Key Words
Varicocele - dilation of the veins that drain the testicle
Motility - a sperm's ability to move
Morphology - sperm shape, includes examining the sperm head, mid-piece and tail
It is estimated that up to 15 percent of all couples encounter a problem with fertility; one-third of the cases are related to the male partner, one-third are related to the female, and one-third are a combination of both. So, in 50 percent of all infertile couples, a male fertility problem plays a role in the couple's inability to conceive. It is generally accepted that an evaluation of fertility problems should begin whenever the patients express concern and that the male and female should be evaluated simultaneously.
Why Male Infertility Occurs
There are many causes of male infertility. It is estimated that between 30-40 percent of men evaluated for infertility will be found to have a varicocele. It is currently believed that the number one cause of male infertility is varicocele. A varicocele is a dilation or swelling of the veins that drain the testicle. Varicocele can occur on one or both sides, but is most common on the left side. It is felt that varicoceles cause male infertility by raising the temperature of the testicles.
Abnormalities in hormone production may be a factor. Decreased testosterone levels can lead to low sperm counts. Other hormones such as Follicle Stimulating Hormone (FSH) and Leutinizing Hormone (LH) may play a role as well.
A wide range of chemical substances can affect sperm quality and/or quantity, including medications. The medications listed below all have been associated with male infertility:
- Anabolic steroids
- Antihypertensives
- Allopurinol
- Erythromycin
- Chemotherapy
- Cimetidine
- Colchicine
- Cyclosporine
- Dilantin
- Gentamycin
- Nitrofurantoin
- Tetracycline
Other drugs associated with infertility include: alcohol, tobacco, excessive caffeine, marijuana, heroin, and methadone.
Previous surgical procedures may play a role. Prior surgeries to the groin, pelvis, or abdominal area may have damaged nerves or structures necessary for ejaculation.
Testicular trauma or torsion may affect fertility. Testicular torsion is a condition in which the testicle twists on the cord that attaches it to the body. Approximately 30-40 percent of men with a history of testicular torsion have an abnormal semen analysis.
Diseases such as diabetes mellitus or multiple sclerosis can impair potency as well as ejaculation.
Infections of the reproductive tract also affect male fertility. Bacteria can affect semen quality and can produce an obstruction within the tract, especially at the epididymis. The most common sites of infection are the prostate gland, the epididymis, the seminal vesicles, and the testicle. The mumps virus, if contracted after puberty, can affect fertility. Testicular damage occurs in approximately 10 percent of patients who develop mumps after puberty.
What to Expect at the Initial Visit
A thorough medical history, physical examination and a semen analysis are the cornerstones of the male fertility evaluation. The patient will be asked to abstain from ejaculation for approximately 72 hours prior to the doctor visit. On the day of the visit, he will be asked to provide a semen sample for analysis. The semen sample provides valuable information, and is more than just the "sperm count." Multiple parameters are examined including, the volume (amount) of the ejaculate, the sperm density (count), percent motility (the percent of sperm moving), and speed (forward progression).
Minimal Standards of Adequacy
Volume 1.5-5.0 milliliters
Sperm 20 million per milliliter
Motility over 60 percent
Speed Grade 2 or higher
Morphology Greater than 60 percent are normal shape
Fructose Present
The sperm count is given, and it is reported in two ways. First, as the number of sperm per milliliter of ejaculate. A "normal" sperm count is typically 60-80 million, but could be much higher. Another very important aspect of the semen analysis is sperm motility. That is, the sperm's ability to move. Between 50-60 percent of the sperm cells should be motile. They are also "graded" on the quality of their movement on a scale from zero to four. The semen analysis also reports the sperm's shape or morphology. To be considered normal, a sperm must have an oval head, a normal mid-piece, and a tail. An abnormal sperm could have a tapered head or two tails. The semen analysis also reports the presence or absence of fructose. A nutrient for sperm, fructose is normally present in the semen. The volume of the ejaculate is also measured and reported. A normal amount is one and a half to five milliliters. Too little semen decreases the odds of the sperm reaching the ovum. Too much semen can dilute the sperm count and reduce the chances of impregnation.
At the initial visit, in addition to the semen analysis, a health history will be obtained. Questions regarding past infections of the urinary tract, past surgical procedures, alcohol and tobacco use, medication use, and past testicular trauma will be asked. Questions regarding conditions of the work environment, such as exposures to chemicals and high temperatures, will also be asked. The health history also includes questions regarding sexual practices, timing of intercourse and sexual habits.
A physical examination will be performed, as well. During the physical, the patient will be evaluated for factors that may contribute to infertility, including, a varicocele.
If the physician suspects a hormone imbalance, hormone levels will be drawn.
