Male Infertility: Management
Some 10 to 15 percent of couples are still trying to conceive a baby after a year of unprotected intercourse. While many people put most of the blame on women, statistics show that this is a shared problem with male factors involved in one third of these infertility cases.
The reassuring news for men is that urologists have a variety of tools and techniques to correct many infertility problems including: hormone manipulation to raise testicular testosterone levels, artificial insemination, medications to counter retrograde ejaculation and microsurgical techniques to undo damage caused by blockages in the epididymis or vas deferens — not to mention correction of swollen veins in the scrotum called varicoceles.
But which problem affects you? More importantly, which treatment will work? The information below should help you discuss male infertility with your urologist and partner.
What occurs under normal conditions?
The male reproductive system is designed to manufacture, store and transport sperm — the microscopic genetic cells that fertilize a woman's ovum. A number of hormones, the most important of which are testosterone and follicle-stimulating hormone (FSH), regulate that process. Like sperm, testosterone is produced in both testicles, organs suspended in a pouch-like skin sac — the scrotum — below the penis.
Sperm production begins when immature cells grow and develop within a network of delicate ducts — microscopic seminiferous tubules — inside the testicles. Because these new sperm cannot move initially on their own, they are dependent on adjacent organs to become functional. They mature while traveling through the epididymis, a coiled channel located behind each testicle.
When climax, or orgasm, occurs, sperm are carried out of the body via semen, a fluid composed of secretions from various male reproductive glands, most notably the prostate and paired seminal vesicles.
What are the causes of male infertility?
Developing and transporting mature, healthy, functional sperm depends on a specific sequence of events occurring in the male reproductive tract. Many disturbances can occur along that path, preventing cells from maturing into sperm production or reaching the woman's fallopian tube where fertilization occurs.
For starters, your infertility may be caused by a diminished output of sperm by your testicles. Abnormal sperm production can also be triggered by genetic factors and a number of lifestyle choices (e.g., smoking, alcohol, and certain medications), all of which impair the normal production of sperm cells, which, in turn, decreases their number. Long-term illnesses (e.g., kidney failure), childhood infections (e.g., mumps), and hormonal or chromosomal deficiencies (e.g., insufficient testosterone) can also account for abnormal sperm numbers.
Perhaps the most prevalent sperm production problem, however, is linked to structural abnormalities, most notably varicoceles. A snake-like bundle of enlarged or dilated varicose veins around the testicles; varicoceles are the most common identifiable cause of male infertility. They are found in about 15 percent of normal males and in approximately 40 percent of infertile men, most often on the left side or simultaneously on both sides. A single, right-sided varicocele is rare. Evidence suggests that by creating an abnormal backflow of blood from the abdomen into the scrotum, triggering a rise in testicular temperature, varicoceles hinder sperm production and cause oligospermia.
Your chances of fathering a child are non-existent if your semen has no sperm to transport. Azoospermia, which accounts for 10 to 15 percent of all male infertility, refers to a complete absence of such sperm cells in your ejaculate. In its "non-obstructive" form, azoospermia can be triggered by various hormonal or chromosomal deficiencies often linked to testicular failure. But just as likely, it is the result of damage to some portion — the epididymis, vas deferens, or ejaculatory duct — of the reproductive delivery system. In fact, 40 percent of azoospermia sufferers are diagnosed with an "obstructive" form, caused by either congenital or acquired problems like infections. Vasectomy, the chief contraceptive method available to men today, is a primary example of an acquired factor. By cutting and sealing the vas deferens to stop sperm from moving through the reproductive tract, pregnancy is prevented. Vasectomies can often be reversed by use of a vasovasotomy in the hands of an experienced urologic microsurgeon. The blockage may be permanent, however, if the extent of the damage is great and the doctor is unskilled. While vasectomies are a formidable factor, there are other potential disturbances within the reproductive tract that can impede sperm. Because a proper erection is essential in impregnating any partner, it is not surprising that impotence or erectile dysfunction (ED), the inability to sustain an erection, is the most easily identified sexual problem linked to male infertility. Retrograde ejaculation, a lesser known issue, involves the improper deposit of sperm and semen. In this case, your ejaculate content may be normal, but instead of leaving the penis for the vagina, it flows backwards into the bladder due to an improperly functioning bladder neck.
