LIKELIHOOD OF OCCURRENCE
You may be unaware that, in 60% of cases, a male factor contributes to a couples’ infertility. That’s why it makes sense to evaluate the man’s role as well as the woman’s in these cases.
Let’s discuss some of the logistics, so the treatment plan makes more sense. Sperm takes three months to produce and mature and oftentimes there’s a four to six month delay between treatment and any resulting changes in the sperm. Because the evaluation of the woman may also take several months, we recommend that a comprehensive semen analysis be performed at the outset, so the male partner is being evaluated and the timing is compatible. In this way treatment of both partners happens at the same time, with no additional delay.
Just like varicose veins in the legs, the scrotum is also subject to dilated veins. What happens is that the veins become dilated when blood doesn’t drain properly from them. This extra blood pools in the scrotum and it negatively impacts sperm production. The positive news is that this is the most common reversible cause of male infertility and may be corrected by minor outpatient surgery.
Most doctors perform this surgery microscopically to preserve the arterial supply and lymphatics. An incision is made about one inch above the penis (it’s called a subinguinal incision) avoiding the abdominal muscles, which means less post-operative pain.
This occurs when the semen is very thick, making it difficult for the sperm to move into the woman’s reproductive tract. An attempt is made to separate the moving sperm from the dead sperm and surrounding debris, process it, and place it directly into the uterus with a small tube. This is called intrauterine insemination (IUI).
Some of these are: sperm carrying ducts that may be missing or blocked; an absence of both sides of the vas deferens since birth; obstructions at the point where the delicate tubular structure drains the testes or higher up in the more muscular vas deferens; or blockage that occurred during hernia or hydrocele repairs or from scar tissue from due to an infection.
The mechanics of the situation are that sperm must travel through the ejaculatory ducts as they go from seminal vesicles to the urethra. If these ducts are blocked, the sperm can’t get through.
Options here include repairing or unblocking the ducts, or if that’s not possible, the sperm can be harvested so they can go through the man’s reproductive tract. In cases like this, sperm is obtained in low numbers, so this procedure must be used in conjunction with advanced reproductive techniques to attempt a pregnancy.
What happens here is that a man has developed antibodies to his own sperm. This could occur because of testicular trauma, testicular infection, large varicoceles, or testicular surgery. Or sometimes, there are unexplained reasons for this occurrence.
The antibodies have a negative effect on fertility, but the exact reason isn’t clear. Most likely, the antibodies act negatively at several points along the pathway to fertilization as the sperm have trouble penetrating the partner’s cervical mucous and making their way to the uterus. It becomes more difficult for the sperm to bind with external membrane or shell of the egg or to fuse with the eggs themselves.
Can the antibodies be treated? Yes, but that treatment is controversial. Men are sometimes treated with corticosteroids but this can result in disease such as noninfectious destruction of the joint (aseptic necrosis), which requires hip replacement. To avoid that, often the first level of treatment is intrauterine insemination. If the couple is planning in-vitro fertilization (IVF) and antibodies are present, the sperm are injected directly into the egg (ICSI) instead of the conventional IVF.
About five percent of couples with infertility have factors relating to intercourse. This includes the inability to obtain or maintain an erection, premature ejaculation, lack of ejaculation, backwards (or retrograde) ejaculation, lack of appropriate timing of intercourse, and excessive masturbation. Interestingly, the most common problem is infrequency of intercourse. Many men will have difficulty with erections under the pressure of trying to achieve conception. These couples can easily learn the technique of self-insemination. Studies have shown that five out of six previously fertile couples having intercourse four times per week will conceive over six months, while only one out of six with intercourse once per week during the same period will conceive.
What this means, in general, is that the sperm-producing part of the testicles can’t make an adequate number of mature sperm. It can happen at any stage in sperm production and for any number of reasons such as: the testicle may lack the cells needed to divide and become sperm; or the sperm can’t complete their development; there are too few sperm to be able to travel through the ducts into the ejaculated fluid. Genetic abnormalities, hormonal factors, or varicoceles, the veins in the scrotum, may cause this situation.
On the plus side, even if your testes are producing a low sperm count, the sperm can be harvested and, using advanced reproductive techniques, pregnancy can be attempted.
This is a condition where a baby boy is born without the testes fully descending into the scrotum and is a possible cause of testicular failure. Since the testes are very sensitive to temperature, if they do not descend into the scrotum prior to adolescence, they will stop producing sperm altogether. In fact, they have a higher rate of malignancy. 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 can be a factor in male infertility. 81 percent of men with one testis in this condition will have normal fertility. 50 percent of men with cryptorchidism in both testes can have normal fertility. This may be due both to something inherent in the testes, to the surgery, or to damage done by not having the testes brought down in time.
