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Male Infertility

Infertility is a common yet complex problem affecting approximately 10 -15 % of couples attempting to conceive a baby. In up to one third of couples having difficulty getting pregnant, the problem is at least in part related to male reproductive issues. It is essential that men be assessed to pinpoint the treatable or untreatable causes of this heartbreaking health issue. Fortunately, with today's high-tech procedures and powerful drugs, a diagnosis of infertility may simply mean the road to parenthood may be challenging but not impossible. So read below to learn more about the available treatment options so you are better prepared when talking with your urologist and/or fertility specialist.

What happens under normal conditions?

Male fertility depends on the production of normal sperm and the delivery of it to a female partner's vagina. The process begins with spermatogenesis, or the development of sperm in the testicles. Sperm cells (spermatozoa) are produced by a complicated process of cell division that occurs over a period of several months. Once formed, sperm leave the testicle and are stored in the epididymis where they fully develop. They are then pushed through the vas deferens and urethra during ejaculation. The production and maturation of sperm require the presence of an intact genetic blueprint in addition to a favorable environment. In particular, the presence of adequate levels of the male hormone testosterone and a slightly decreased scrotal temperature are necessary.

What is male infertility?

Male infertility is any condition in which the man adversely affects the chances of initiating a pregnancy with his female partner. Most commonly, those problems arise when the man is unable to produce or deliver fully-functioning sperm.

What causes male infertility?

Your doctor will be interested in any factor, including possible structural and other defects in the reproductive system, hormonal deficiencies, illness or even trauma that might be impairing your fertility. Their investigation will center on many possible combinations of factors, the most common of which are:

Sperm disorders: Problems with the production and development of sperm are the most common problems of male infertility. Sperm may be underdeveloped, abnormally shaped or unable to move properly. Or, normal sperm may be produced in abnormally low numbers (oligospermia) or seemingly not at all (azoospermia).

Varicoceles: These dilated scrotal veins are present in 16 percent of all men but are more common in infertile men—40 percent. They impair sperm development by preventing proper drainage of blood. Varicoceles are easily discovered on physical examination since the veins feel distinctively like a bag of worms. They may also be enlarged and twisted enough to be visible in the scrotum. This is the most common correctable cause of male infertility.

Retrograde ejaculation: Retrograde ejaculation occurs when semen pushes backwards into the bladder instead of out the penis. This is caused by the failure of nerves and muscles in the bladder neck to close during orgasm. It is one of several difficulties couples may have delivering sperm to the vagina during intercourse. Retrograde ejaculation can be caused by previous surgery, medications or diseases affecting the nervous system. Signs of this condition may include cloudy urine after ejaculation and diminished or "dry" ejaculation with orgasm.

Immunologic infertility: Triggered by a man's immunologic response to his own sperm, antibodies are usually the product of injury, surgery or infection. In attacking the sperm, they prevent normal movement and function of the sperm. Although researchers do not yet understand just exactly how antibodies damage fertility, they know that these antibodies can make it more difficult for sperm to swim to the uterus and penetrate eggs.

Obstruction: Blocking sperm from its normal passage, obstructions can be caused by a number of factors, such as repeated infections, prior surgery (including vasectomy), inflammation or development problems. Any portion of the male reproductive tract, such as the vas deferens or epididymis, can be obstructed, preventing normal transport of sperm from the testicles to the urethra, where it leaves the body during ejaculation.

Hormones: Hormones produced by the pituitary gland are responsible for stimulating the testicles to make sperm. Therefore, when levels are severely low, poor sperm development can result.

Genetics: Genetics play a central role in fertility, particularly since sperm carry half of the DNA mix to the partner's egg. Abnormalities in chromosomal numbers and structure as well as deletions on the important Y chromosome present in normal males can also impact fertility.

Medication: Certain medications can affect sperm production, function and ejaculation. Such medications are usually prescribed to treat conditions like arthritis, depression, digestive problems, infections, hypertension and even cancer.

How is male infertility diagnosed?

The process begins with a complete history and physical exam and is usually followed by blood work and semen analysis.

From a sample of semen routinely obtained through masturbation into a sterilized cup, the physician will be able to assess factors—volume, count, concentration, movement and structure of spermatozoa—that help or hinder conception.

Even if the semen analysis shows low sperm numbers, or even no sperm, it does not necessarily mean absolute infertility. Low values in any of the above categories may just indicate a problem with the development or delivery of sperm that simply requires further evaluation.