How is male infertility diagnosed?
Unlike female infertility, the cause of which is often easily identified, diagnosing male factors can be difficult. The problems, however, usually fall in one of two areas — sperm production and/or delivery.
Because male infertility results from such varied factors, you will need to see your physician to sort out the possibilities. A primary care doctor can often locate the problem, correctable or not, by completing an initial evaluation. You will probably need further evaluation by a urologist or reproductive specialist if you and your partner have been trying unsuccessfully for a year to get pregnant or if you have a known male factor, such as an undescended testicle.
In any case, the evaluation usually includes medical and surgical histories. The doctor will want to know about childhood diseases (e.g., mumps), current health problems (e.g., diabetes), or even medications (e.g., anabolic steroids) that might interfere with the formation of sperm. He or she will also ask about your use of alcohol, marijuana and other recreational drugs, as well as your exposure to the occupational hazards of ionizing radiation, heavy metals and pesticides. All of these factors can affect fertility.
Every evaluation will also include an assessment of your sexual performance, along with you and your partner's joint efforts to achieve pregnancy. For instance, your doctor will investigate whether you have had difficulty with erections and if your ejaculate has sufficient quality and volume. Such factors can adversely affect your sperm's effectiveness for pregnancy.
In addition to conducting a general exam, your doctor will look for any abnormalities of the penis, epididymis, vas deferens, and testicles. He or she will focus specifically on varicoceles, which can be identified easily in the scrotum when the patient is standing because they feel like a "bag of worms."
Semen analysis is a routine test that is the single most important lab indicator for male infertility. Completed twice, it helps urologists define each factor and its severity. Performed by examining ejaculate within a few hours of masturbation, a semen analysis provides important information about semen volume and content. It also measures the amount, motility (movement) and appearance (shape) of individual sperm. Each factor tells you and your doctor much about your ability to conceive. Your semen is normal, for instance, if it liquefies from a pearly gel into a liquid within 20 minutes. A breakdown in this sequence may indicate a problem with your seminal vesicles. Likewise, a lack of fructose (sugar) in a sperm-free specimen may indicate a congenital absence of the seminal vesicles or your ejaculatory duct may be entirely blocked.
In addition to the above screens, your doctor may order other tools to assess fertility, including transurethral ultrasonography, which detects ejaculatory duct obstructions, and testicular biopsies, which confirm any reproductive blockages. Getting a complete evaluation should help you and your partner understand your infertility issues, not to mention make better decisions about treatment.
What are some treatment options?
Your treatment options will depend entirely on the factors causing your infertility. The good news is that few medical fields have changed as dramatically during the past decades as reproductive medicine, particularly as it pertains to men.
Today, many conditions can be corrected with drugs or surgery thus enabling conception to occur through normal intercourse.
Surgical Therapies for Male Infertility
Among the most exciting treatment developments are microsurgical approaches to repair dilated varicose scrotal veins to improve semen quality. You should consider treatment if you meet the following criteria:
- you and your partner are trying to conceive a child, but thus far have been unsuccessful
- you have been diagnosed with a varicocele that can be felt
- your semen analysis or sperm function tests are abnormal
- your partner has normal fertility or treatable infertility
- you are contending with a varicocele and abnormal semen
- you are an adolescent male with a varicocele and reduced testicle size
If you fit the profile, your doctor can correct your varicocele with any number of surgical options, all of which can be performed in an outpatient center under anesthesia. Some of these approaches include:
Retroperitoneal (or abdominal) approach: This conventional "open" varicocelectomy is best suited to men whose previously attempted varicocele or hernia repair resulted in significant groin scarring. Complications, which occur at a rate of 5 to 30 percent, include hydroceles, testicular atrophy and injury to the vas deferens.
