce a zygote.

Testicular Sperm Extraction (TESE)

When sperm is present in the testes, but not in the ejaculate, it can be retrieved from the testicle by direct biopsy (TESE) or by fine needle biopsy technique called Testicular Sperm Aspiration (TESA). The extracted testicular sperm can be utilized in an In Vitro Fertilization (IVF) procedure where a single sperm is injected into the egg (ICSI).

Donor Insemination

Donor sperm insemination is a relatively low cost alternative treatment for couples with male infertility who do not wish to consider In Vitro Fertilization (IVF), or in cases where despite all efforts, no sperm could be retrieved from the male partner for IVF treatment.

Adoption

With proper evaluation and treatment, most infertile couples will eventually conceive. For those couples who remain infertile, adoption is often considered. There are numerous adoption agencies that specialize in different types of adoptions including domestic private, domestic public and international adoptions.