Considerable discussion often occurs at the initial physician visit. Quite frequently, couples have questions. The physician and the patient (or couple) discuss the possible causes of the infertility, as well as decide on a treatment plan.
Treatment Options
The treatment plan begins with the physician counseling the patients regarding sexual practices. They are reminded that the optimal timing for intercourse if every 48 hours during the time when ovulation is most likely. They are cautioned to avoid lubricants, or use them very sparingly, as lubricants can impair sperm survival. Even saliva can impair sperm survival.
Lifestyle changes may be a part of the treatment plan. Alcohol, tobacco, and marijuana are all considered toxic to sperm. Decreasing the consumption of these drugs, or eliminating them altogether, will be recommended.
If hormonal abnormalities are found to be the cause of the infertility, hormonal replacement therapy is prescribed. This may be either in the form of an injection self-administered periodically throughout the week, or a tablet taken every day.
Treatment with antibiotics may be prescribed if a patient shows an infection or inflammation in any of the organs associated with sperm production or transportation. Such infections can lead to decreased fertility.
It is possible to correct a varicocele with a surgical procedure called varicocelectomy, or varix ligation. During this procedure, a small incision is made in the groin area and the enlarged veins are tied off. This procedure is performed on an outpatient basis.
Assisted Reproductive Treatments have revolutionized male infertility care. These procedures manipulate sperm in a controlled manner and have greatly facilitated pregnancy. The procedures include:
IUI (Intrauterine insemination) - involves depositing a large number of specially processed sperm into the uterus at the optimal point in the menstrual cycle.
IVF (In vitro fertilization) - involves harvesting eggs from the female partner and combining them with sperm in a carefully controlled laboratory procedure.
GIFT (Gamete intrafallopian transfer) - involves hyperstimulation of the ovum. The ovum are not removed from the body, rather, they are mixed with processed sperm in a specialized catheter and immediately transferred to the fallopian tubes.
ICSI (Intracytoplasmic sperm injection) - usually performed in a major IVF center; involves injecting a single sperm into an egg; considered a highly-specialized technique.
These new technologies have added an entirely new dimension to male infertility treatment. One important consideration in the use of these "high-tech" treatments is the cost. Unfortunately, these forms of treatment may not be covered by insurance plans.
Special Populations
Men who have sustained spinal cord injuries may be unable to ejaculate. Yet it may be possible for them to father a child utilizing one of several outpatient procedures. In the first procedure, which requires approximately five minutes, a special vibrator is placed on the underside of the tip of the penis. This stimulates the ejaculatory reflex and ejaculation may occur. If it does not stimulate the reflex, other procedures such as electro-ejaculation or vasal aspiration may be performed. The sperm obtained may then be manipulated for use in any of the above-mentioned assisted reproductive treatments.
Vasectomy reversal has greatly increased over the past 20 years, owing in part to the increasing number of men who have had a vasectomy and subsequently desire more children. During the procedure, the surgeon uses an operating microscope to assist with the reconnection of the ends of the vas deferens. One factor that influences the success rate is the length of time between the vasectomy and the reversal. The longer the time interval, the lower the success rate. Another factor is surgical expertise. When researching surgeons, it is important to ask how many procedures he/she has performed, how often, and specifics regarding his/her success rate.
The diagnosis of male infertility can invoke many emotions. Frustration, fear, anger, anxiety and depression are all common emotional responses. When approaching the diagnostic process, it is important to remember that male infertility is not uncommon, it is treatable and that knowledgeable, expert health care professionals can assist the patients in achieving their goal.
Frequently Asked Questions
Are there any sexual positions that you recommend to increase chances of pregnancy?
Typically, the only one that has been shown to make any difference, is after ejaculation, having the woman lie with her legs elevated or propped up on a pillow for about 15 or 20 minutes.
How can a couple tell whether there lack of ability to conceive is caused my the man or the woman?
Since approximately half of infertility problems involve the man, we typically recommend obtaining one or two semen analyses prior to the workup of the woman, unless there are obvious female problems.
Are there any over the counter products that increase fertility?
No. There is a dietary supplement that has been advertised but, to date, there is insufficient evidence to show that it really changes fertility.
How do tight jeans cause a low sperm count?
That is actually a myth. There is very good evidence that shows that tight jeans and tight underwear, as well as all types of clothing do not have any effect on sperm count. There is really no difference in boxers versus briefs, tight jeans versus loose pants.
Can a vasectomy be reversed?
Yes. Vasectomy reversal can be successful. It is dependent upon several factors including the time from vasectomy, the experience of the surgeon, and type of vasectomy reversal performed.
How much time do you usually let go by before testing for a fertility problem?