Laparoscopic varicocelectomy: While this minimally invasive technique can be used successfully to isolate and repair vessels, it is accompanied by a 6 to 15 percent recurrence rate due, in part, to the preservation of a series of fine veins that may dilate with time and cause recurrence. Also, events such as intestinal injuries or infection give it an 8 to 12 percent complication rate. In addition, laparoscopy must be performed by a urologist experienced in the procedure, which is a limitation.
Microsurgical varicocelectomy: Cited by many specialists as their preferred approach, this operation uses the optical magnification of a high-powered microscope to provide direct visual access to veins and arteries. Through a mini-incision in the groin, the doctor can reliably separate and preserve testicular arteries, while identifying and ligating both large and small veins that could dilate in the future. Also, while technically demanding, microsurgical varicocelectomy virtually eliminates hydroceles, the most common surgical complications. In fact, microsurgical techniques have significantly reduced recurrence rates to less than 2 percent and complications rates to less than 5 percent while increasing fertility. The effectiveness of this procedure has been reported in the scientific literature to be as high as a 43 percent pregnancy rate for couples after one year and 69 percent after two years.
Percutaneous embolization: This non-surgical approach is aimed at occluding the varicocele after it is viewed with a specialized X-ray technique. The procedure itself uses a flexible tube inserted into the groin to place a blocking agent that helps obstruct the center of the vessel. This minimally invasive technique is often less painful than surgery, but it requires a physician with experience in interventional radiologic techniques. As such, it is performed in the radiology department.
There is no evidence to suggest that any approach is the best for correcting varicoceles. While surgery removes more than 90 percent of the swollen vein, percutaneous embolization gets rid of 80 to 85 percent. After repair, about 60 percent of men show improved sperm counts and/or motility. The effects of either treatment on fertility, however, are much less clear. While some studies show improvement, others suggest no significant change. Regardless, many infertile couples still choose varicocele repair because it improves semen in many men and may improve fertility, both at little risk.
If your semen lacks sperm (azoospermia) as a result of blockage: there are several surgical treatment options at your disposal:
Microsurgical vasovasostomy: Is designed to restore fertility by reconnecting the severed vas deferens in each testicle. The procedure, which should clear the way for sperm to leave the body, can be accomplished through various approaches, all performed in outpatient hospital or ambulatory surgical settings under general anesthesia, spinal epidurals or sometimes with localized numbing and sedation. In more than 90 percent of patients, sperm returns in the semen, yielding pregnancy in more than 50 percent of cases.
Transurethral resection of the ejaculatory duct (TURED): When properly diagnosed, ejaculatory duct obstructions can be managed surgically by passing a cystoscope into the urethra and opening the offending blockages. Resecting the duct triggers release of sperm into the ejaculate in about 50 to 75 percent of men. But there can be complications — recurrent blockages, incontinence and even retrograde ejaculation due to bladder injuries. Also, pregnancy rates are only about 25 percent.
Vasoepididymostomy: The most common microsurgical procedure for treating epididymal obstructions, vasoepididymostomy is also one of the most difficult of all treatments for male infertility. Surgeons must have excellent skills and extensive experience to perform this procedure, a surgical joining of the vas deferens and epididymis to facilitate the transport of fluid. The approach relies on the precise positioning and tying of sutures to secure tissue layers between the structures. When successful, however, an opened channel is restored in 50 to 70 percent of cases; pregnancy rates vary from 25 to 57 percent.
What can I expect after treatment?
Male infertility factors can usually be corrected in an outpatient procedure using general anesthesia or intravenous sedation. While postoperative pain is usually mild, postoperative recovery and follow up varies.
After varicocele repair, your doctor should perform a physical examination to see if the vein is completely gone. Semen should be tested about every three months for at least one year or until pregnancy. If your varicocele returns, or you remain infertile after the repair, ask your doctor about assisted reproductive techniques (ART). These high-tech procedures are often successful in circumventing the same problem to produce a pregnancy.