Even fairly common drugs could have a negative effect on sperm production and/or function. Some of those include:
- Ketoconazole (an anti-fungal)
- Sulfasalazine (for inflammatory bowel disease)
- Spironolactone (an anti-hypertensive)
- Calcium Channel Blockers (anti-hypertensives)
- Allopurinol, Colchicine (for gout)
- Antibiotics: Nitrofuran, 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 need pituitary hormones to be stimulated to make sperm. If these are absent or severely decreased, the testes cannot produce sperm to maximum capacity. Importantly, men who take androgens (steroids) for body building, either by mouth or injection, shut down the production of hormones for sperm production.
If you’re a male with infertility problems we do a hormonal profile. It’s an important check in order to rule out serious medical conditions, get more information on the sperm-producing ability of the testes, and tell us whether we should go ahead with hormonal treatment.
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).
After passing through puberty, if you’ve had a viral infection of the testes, it may have caused absolute and irreversible infertility. Other issues are bacterial infections or sexually transmitted diseases that can cause blockages of the sperm ducts. Here, the sperm production may be normal but the ducts carrying them are blocked.
If bacterial or viral infections are active, that may also have a negative effect on sperm production or function. Additionally, white blood cells, the body’s response to infection, may also have a negative effect on sperm membranes, making them less hearty.
We recommend having a culture done if excessive white blood cells (more than one million/cc) are seen in a semen specimen. This usually includes cultures for commonly asymptomatic, sexually-transmitted diseases including mycoplasma, ureaplasma, and Chlamydia. Also, a general genital culture is usually taken. If the infection and the white blood cells are persistent, antibiotics may be considered.
You should understand that in most men, the ejaculate isn’t sterile, often testing positive for two organisms. That’s why it’s important to be judicious in treating non-sexually-transmitted organisms found on cultures.
When these conditions are treated, a man will often see a significant improvement in his semen analysis.
It’s a fact that cigarette smoking significantly affects semen quality.
A regular smoker has a 23% decrease in sperm density (concentration) and a 13% decrease in its ability to move (when averages are taken from nine separate studies). To a lesser extent, smoking causes toxicity to the fluid ejaculated with the sperm (seminal plasma). And when sperm from non-smokers were placed in the seminal plasma (hormonal) of smokers, the sperm were adversely affected (had significantly decreased viability).
Smoking affects the hypothalamic-pituitary-gonatropin axis, most commonly affecting levels of estrogens, which are hormones found in higher concentrations in women (estradiol and estrone). Other problems are secretory dysfunction in the Leydig Cells, which are in the testes and produce testosterone. Most worrisome is that there is evidence that suggests that paternal smoking may also be associated with congenital abnormalities and childhood cancer, though the relative risk in most studies is less than two.
Marijuana often causes a decreased average sperm count, movement of the sperm (motility), and when the sperm is viewed under a microscope the size and shape may be compromised (normal morphology). It affects the hormonal axis (HPG), causing decreased plasma testosterone. It may also have a direct negative effect on the Leydig Cells.
Even infrequent cocaine use causes decreased sperm count, motility, and normal morphology. These effects can be found in men who have used cocaine in the two years preceding their initial semen analysis. Cocaine also decreases the ability of sperm to penetrate the cervical mucous, making it difficult for them to enter the uterus.
Anabolic Steroids (male hormones)
The use of anabolic androgenic steroids has reached almost epidemic proportions. Nearly seven percent of 12th-grade males use or have used them to build muscle mass and improve athletic performance. These male hormones suppress the testes’ ability to make testosterone. This decreases the intratesticular testosterone level. This may cause severely diminished spermatogenesis or complete absence of sperm (azoospermia). 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. However, excessive alcohol use affects the hormonal axis and has negatively affects the gonads. It may cause associated liver dysfunction and nutritional deficiencies, which are also detrimental for sperm production.
Most vaginal lubricants, including K-Y Jelly, Surgilube, and Lubifax, are toxic to sperm. Couples should avoid their use during the fertile time of a woman’s cycle.
During the semen analysis or, if appropriate, the consultation, we identify any problems and then address them 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 analysis results. Therefore, the most important first step in any man’s evaluation is the semen analysis.