For instance, your physician may order a transrectal ultrasound, an imaging test that places a probe into the rectum to beam high-frequency sound waves to nearby ejaculatory ducts. This test can help your physician determine if these structures are either poorly developed or obstructed with cysts, calcifications or other blockages.

A testicular biopsy comes into play when a semen analysis shows very low number of sperm or no sperm. This test is performed in an operating room under general or regional anesthesia through a small cut in the scrotum. It may also be done in a clinic using a needle inserted through skin over the testicle that has been anesthetized. In either case, a small piece of tissue is removed from each testicle for microscopic evaluation. The biopsy serves two purposes: to determine the cause of infertility, and, if necessary, to retrieve sperm for use in assisted reproduction.

Besides a semen analysis, your doctor may order a hormonal profile to discover the sperm-producing ability of your testicles and to rule out serious conditions. For instance, follicle-stimulating hormone (FSH) is the pituitary hormone responsible for stimulating testicles to produce sperm. High levels may indicate that the pituitary is trying to stimulate the testicles to make sperm though they are not responding.

How is male infertility treated?

The treatment for male infertility depends on the specific problem. In some severe cases, no treatment is available. However, many times there are a mix of medications, surgical approaches and assisted reproductive techniques (ART) available to overcome many of the underlying fertility problems. The options are:

Surgery: Minor outpatient surgery (varicocelectomy) is frequently used to repair dilated scrotal veins (varicoceles). Studies have shown that repairing these dilated veins results in improved sperm movement, concentration and structure. In some cases, obstruction causing infertility can also be surgically corrected. In the case of a previous vasectomy, surgery using an operating microscope has been found to be very successful in reversing the obstruction.

Medication: Drugs are key in correcting retrograde ejaculation and immunologic infertility. In addition, pituitary hormone deficiency may be corrected with drugs such as clomiphene or gonadotropin.

If these techniques fail, fertility specialists have a variety of other high-tech assisted reproductive techniques that promote conception without intercourse. Depending on your problem your physician may look to:

Intrauterine insemination (IUI): By placing sperm directly into the uterus via a catheter, IUI bypasses cervical mucus that may be hostile to the sperm and puts them close to the fallopian tubes where fertilization occurs. IUI is often successful in overcoming sperm count and movement problems, retrograde ejaculation, immunologic infertility and other causes of infertility.

In vitro fertilization (IVF): Refers to fertilization taking place outside the body in a laboratory Petri dish. There, the egg of a female partner or donor is joined with sperm. With IVF, the ovaries must be overly stimulated, usually with fertility drugs that allow retrieval of multiple mature eggs. After 48 to 72 hours of incubation, the fertilized egg (embryo) is inserted in the uterus and normal pregnancy should result. While IVF is employed mostly for women with obstructed fallopian tubes, it is occasionally used for men with oligospermia.

Intracytoplasmic sperm injection (ICSI): A variation of in vitro fertilization, this procedure has revolutionized treatment of severe male infertility, permitting couples previously thought infertile to conceive. It involves injecting a single sperm directly into the egg with a microscopic needle and then, once it is fertilized, transferring it to the female partner's uterus. Your doctor is likely to use ICSI if you have very poor semen quality or lack of sperm in the semen caused by an obstruction or testicular failure. In some cases, sperm may be surgically extracted from the testicles or epididymis for this procedure.

Frequently asked questions:

What diseases can cause male factor infertility?

A variety of diseases—from kidney disease to testicular cancer—can result in male infertility. For instance, systemic conditions and metabolic disorders, along with ordinary fevers and infections, can impair the development of sperm. In addition, sexually transmitted diseases can lead to obstruction and scarring of the reproductive tract while genetic conditions, such as cystic fibrosis, may result in lack of sperm due to missing vas deferens or seminal vesicles. Since any number of illnesses can be a factor, it is essential that both you and your partner know and share your family and personal medical histories with your doctor.

Can cigarette smoke affect semen?

Yes. Research has shown that regular smoking impacts the sperm in a variety of ways. It decreases the size and movement of these cells and damages their DNA content. Smoking also can impact the seminal fluid, ejaculated with the sperm.

Can the use of steroids for body building cause infertility?

Yes. Steroids taken either by mouth or injection can shut down the production of hormones needed for sperm production.

Do abnormal semen analyses or sperm lead to children with birth defects?