While vasectomy reversals cause only mild postoperative pain, expect an out-of-work recovery of four to seven days. The chance for pregnancy depends on many factors, most importantly, the age and fertility status of your female partner and the number of years between your original vasectomy and this procedure. The longer you wait, the less likely you will have a successful reversal.
How are specific male infertility conditions treated without surgery?
Anejaculation: A relatively uncommon disorder, anejaculation — or the absence of any semen — can occur as a result of spinal cord injury, previous surgery, diabetes, or multiple sclerosis. It may also be caused by abnormalities present at birth as well as other mental, emotional or unknown problems. Medical therapy with drugs is usually the first line of treatment, but if that fails, the next step is either rectal probe electroejaculation (RPE) or penile vibratory stimulation (PVS). PVS consists of rhythmic vibratory stimulation of the tip and shaft of the penis to encourage a natural climax. While relatively non-invasive, it is less successful than RPE, particularly in severe cases. RPE, except in the spinal cord injured patient, is usually performed under anesthesia and retrieves sperm in 90 percent of patients. While cell density with this procedure is excellent, sperm movement and shape are still limiting fertility factors. Assisted reproductive techniques, such as in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), have become increasingly important to patients with anejaculation.
Congenital adrenal hyperplasia (CAH): A rare cause of male factor infertility, CAH involves congenital deficiencies in certain enzymes, resulting in abnormal hormone production. CAH is usually diagnosed by demonstrating excess steroids in the blood and urine. When treated successfully with hormone replacement, sperm production increases.
Genital tract infection: It is rare that acute genital tract infections can be linked to infertility, but it does happen in approximately 2 percent of men suffering from reproduction problems. The problem is usually picked up following a simple semen analysis where white blood cells are found. White blood cells generate excess oxidants — reactive oxygen species (ROS) — known to harm the fertilizing potential of sperm. But an infection need not be acute to cause reproductive problems. For instance, testicular atrophy, along with epididymal duct obstruction, may occur following severe infection of the epididymis and testes. Chronic prostatitis, on rare occasions, may also cause obstruction by occluding the ejaculatory ducts. While antibiotics are generally prescribed for full-blown infections, they are not warranted for lesser inflammations since they can be occasionally harmful to sperm production. In those cases, non-steroidal anti-inflammatories are usually recommended.
Hyperprolactinemia: This condition of excessive production of the hormone prolactin by the pituitary gland, has been implicated in both infertility and erectile dysfunction. Treatment of hyperprolactinemia is based on the cause of the increased secretion. If medications are the root, they should be discontinued immediately. Medical therapy may consist of medications to bring prolactin levels to normal.
Hypogonadotropic hypogonadism: Hypogonadotropic hypogonadism refers to the failure of the testicles to produce sperm due to a hypothalamic or pituitary disorder. It is the cause of infertility in a small percentage of patients and can exist at birth or be acquired. Known also as Kallmann's syndrome, the congenital form results from an abnormal production of gonadotropin-releasing hormone (GnRH), a hormone produced by the hypothalamus. Acquired hypogonadotropic hypogonadism can be triggered by a variety of other conditions, including pituitary tumors, head trauma and anabolic steroid use.
When hypogonadotropic hypogonadism is suspected, doctors usually order an MRI along with serum prolactin concentrations to rule out pituitary tumors. If levels of the prolactin are excessive but there is no mass, treatment will consist of lowering prolactin concentrations before proceeding with gonadotropin replacement therapy. During treatment, blood testosterone levels and semen analyses are obtained. Chances for pregnancy are excellent, since resultant sperm are essentially normal.
Immunologic Infertility: Since the early 1950s, when scientists first demonstrated that some cases of infertility were linked to immunologic causes, much research has focused on this area. While oral steroids to decrease significant antisperm antibody have been advocated, this treatment is rarely successful. In vitro fertilization with ICSI is now the treatment of choice for immunological male factor problems.
