What is male infertility?

Reproduction (or making a baby) is a simple and natural experience for most couples. However, for some couples it is very difficult to conceive. A man’s fertility generally relies on the quantity and quality of his sperm. If the number of sperm a man ejaculates is low or if the sperm are of a poor quality, it will be difficult, and sometimes impossible, for him to cause a pregnancy. Male infertility is diagnosed when, after testing both partners, reproductive problems have been found in the male. Infertility is a widespread problem. For about one in five infertile couples the problem lies solely in the male partner. It is estimated that one in 20 men has some kind of fertility problem with low numbers of sperm in his ejaculate. However, only about one in every 100 men has no sperm in his ejaculate.

What causes male infertility?

Male infertility is usually caused by problems that affect either sperm production or sperm transport. Through medical testing, the doctor may be able to find the cause of the problem. About two-thirds of infertile men have a problem with making sperm in the testes. Either low numbers of sperm are made and/or the sperm that are made do not work properly. Sperm transport problems are found in about one in every five infertile men, including men who have had a vasectomy but now wish to have more children. Blockages (often referred to as obstructions) in the tubes leading sperm away from the testes to the penis can cause a complete lack of sperm in the ejaculated semen.

Other less common causes of infertility include: sexual problems that affect whether semen is able to enter the woman’s vagina for fertilization to take place (one in 100 infertile couples); low levels of hormones made in the pituitary gland that act on the testes (one in 100 infertile men); and sperm antibodies (found in one in 16 infertile men). In most men sperm antibodies will not affect the chance of a pregnancy but in some men sperm antibodies reduce fertility.

Known causes of male infertility

Sperm production problems •     Chromosomal or genetic causes
•     Undescended testes (failure of the testes to descend at birth)
•     Infections
•     Torsion (twisting of the testis in scrotum)
•     Varicocele (varicose veins of the testes)
•     Medicines and chemicals
•     Radiation damage
•     Unknown cause
Blockage of sperm transport •     Infections
•     Prostate-related problems
•     Absence of vas deferens
•     Vasectomy
Sexual problems
(erection and ejaculation problems)
•     Retrograde and premature ejaculation
•     Failure of ejaculation
•     Erectile dysfunction
•     Infrequent intercourse
•     Spinal cord injury
•     Prostate surgery
•     Damage to nerves
•     Some medicines
Hormonal problems •     Pituitary tumours
•     Congenital lack of LH/FSH (pituitary problem from birth)
•     Anabolic (androgenic) steroid abuse
Sperm antibodies •     Vasectomy
•     Injury or infection in the epididymis
•     Unknown cause

Male Infertility Treatment

The treatment of male infertility depends upon the underlying cause. Several months to years of treatment are usually necessary to achieve fertility. The treatment often involves both male and female partners.

Blockage of the reproductive tract - Men who have a blockage in the ducts conveying the sperm from the testis until ejaculation (so that sperm cannot get out) can undergo surgery to correct the blockage. If it is not successful, another option is assisted reproductive technologies using sperm retrieved from the testes.

Vasectomy (male sterilization) is a different type of blockage. Vasectomies can be reversed in up to 85 percent of cases; over 50 percent of couples can achieve pregnancy following vasectomy reversal. However, the more time that has passed since the vasectomy, the less likely vasectomy reversal is to restore fertility.

Treatment of hypothalamic or pituitary deficiency - in a small percentage of cases (1 to 2 percent), male infertility is due to problems in the hypothalamus and pituitary gland (parts of the brain that regulates hormone production). In this case, treatment with human chorionic gonadotropin (hCG), recombinant human follicle stimulating hormone (rhFSH), also called gonadotropin treatment, is often given.

Gonadotropin treatment - Gonadotropin treatment is started with injections of hCG three times per week (or sometimes every other day) for up to six months. Blood tests are used to monitor blood testosterone levels and to adjust the dose if necessary. If sperm cells do not appear in semen after six months of treatment, recombinant human follicle stimulating hormone (rhFSH) is added; this is also given by injection. The success rate for this therapy is high as most men will eventually develop sperm in the ejaculate. In many cases, a total of one to two years of treatment is needed to achieve normal fertility. The cost of these treatments can be significant, especially if health insurance does not cover the costs of infertility treatments.

Varicocele - avaricocele is a dilation of a vein (like a varicose vein) in the scrotum. Many men with varicocele have a low sperm count or abnormal sperm morphology (shape). The reason a varicoceleaffects the sperm may be related to a higher than normal temperature in the testicles, poor oxygen supply, and poor blood flow in the testes.

Varicocele can be treated surgically by cutting the veins connected to the varicocele. However, surgery does not always improve fertility and is not recommended for most men unless there is a large varicocele. A varicocele that has been present for a long time can cause irreversible damage that cannot be surgically treated.

An alternative to varicocele repair is assisted reproductive techniques (ART), such as intracytoplasmic sperm injection (ICSI). With ICSI, only a small number of sperm are needed

Clomid therapy for unexplained low sperm count. If there is a mild decrease in the male partner’s sperm count or motility, a urologist may prescribe Clomid, an infertility pill commonly used to treat women who fail to ovulate. Clomid can stimulate the hormones responsible for sperm production. Sperm counts are re-analyzed 3-6 months after medication is started to evaluate any improvement in sperm production.

Anti - Oxidants and Micronutrients. Most cases of male factor infertility, even after full evaluation, will be labeled “idiopathic,” which means that we do not know why there is a low count, low motility, or poor sperm morphology (poorly formed abnormally shaped sperm). It may be environmental (pollutants, toxins) or related to lifestyle (hot tub or hot bath use, smoking). When the causative factor can be found and changed, of course this will be advised. However, even men without known toxic exposures or lifestyle factors can have low sperm parameters. There are many dietary supplements that are known to improve sperm production and function (such as L-carnitine and zinc). A reproductive endocrinologist or andrologist may recommend beginning a vitamin and mineral supplement to help make the sperm as good as it can be.

IUI (intrauterine insemination cycle). When there is mild, unexplained low sperm count or motility, we may recommend an intrauterine insemination cycle (IUI) Sperm is processed and placed into the female partner’s uterus around the time of ovulation, giving sluggish sperm a big head start towards the egg or eggs.

What to expect from the IUI procedure. The male partner will be asked to provide a sperm sample through masturbation either at home or in our clinic. His sperm is then sent to our laboratory where it is prepared for transfer into the female partner’s uterus. The most active, motile (normal, forward moving) and healthy sperm are extracted and this optimal sperm sample placed into the uterus via a catheter.

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