I leave that up to the couple. The definition of infertility is inability to get pregnant after one year of unprotected intercourse. Some couples want to know before a year, and it is not unreasonable to start with something easy such as a semen analysis.
What is retrograde ejaculation, and how can it be prevented?
Retrograde ejaculation is fairly uncommon and is typically associated with a neurologic disorder or previous abdominal surgery. It is not something that can be prevented, but it can be treated. Treatment is based on the specific underlying problem.
Quick question!! I had a tubal pregnancy; after that he had a vasectomy, what are the chances of that failing?
The chances of a vasectomy failing are dependent upon whether or not the man has undergone an adequate test to show that he truly is sterile. Once he has been confirmed to be sterile, the chances of failure are approximately 1 in 4,500.
What causes varicocele, and how does it affect fertility? What can be done to correct it?
Varicoceles are very common and tend to develop during adolescence. 15 percent of all men have varicoceles, but not all varicoceles affect fertility. It appears that decreased fertility is based on increased temperature within the testicles. They can be corrected by surgery or by radiologic placement of coils in the dilated veins. The success rate is fairly reasonable with improvement in sperm parameters in approximately 65 to 70 percent of patients and natural conception occurring in approximately 30 to 40 percent of patients.
What is Peyronie's disease, and can it cause infertility?
Peyronie's disease does not cause infertility, but may be associated with erectile dysfunction. It is a curvature of the penis when it is erect. It is typically seen in men between ages 30 and 50. It tends to be self-limited, meaning, it will stop progressing by itself. It does not always need to be treated.
What are the chances of conceiving after a man has a vasectomy?
The chances of conception after a man has had a vasectomy and has been confirmed to be sterile are approximately 1 in 4,500. The chances of conception after a vasectomy reversal are related to several issues including the type of reversal, the age of the female partner, the time from vasectomy, and the sperm count after the reversal.
What chances are there if I have a spinal injury? I do ejaculate.
If you do ejaculate, then the chance of conception would be related to the ability to get an erection as well as the sperm count and motility. Assisted reproductive techniques such as artificial insemination may improve those chances.
I have heard that a new food supplement called Proxeed can help couples improve their chances for conception by improving the quality of the man’s sperm. Is there any truth to this one?
This is the dietary supplement that I referred to earlier. There are very few studies that talk about the effect and none of these studies examine the chance for conception. For now, I tend to tell couples to use caution with this product, as there have not been any good studies performed to date.
What causes some men to have fertility problems?
Fertility problems can be related to many factors including varicoceles, blockages, infection, hormonal problems, as well as genetic causes. Seeking help from a male fertility specialist is a good start to determining the problem as well as the answer.
It has been a year, and no pregnancy, so should we assume he is infertile?
Although there has been no pregnancy after a year, I would not consider him sterile without a semen specimen showing no sperm.
My husband had a disease when he was a child that has led to him not producing sperm at all. Is there anyway to change that?
That one is best answered by consultation with a male fertility specialist to determine if there are any reversible causes for his condition.
My boyfriend doesn’t have any trouble getting an erection, but doesn't always ejaculate. Is this ok?
Yes. It is not uncommon to occasionally not ejaculate.
Do men go through any type of male menopause?
This is controversial. There are some who believe that as men age, they go through what is called "andropause." However, the evidence is conflicting, and there is no definite agreement on this condition.
What causes lack of ejaculate?
That can be due to different causes including infection, blockage, or neurologic problems. It would require evaluation by a urologist or male fertility specialist.
What are the latest treatments for infertility?
This is a fairly broad question. Much of the treatments now evolve around assisted reproductive techniques such as artificial insemination and in vitro fertilization. However, it is very important that prior to proceeding with these treatments, both partners are evaluated. There are often problems discovered, some of which are medically important when evaluating the infertile male. These should be addressed.
Can you tell us more about Varicoceles?
As I mentioned, varicoceles are dilated veins around the testicles. Although they do not cause fertility problems in all men who have them, they are the most common cause of male infertility. They typically lead to increased testicular temperature, even when they are only on one side. They can cause low sperm counts, low motility, and even effect sperm function. They are typically diagnosed by physical exam and treatment is aimed at eradicating the veins. This can be either through surgery or radiographic methods.
What is the process for in-vitro?
In vitro fertilization is essentially uniting an egg and a sperm in a dish to promote fertilization. The fertilized egg is then placed back inside the woman so that implantation can occur. Typically, the woman is placed on hormonal injections so that she will make multiple eggs for fertilization.
What is the percentage of infertility being caused by psychological problems?
Male sexual problems are estimated to account for approximately 5% of male infertility cases. There is some evidence that psychological problems, including stress, can affect hormonal function. This, in turn, can have an effect on fertility. Other factors may also be involved.