Reactive Oxygen Species (ROS): A relatively new interest area in male infertility, ROS refers to small molecules present in many bodily fluids, such as seminal white blood and sperm cells. When in appropriate concentrations, ROS can help prepare the sperm for fertilization. However, if in excess, ROS can be harmful to other cells. Because of their already high polyunsaturated fatty acid content, human sperm membranes are particularly sensitive to ROS-related damage. Recent studies have demonstrated an increase in presence of these molecules in the semen of infertile men. Several compounds have been used to detoxify or "scavenge" ROS. The most effective of these, vitamin E (400 IU twice daily) is a very effective antioxidant. Pentoxifylline, a medication employed occasionally to decrease the thickness of blood, has also been shown to decrease sperm oxidant production, but is used much less frequently than vitamin E.
Retrograde ejaculation: Defined as an abnormal backward flow of semen into the bladder with ejaculation, it can be caused by problems that are: anatomic (e.g., previous prostate or bladder neck surgeries); neurogenic (e.g., diabetes, spinal cord injury, and previous surgery); pharmacologic (e.g., anti-depressants, certain anti-hypertensives, and medication used to treat BPH, prostate enlargement); and idiopathic (other unknown problems). Retrograde ejaculation is diagnosed by the patient urinating immediately following ejaculation to produce a sample that is evaluated microscopically for sperm. Initial treatment for retrograde ejaculation consists of commonly used medications (e.g., Sudafed). If medical therapy should fail, however, doctors may try to recover sperm from the bladder after ejaculation in conjunction with intrauterine insemination.
How are non-specific (idiopathic) male infertility conditions treated without surgery?
Non-specific male infertility factors are often unexplained or ill-defined unlike specific conditions such as retrograde ejaculation or genital tract infection. However, because these procedures often involve the body's hormonal activities, they are just as troublesome to both the treating physician and the patient. In many cases, empiric therapy — designed to address hormonal imbalances — is used.
Empiric therapies generally involve hormonal manipulation. Assessing the impact of empiric treatments is very difficult, given variations in patients as well as dosing regimens, treatment durations and outcome definitions. As such, treatment decisions chosen by individual physicians are often based on their own personal philosophies.
Frequently Asked Questions:
What is assisted reproductive techniques (ART)?
ART refers to a series of high-tech procedures used to join a sperm with eggs when sexual intercourse cannot accomplish the task. Your doctor may recommend one or a combination of these techniques, particularly if you are among the many men who fail to achieve natural pregnancy, despite a return of sperm to their ejaculate. Intrauterine insemination (IUI) — placing retrieved and processed sperm into the uterus via a catheter — or in vitro fertilization (IVF)/ intracytoplasmic sperm injection (ICSI) — may be the best and only route to pregnancy. IVF, fertilizing an egg outside the body in a laboratory setting and implanting the resulting embryo into the uterus, and ICSI, injecting a single retrieved sperm into a mature egg, are also indicated in men who choose not to have reconstructive surgery or whose duct obstruction cannot be fixed.
How sperm are surgically retrieved?
Sperm blocked by obstructive azoospermia can be removed by various microsurgical approaches. In each case, the goal is to obtain the best quality and number of cells, not to mention minimizing damage to the reproductive tract so future attempts at retrieval or surgical reconstruction are not jeopardized. Often known by their acronyms, these procedures include:
Testicular sperm extraction (TESE): This is a most common technique to not only diagnose the cause of azoospermia, but also to obtain sufficient tissue for sperm extraction to be used either fresh or as a cryopreserved (frozen) specimen. It involves one or multiple small biopsies often performed in the office.
Testicular fine needle aspiration (TFNA): Initially a diagnostic procedure in azoospermic men, it is now sometimes used to recover sperm from the testicles. A needle and syringe puncture the skin to aspirate a sperm specimen.
Percutaneous epididymal sperm aspiration (PESA): Advocated because it can be performed repeatedly at low cost, PESA, like TFNA, can be completed without a surgical incision. Because it does not require a high-powered microscope, it also does not necessitate microsurgical expertise. Instead, it is done under local or general anesthesia with the physician inserting a needle attached to a syringe into the epididymis, then gently withdrawing fluid. Sperm may not always be obtained, and the surgeon must be prepared to perform an open procedure.
