SYMPTOMS & DIAGNOSIS
Male infertility often has no obvious symptoms beyond difficulty conceiving, but underlying issues can include low sperm count, poor sperm motility or shape, hormonal imbalances, erectile or ejaculatory problems, and testicular or varicocele pain. At Maze Men’s Health, we perform a comprehensive semen analysis — the most important first step in diagnosing male infertility — along with hormone testing and physical evaluation to identify the root cause. Led by Michael A. Werner, MD, our team uses advanced diagnostics to uncover even subtle factors affecting fertility, helping men across Westchester, NYC, Connecticut, and New Jersey find answers and effective treatment paths.
Varicoceles & Poor Sperm Production
Just like people can have varicose veins in the legs, a man can have dilated veins in the scrotum. When the blood doesn’t drain properly, the veins dilate (or enlarge). This extra blood that pools in the scrotum, raises the temperature and negatively impacts sperm production. The good news is that this is a common cause of male infertility and may be corrected with minor outpatient surgery.
Our highly trained specialists will perform this surgery microscopically to preserve the arterial supply and lymphatics. An incision is made about one inch above and to the side of the penis (a subinguinal incision) avoiding the abdominal muscles. This procedure, referred to as a “microscopic subinguinal varicocelectomy”, means less post-operative pain for the patient.
Seminal Fluid Abnormalities
Ductal System Problems/Blockages
There can be a number of problems with the ducts that carry sperm. A man can be born missing ducts on either or both sides of the vas deferens, there can be an obstruction at the point where the delicate tubular structure drains the testes, or there can be an obstruction higher up in the more muscular vas deferens. Additionally a man can have blockages that occur as a result of a repair of a hernia or hydrocele or from scar tissue due to an infection.
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.
The first treatment option is repairing or unblocking the ducts. If that is not possible, the sperm can be harvested (removed by a physician) for insemination. When sperm is harvested, physicians can usually only harvest low numbers, so this procedure must be used in conjunction with advanced reproductive techniques in order to attempt a pregnancy.
Immune System Disorders & Sperm Antibodies
It is possible for a man to develop antibodies to his own sperm. This can occur because of testicular trauma, testicular infection, large varicoceles, or testicular surgery. Sometimes, there are unexplained reasons for this occurrence.
The antibodies have a negative effect on fertility, but the reason isn’t clear. Most likely, the antibodies cause the sperm to have trouble penetrating the partner’s cervical mucous and making their way to the uterus. It may become more difficult for the sperm to bind with the external membrane, shell, of the egg, or to fuse with the eggs themselves.
Can the antibodies be treated? Yes, but that treatment is controversial and the side effects problematic. To avoid complicated side effects, often the first level of treatment is intrauterine insemination. If the couple is planning in vitro fertilization (IVF) and antibodies are present, the sperm can be injected directly into the egg (ICSI) instead of using the conventional IVF procedure, which may be affected by the antibodies.
Erectile Dysfunction & Ejaculatory Disorders
In about 5% of couples with infertility the problem is partially due to difficulties related to intercourse1. This includes the inability to obtain or maintain an erection, premature ejaculation, lack of ejaculation, retrograde (or backward) ejaculation, lack of appropriate timing of intercourse, and excessive masturbation. Many men may have difficulty with erections under the pressure of trying to achieve conception. Interestingly, the most common problem is infrequency of intercourse. 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 will conceive if they have intercourse once per week during the same period1. In most of these situations the problem can be solved when these couples learn the technique of self-insemination.
Testicular Failure
When the sperm-producing part of the testicles can’t make an adequate number of mature sperm, it is called testicular failure. It can happen for any number of reasons: the testicle may lack the cells needed to divide and become sperm, the sperm can’t complete their development or there are too few sperm to travel through the ducts into the ejaculated fluid. Genetic abnormalities, hormonal factors, or varicoceles, the veins in the scrotum, may cause this situation.
The good news is that even if your testes are producing very little sperm, the sperm can be harvested and, using advanced reproductive techniques, pregnancy can be attempted. We have seen success.
Undescended Testicles (Cryptorchidism)
Cryptorchidism, a condition where a baby boy is born without the testes fully descending into the scrotum, is a possible cause of testicular failure. The testes are very sensitive to temperature and if they do not descend into the scrotum prior to adolescence, the body’s heat will stop them from producing sperm. They will also 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, this is corrected surgically.
Cryptorchidism can be a factor in male infertility. 19% of men with one testis in this condition will have fertility issues. 50% of men with cryptorchidism in both testes will have normal fertility. This may be due either to something inherent in the testes which made them unable to descent or to damage done by not having the testes brought down in time.
Medications & Drug Use Impacting Fertility
Even fairly common drugs may 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
Hormonal Abnormalities Affecting Sperm Production
The testicles need pituitary hormones to stimulate them to make sperm. If these hormones are absent or severely decreased, the testes cannot produce sperm to maximum capacity. It is important to note that 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, it is important to run blood tests in order to understand your hormonal profile. A hormonal profile will rule out some serious medical conditions, provide more information on the sperm-producing ability of the testes, and inform the physician of the possibility of future hormonal treatment.
Infections That Affect Sperm Health
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 puberty, in rare cases, viruses can result in absolute and irreversible infertility. Bacterial infections or sexually transmitted diseases can cause blockages of the sperm ducts. In these cases, sperm production may be normal but the ducts carrying them are blocked.
Active bacterial or viral infections may also have a negative effect on sperm production or function. White blood cells, the body’s response to infection, can also have a negative effect on sperm membranes, making them less hearty.
When excessive white blood cells (more than 1 million/cc) are found in a semen specimen, we recommend having cultures performed on the specimen. These cultures include tests for commonly asymptomatic, sexually-transmitted diseases: 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.
Ejaculate isn’t sterile and most men will test positive for two organisms. That’s why it’s important to be judicious in treating non-sexually-transmitted organisms found on cultures.
Genetic Conditions & Chromosomal Abnormalities
This is an area of active research. At this point it is recommended that all men receive basic genetic testing, measuring the number of chromosomes and looking at the blocks of genetic material. Screening for the genes that can cause cystic fibrosis is sometimes suggested. There are tests for specific genetic abnormalities on the male chromosomes that can cause azoospermia. If a son were to inherit this, he may have the same problem.
Lifestyle Factors (Obesity, Smoking, Stress, Diet, & Heat Exposure)
Smoking
Cigarette smoking significantly affects semen quality. A regular smoker has a 23% decrease in sperm density (concentration) and a 13% decrease in sperm motility (ability to move)2. 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-gonadotropic axis, most commonly affecting levels of estrogens. 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.
Recreational Drugs
Marijuana
Marijuana often causes a decreased average sperm count, a change in the movement of the sperm (motility), and compromised size and shape (normal morphology). It affects the hormonal axis (HPG), causing decreased plasma testosterone. It may also have a direct negative effect on the Leydig Cells.
Cocaine
Anabolic Steroids (Male Hormones)
The use of anabolic androgenic steroids has reached almost epidemic proportions. Nearly 7% of 12th-grade males use or have used them to build muscle mass and improve athletic performance. These male hormones suppress normal testosterone production. This decreases the intratesticular testosterone level. This may cause severely diminished spermatogenesis or complete absence of sperm (azoospermia). These steroids cause a persistent depression of the hypothalamus and pituitary, which may be irreversible even when the steroids are stopped.
Alcohol
Lubricants
Most vaginal lubricants, including K-Y Jelly, Surgilube, and Lubifax, are toxic to sperm. Couples should avoid their use when trying to achieve a pregnancy. There are lubricants that are specifically formulated for use when trying to conceive.