Not necessarily. For the majority of couples seeking fertility treatment, the risk of conceiving a child with a birth defect is the same as the general population. Though, some disorders (especially genetic disorders) that cause infertility may also cause an increased risk of conceiving a child with birth defects. It is for this reason that couples need thorough evaluation and counseling prior to proceeding with some forms of assisted reproductive techniques.

What is the most important thing I should remember about male infertility?

Neither you nor your partner should be blamed for any problems you have with fertility. The American Society of Reproductive Medicine (ASRM) estimates that roughly one-third of infertility cases can be attributed to male factors, with another one-third due to women. In the remaining one-third of infertile couples, infertility is caused by either a combination of factors, or, in 20 percent of cases, is still unexplained. (In men, few or no sperm is the biggest problem; in women, the common problems are ovulation disorders and blocked tubes.) But today, physicians have the technology and surgical tools to address many of those problems.

Where can I find more information?

Male Infertility: Management

Varicoceles

Hormone Health Network's Infertility and Men Fact Sheet.


Reviewed: January 2011

Last updated: July 2013

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Male Infertility Glossary
  • anesthesia: Loss of sensation in any part of the body induced by a numbing or paralyzing agent. Often used during surgery to put a person to sleep.

  • anesthetized: Administered an anesthetic.

  • antibodies: Proteins that fight infections.

  • azoospermia: Absence of sperm in the ejaculate fluid.

  • biopsy: A procedure in which a tiny piece of a body part (tissue sample), such as the kidney or bladder, is removed (with a needle or during surgery) for examination under a microscope; to determine if cancer or other abnormal cells are present.

  • bladder: The bladder is a thick muscular balloon-shaped pouch in which urine is stored before being discharged through the urethra.

  • bladder neck: Area of thickened muscle fiber where the bladder joins the urethra. Acting on signals from the brain, bladder neck muscles can either tighten to hold urine in the bladder or relax to allow urine out and into the urethra. These muscles also tighten during ejaculation to prevent backflow of semen into the bladder.

  • calcification: Abnormal hardening or stiffening of a body part.

  • cancer: An abnormal growth that can invade nearby structures and spread to other parts of the body and may be a threat to life.

  • catheter: A thin tube that is inserted through the urethra into the bladder to allow urine to drain or for performance of a procedure or test, such as insertion of a substance during a bladder X-ray.

  • cervical: Relating to the neck or any part of the body that resembles a neck. In the context of reproduction, it refers to the neck of the uterus (the cervix) in the female.

  • chromosomal: Relating to a rod-shaped structure in a cell nucleus that carries the genes that determines sex and the characteristics an organism inherits from its parents.

  • chromosome: A structure consisting of DNA and proteins, found in the nucleus of a cell, which carries the genetic information in living organisms.

  • counseling: The providing of advice and guidance to a patient by a health professional.

  • cyst: An abnormal sac containing gas, fluid or a semisolid material. Cysts may form in kidneys or other parts of the body.

  • cystic: Used to describe a cyst or material that forms, contains or is enclosed in a cyst.

  • cystic fibrosis: A hereditary disease starting in infancy that affects various glands and results in secretion of thick mucous that blocks internal passages, including those of the lungs causing respiratory infections.

  • cysts: Abnormal sacs containing gas, fluid or a semisolid material.

  • depression: A disorder characterized by feelings of extreme sadness, guilt, helplessness and hopelessness, and thoughts of death.

  • diagnosis: The process by which a doctor determines what disease or condition a patient has by studying the patient's symptoms and medical history, and analyzing any tests performed (e.g., blood tets, urine tests, brain scans, etc.).

  • dilate: Widen.

  • dilated: Widened.

  • diminished: Made or became smaller

  • DNA: Also known as deoxyribonucleic acid. A molecule in the form of a twisted double strand that is the major component of chromosomes and carries genetic information.

  • ejaculate: The fluid that is expelled from a man's penis during sexual climax (orgasm). To release semen from the penis during an orgasm.

  • ejaculation: Release of semen from the penis during sexual climax (orgasm).

  • ejaculatory: Involved in or related to the structure involved in the release of semen from the penis during orgasm.

  • ejaculatory duct: The passage through which semen enters the urethra.

  • embryo: A human offspring in the early stages following conception up to the end of the eighth week.

  • epididymis: A coiled tube attached to the back and upper side of the testicle that stores sperm and is connected to the vas deferens

  • fallopian tubes: There are two fallopian tubes, one on each side of the uterus. They transport an egg from the ovary to the uterus.

  • fertile: Able to produce offspring.

  • fertility: The ability to conceive and have children.