What drugs are best for hypertension if you are trying to have a baby?
The only antihypertensives that would have an effect on the male would be those that would cause difficulties with erection. The physician monitoring hypertension can select a drug that will have minimal effects.
Does the use of marijuana cause infertility or other testicular problems?
Yes. Marijuana is a well-known cause of fertility problems. It tends to cause hormonal problems as well as having a direct effect on the testicles. This can be with long-term as well as short-term use although short-term use tends to be reversible. However, it is important to realize that it takes approximately three months for the testicles to make sperm. Therefore, even after the marijuana is no longer used, it may be several months or more before those effects have been reversed.
What other drugs cause fertility problems?
Many drugs can have an effect on sperm production. Sulfasalazine, a drug that is used in Crohn's disease, is well known to do this. Most hormonal supplements, including anabolic steroids, as well as other street drugs, can have an adverse effect on fertility. Antibiotics, alcohol, and tobacco all have been shown to have some effects on fertility.
What questions should a patient ask before undergoing a vasectomy reversal?
The success rate of vasectomy reversal is dependent upon several factors. Although the time from vasectomy is important, the experience of the surgeon performing the procedure is also an important factor. A surgeon should be able to perform both a vasovasostomy as well as vasoepididymostomy. It is also important that the surgeon uses an operating microscope and performs reversals on a regular basis. Furthermore, it is important to find out that individual surgeon's success rate, not the success rate quoted in the literature. Finally, the pregnancy rates are dependent upon female factors as well. Therefore, women over 40 may have a lower pregnancy rate even if the reversal is technically successful. This information should be readily shared with the patient prior to undergoing a procedure. However, it is also important not to undergo a vasectomy in the first place if you anticipate wanting to become fertile at some future time.
Do hot baths cause a low sperm count or is that just and old wives' tale?
Frequent and regular use of hot tubs can decrease a man's sperm count. Having said that, it probably should not be used as a method of birth control. Couples that are trying to conceive should probably avoid frequent hot tub use.
What other myths would you like to clear up regarding fertility and possibly men's sexual health?
One of the oldest myths is that there are no infertile men, only infertile women. This is obviously not true. Nearly 50 percent of infertility problems involve the male. Furthermore, there is much that can be done to improve male reproductive health, thus improving the couple's chances of conception.
Who should NOT get a vasectomy?
That is a difficult question - there are some physicians who will not perform a vasectomy on a young single male or on a man without children. My feeling is that the patient should be adequately counseled regarding the risks and benefits as well as the possibility of sperm banking prior to the vasectomy. There are no absolutes in terms of who should not get a vasectomy. The only other important point is that the patient's wife, or partner, is in complete agreement.
I have heard that exposure to toxic chemicals or radiation can cause infertility. Is this very common?
The number of toxic chemicals in use today that can cause infertility is becoming much smaller. However, we know that exposure to radiation can certainly have an effect on fertility.
I was here earlier, Please tell what can you do short of in-vitro? Our salaries will not allow that expense.
Options other than in vitro are dependent upon the cause of infertility, the male and the female factors involved, as well as the sperm count and motility.
Should the man be evaluated prior to in vitro fertilization?
There is good evidence that much of male factor infertility can be treated. Furthermore, a small but significant percentage of men with infertility have an underlying medical problem that is discovered during their evaluation. This can include hormonal problems as well as testicular cancer, infection, or blockages. Therefore, it is important that the urologist or male fertility specialist prior to proceeding with in vitro fertilization evaluate the male partner.
Does smoking or alcohol affect fertility?
Recently several studies have addressed the effects of smoking on male fertility. There is some very good evidence that smoking can have an adverse effect on sperm count, motility, and function. It is always a good idea to quit smoking, particularly when trying to conceive. Alcohol is slightly more controversial. Mild to moderate amounts of alcohol have not been shown to have any effects; however, moderate to heavy amounts can affect sperm count as well as hormone production.
Is infertility often an indicator of cancer?
No. It can be, but this is a rare finding. However, the most common type of cancer in men of reproductive age is testicular cancer. This would be discovered during the evaluation of the man.
I've read that bike-riders have to be careful what kind of seat they use as to not damage the testicles. True?
The best evidence regarding bicycle seats pertains to erection, not fertility. Any seat that causes numbness could potentially damage a man's erection. However, there has not been any evidence to show that fertility is affected.
I still want a baby, and I'm a paralyzed guy who can function correctly.... Any advice?
If natural conception has been unsuccessful, I would seek an evaluation from an urologist including a history, physical exam, and a semen analysis. Specific treatment options can then be recommended.
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