Microsurgical epididymal sperm aspiration (MESA): Performed under a microscope, MESA involves direct retrieval of sperm from individual epididymal tubules. It is completed by isolating the tubes and then aspirating the fluid. Designed to limit damage to the epididymis, while avoiding blood contamination of its fluid, MESA yields high quantities of motile sperm that can be readily frozen and thawed for subsequent IVF treatments. While general anesthesia and microsurgical skill could be considered disadvantages to this process, a lower complication rate, better sperm motility and the ability to consistently have sufficient sperm for banking make MESA a simple and safe, sperm recovery technique.
If I am suffering from obstructive azoospermia, when should my partner and I consider sperm retrieval with an assisted reproductive technique rather than surgery?
Intracytoplasmic sperm injection (ICSI), a form of IVF, must be used in virtually all obstructive azoospermia cases when sperm are removed from the testicle or epididymis. This technique is employed because the number of motile sperm that can be obtained is frequently limited and the functional capacity of the sperm impaired.
Retrieving sperm cells for ICSI involves several methods (described above), the choice of which will be up to you and your urologist. It can be performed prior to or simultaneously with your partner's egg retrieval. While many reproductive centers prefer to use the "fresh" sperm obtained on the same day as the retrieval, others prefer previously harvested and frozen cells. As stated, sperm retrieval can often be accomplished by either a needle aspiration or microsurgical techniques.
If I am suffering from a varicocele, when should my partner and I consider an assisted reproductive technique (ART) rather than surgery?
If you and your partner both have fertility factors where the female cannot conceive naturally, then you may benefit from any one of several ART procedures — intrauterine insemination (IUI), in vitro fertilization (IVF)/intracytoplasmic injection (ICSI) — rather than surgical treatment of the male. The choice is not always clear, however. Since so many factors come into play, you and your doctor will want to consider the following:
- the wife's age and assessment of ovarian function
- the possibility that a varicocele repair will not definitely restore your infertility
- the fact that ART is needed for each try at pregnancy
Varicocele repair should remain the treatment of choice, however, if you do not have ideal semen but your partner is normal. Conversely, IVF, with or without ICSI, should be considered the primary option when there is a special need for such methods to treat a female factor.
Are there risks associated with IVF/ICSI?
Yes, some risks exist, especially for women. For instance, ovarian hyperstimulation, due to the hormones used in the IVF/ICSI process, can result in high blood pressure, fluid accumulation, malaise, weakness, and other symptoms. Mild stimulation, usually tolerated easily by women, occurs in up to 20 percent of patients. Moderate hyperstimulation shows up in 5 percent of women undergoing IVF. Only one percent of women undergoing IVF suffer from severe ovarian hyperstimulation, the form that can cause severe medical problems. Multiple births present another potential issue for IVF/ICSI couples. In the United States, following IVF there is a 30 to 35 percent risk for twin gestations and 5 to 10 percent for triplets (or higher).
Are the pituitary tumors that cause low gonadotropin or elevated prolactin levels malignant tumors?
No. These are usually benign lesions of the pituitary gland. If the tumor is large enough, you should consult a neurosurgeon to possibly remove the growth. Removal is usually performed through the nasal passages.
Should I try empiric hormonal therapy if I also have a varicocele?
The general rule of thumb is that unproven empiric therapies should not be tried until known reversible causes of male infertility are addressed. Varicocele remains the leading cause of impaired sperm production in the United States. Serious consideration should be given to any such repair prior to any empiric hormonal therapy.
In light of the detrimental effects of oxidants on sperm function, should all infertile men take the antioxidant, vitamin E?
Vitamin E is a safe, well-tolerated supplement that has been shown in studies to reduce the risk of heart disease. Ingestion of 400 IU twice daily is also an inexpensive, effective way to treat any oxidants that maybe affecting fertility. This treatment course, however, does not replace careful examination of other known infertility causes in either men or women.
For more information, see Hormone Health Network's Infertility and Men Fact Sheet.
Reviewed: January 2011
Last updated: April 2013
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