Semen is the fluid that a man ejaculates. This fluid is produced at several different sites. 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 key thing to know is that we’re not looking for a specific, magic number in the semen analysis of men whose partners will get pregnant and those who won’t. The partners of some men with a very poor semen analysis may conceive easily. The partners of some men with an excellent semen analysis may experience difficulty. However, men with good semen analysis results will, as a group, conceive at significantly higher rates than those with poor semen analysis results. The semen analysis will help determine whether there is a male factor involved in the couple’s sub-fertility. If that’s the case, we’ll recommend an evaluation. Some findings of the semen analysis suggest certain specific potential problems. For example, an increased white blood cell count may indicate infection or inflammation. However, other abnormalities in many of the main parameters are non-specific. For example, there are a number of different causes for a decreased sperm count or diminished sperm movement. Some of these causes have other serious medical implications. A thorough evaluation helps determine the cause of an abnormal semen analysis and rules out medical problems.
Almost all laboratories will conduct tests and report on the following information, using values established by the World Health Organization:
- Concentration (sometimes referred to as the count): This is a measurement of how many million sperm there are in each milliliter of fluid. There are various techniques for obtaining this number. Some prove to be more accurate than others. Average sperm concentration is more than 60 million per milliliter (>60 million/cc). Counts of less than 20 million per milliliter (<20 million/cc) are considered sub-fertile.
- Motility (sometimes referred to as mobility): This describes the percentage of sperm that are moving. Fifty percent or more of the sperm should be moving.
- Morphology: This describes the shape of the sperm. The sperm are examined under a microscope and must meet specific sets of criteria for several sperm characteristics in order to be considered normal. Most commercial laboratories will report WHO morphology (use World Health Organization criterion). Thirty percent of the sperm should be normal by these criteria.
- Volume: This is a measurement of the volume of the ejaculate. Normal is two milliliters (two ccs) or greater. The volume may be low if a man is anxious when producing a specimen, if the entire specimen is not caught in the collection container, or if there are hormonal abnormalities or ductal blockages.
- Total Motile Count: This is the number of moving sperm in the entire ejaculate. It is calculated by multiplying the volume (cc) by the concentration (million sperm/cc) by the motility (percent moving). There should be more than 40 million motile sperm in the ejaculate.
- Standard Semen Fluid Tests: Color, viscosity (how thick the semen is), and the time until the specimen liquefies should also be measured. Abnormalities in the seminal fluid may adversely affect the sperm. For example, if the semen is very thick, it may be difficult for the sperm to move through it and into the woman’s reproductive tract.
- Forward Progression: This describes how well the sperm that are moving are making progress. Only when the motility (percent moving) is combined with the forward progression is an accurate picture of sperm movement obtained. Unfortunately, this is often not tested by commercial laboratories. 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. Slides are specially stained and the sperm examined microscopically under high-power magnification. The sperm must meet a stringent set of criteria that evaluate the shape and size of the head, midpiece, and tail in order to be considered normal. 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. These antibodies may decrease fertility rates in a number of ways. They may impede the movement of sperm through a woman’s cervical mucous, inhibit the binding of a sperm to the egg, and/or inhibit its penetration into the egg. Men who are most at risk for developing antibodies are those with previous testicular and epididymal infection, trauma, surgery, or large varicoceles. The presence of these antibodies is often not predictable from other semen parameters or from the man’s history.
- White Blood Cells: The semen may contain a high number of white blood cells, which may be an indication of either infection or inflammation. White blood cells are considered significant if more than one million are found in each milliliter of the ejaculate.
White blood cells 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 white blood cells.
If the white blood cell count is elevated, semen cultures should be performed on a subsequent specimen. Unfortunately, the semen culture cannot be performed on the original specimen as it must be the first step performed on the specimen in order to keep it sterile.
In certain situations, specialized tests are needed. These depend on the findings at the time of the analysis and can often be performed on that 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 very 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 on the bottom of the tube and then examining the pellet beneath the microscope.
- Viability: Sperm may be alive, but not moving. A specialized staining technique is used to determine what percentage of the sperm are alive and 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: As a semen analysis is being performed, certain findings may indicate the need for additional tests. Ideally, 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.
The purpose of all of this testing is to move ahead with a treatment that can improve your fertility or to discuss other ways to achieve results. More than 50% of men will have a treatable cause of male factor infertility. These factors include varicoceles (dilated veins in the scrotum), infections, hormonal abnormalities, abnormalities in the seminal fluid, ductal blockages, and difficulties with erections and ejaculation. When these conditions are treated, either through medication (hormones or antibiotics) or surgery (varicocelectomy, vasal reconstruction, repair of a blocked ejaculatory duct), a man will often see a significant improvement in his semen analysis.
Those men with poor semen analyses 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.