  • fibrosis: An abnormal thickening and scarring of connective tissues.

  • frequency: The need to urinate more often than is normal.

  • gas: Material that results from: swallowed air, air produced from certain foods or that is created when bacteria in the colon break down waste material. Gas that is released from the rectum is called flatulence.

  • gene: The basic unit capable of transmitting characteristics from one generation to the next.

  • genetic: Relating to the origin of something.

  • gland: A mass of cells or an organ that removes substances from the bloodstream and excretes them or secretes them back into the blood with a specific physiological purpose.

  • gonad: The organ that forms the reproductive cells. In females, this is the ovary. In males, it is the testicles.

  • hormone: A natural chemical produced in one part of the body and released into the blood to trigger or regulate particular functions of the body. Antidiuretic hormone tells the kidneys to slow down urine production.

  • hypertension: High blood pressure, which can be caused either by too much fluid in the blood vessels or by the narrowing of blood vessels.

  • ICSI: Also referred to as intracytoplasmic sperm injection. Involves the injection of a single sperm directly into the cytoplasm of a mature egg using a glass needle.

  • immunologic: Relates to the immune system.

  • immunologic infertility: Due to antibodies to sperm, which can prevent the normal motility and function of sperm.

  • in vitro: An artificial environment like a test tube.

  • in vitro fertilization: Also referred to as IVF. A complicated process during which a woman is given medications to stimulate her ovaries to produce multiple eggs. The eggs are retrieved by aspiration and are then exposed to a man's sperm. Resulting embryos that develop may then be placed into the woman's uterus.

  • infection: A condition resulting from the presence of bacteria or other microorganisms.

  • infertile: Physically incapable of conceiving children.

  • infertility: The diminished ability or the inability to conceive and have offspring.

  • inflammation: Swelling, redness, heat and/or pain produced in the area of the body as a result of irritation, injury or infection.

  • insemination: Insertion of sperm into the woman's uterus.

  • ions: Electrically charged atoms.

  • IV: Also referred to as intravenous. Existing or occurring inside a vein.

  • IVF: Also referred to as in vitro fertilization. A complicated process during which a woman is given medications to stimulate her ovaries to produce multiple eggs. The eggs are retrieved by aspiration and are then exposed to a man's sperm. Resulting embryos that develop may then be placed into the woman's uterus.

  • kidney: One of two bean-shaped organs that filter wastes from the blood and discharge these waste products in urine. The kidneys are located on either side at the level of the 12th ribs toward the back. The kidneys send urine to the bladder through tubes called ureters.

  • liver: A large, vital organ that secretes bile, stores and filters blood, and takes part in many metabolic functions, for example, the conversion of sugars into glycogen. The liver is reddish-brown, multilobed, and in humans is located in the upper right part of the abdominal cavity.

  • male infertility: Diminished or absent capacity to produce offspring due to absence or deficiency of spermatozoa in the semen, or failure of formation of spermatozoa; the term does not denote complete inability to produce offspring as does sterility.

  • masturbation: Stimulation of genitals or other parts of the body causing sexual excitement, usually to orgasm, by some means other than sexual intercourse.

  • obstruction: something that obstructs, blocks, or closes up with an obstacle

  • oligospermia: Low number of sperm in the ejaculate.

  • orgasm: The climax of sexual excitement, consisting of intense muscle tightening around the genital area experienced as a pleasurable wave of tingling sensations through parts of the body.

  • ovaries: Female reproductive organs that produce eggs and also produce the sex hormones estrogen and progesterone.

  • ovulation: Ripening and discharge of an egg from the ovary for possible fertilization.

  • penis: The male organ used for urination and sex.

  • pituitary: Relating to or produced by the pituitary gland.

  • pituitary gland: The main endocrine gland. It is a small oval shaped structure in the head and it regulates growth, sexual maturing and metabolism.

  • pregnancy: The condition of being pregnant.

  • probe: Small device for measuring and testing.

  • pus: The yellowish or greenish fluid that forms at sites of infection.

  • rectal: Relating to, involving or in the rectum.

  • rectal ultrasound: A diagnostic test that uses very high frequency sound waves to produce an image of the rectum.

  • rectum: The lower part of the large intestine, ending in the anal opening.

  • retrograde: Backwards.

  • retrograde ejaculation: Cuased by the failure of the bladder neck to close during ejaculation allowing the ejaculate to be propelled into the bladder instead of out the penis.

  • retrograde ejaculation: Caused by the failure of the bladder neck to close during ejaculation allowing the ejaculate to be propelled into the bladder instead of out the penis.

  • scrotal: Relating to the scrotum, the sac of tissue that hangs below the penis and contains the testicles.

  • scrotal: Relating to the scrotum, the sac of tissue that hangs below the penis and contains the testicles.

  • scrotum: Also referred to as the scrotal sac. The sac of tissue that hangs below the penis and contains the testicles.

  • semen: Also known as seminal fluid or ejaculate fluid. Thick, whitish fluid produced by glands of the male reproductive system, that carries the sperm (reproductive cells) through the penis during ejaculation.

  • semen: The thick whitish fluid, produced by glands of the male reproductive system, that carries the sperm (reproductive cells) through the penis during ejaculation.

  • semen analysis: A laboratory study of semen to determine the concentration, shape and motility of sperm.

  • seminal fluid: Also known as semen or ejaculate fluid. The fluid released at orgasm which contains sperm and secretions from the prostate.

  • seminal vesicle: Two pouch-like glands behind the bladder. They produce a sugar-rich fluid called fructose that provides sperm with a source of energy that helps sperm move. The fluid of the seminal vesicles makes up most of the volume of a man's ejaculatory fluid, or ejaculate.

  • sperm: Also referred to as spermatozoa. Male germ cells (gametes or reproductive cells) that are produced by the testicles and that are capable of fertilizing the female partner's eggs. Cells resemble tadpoles if seen by the naked eye.

  • sperm count: The laboratory measurement of the number of sperm in the semen.

  • spermatozoa: Also referred to as sperm. Male germ cells that are produced by the testicles and that are capable of fertilizing the female partner's eggs. Cells resemble tadpoles if seen by the naked eye.

  • steroid: An organic fat-soluble compound.

  • systemic: Affecting the whole body.

  • testicle: Also known as testis. Either of the paired, egg-shaped glands contained in a pouch (scrotum) below the penis. They produce sperm and the male hormone testosterone.

  • testicular: Relating to the testicle (testis).

  • testicular biopsy: Removal of a sample of testicle tissue for laboratory examination.

  • testicular cancer: Cancer of the testis.

  • testosterone: Male hormone responsible for sexual desire and for regulating a number of body functions.

  • tissue: Group of cells in an organism that are similar in form and function.

  • transrectal ultrasound: Also referred to as TRUS. This is a special kind of ultrasound test in which the sound waves are produced by a probe inserted into the rectum. In men, the structures most commonly examined with this test are the prostate, bladder, seminal vesicles and ejaculatory ducts.

  • ultrasound: Also referred to as a sonogram. A technique that bounces painless sound waves off organs to create an image of their structure to detect abnormalities.

  • urethra: A tube that carries urine from the bladder to the outside of the body. In males, the urethra serves as the channel through which semen is ejaculated and it extends from the bladder to the tip of the penis. In females, the urethra is much shorter than in males.

  • urge: Strong desire to urinate.

  • urine: Liquid waste product filtered from the blood by the kidneys, stored in the bladder and expelled from the body through the urethra by the act of urinating (voiding). About 96 percent of which is water and the rest waste products.

  • urologist: A doctor who specializes in diseases of the male and female urinary systems and the male reproductive system. Click here to learn more about urologists. (Download the free Acrobat reader.)

  • urology: Branch of medicine concerned with the urinary tract in males and females and with the genital tract and reproductive system of males.

  • uterus: A hallow, muscular organ in the pelvis cavity of females in which the embryo is nourished and develops before birth.

  • vagina: The tube in a woman's body that runs beside the urethra and connects the uterus (womb)to the outside of the body. Sometimes called the birth canal. Sexual intercourse, the outflow of blood during menstruation and the birth of a baby all take place through the vagina.

  • varicocelectomy: The ligation (tying off) of a varicocele.

  • varicoceles: Dilated varicose veins in the scrotum that drain the testis and can impair the process of formation of sperm.

  • vas: Also referred to as vas deferens. The cordlike structure that carries sperm from the testicle to the urethra.

  • vas deferens: Also referred to as vas. The cordlike structure that carries sperm from the testicle to the ejaculatory duct, whicn in turn carries it to the urethra.

  • vasectomy: A surgical operation in which the vas deferens from each testicle is cut and tied to prevent the transfer of sperm during ejaculation.

  • vein: Blood vessel that drains blood away from an organ or tissue.

  • Y chromosome: The sex chromosome that determines the male sex.

Male Infertility Anatomical Drawings

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