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Male Infertility

The male partner must contribute 50% of the genetic material to conceive a baby. This is accomplished through the sperm carrying this genetic contribution and fertilizing the egg.  If the sperm is unable to fertilized egg or there is an absence of sperm then infertility results.

Of couples evaluated for infertility, 30% of infertility is due to the direct cause of male factor infertility and another 20% are the result of both partners harboring a fertility issue.

To evaluate for male infertility the semen analysis is the starting point and considered critical to evaluating a couple who fail the key to conceive.  The semen analysis analyzes the physical attributes of sperm observed under the microscope which include: volume, concentration (millions of sperm per milliliter), and the percent motile.  Other parameters also included in the evaluation of the sperm may include: overall appearance, liquefication, viscosity, morphology.  Using the above measured parameters certain calculations can be made to assist with an assessment of the sperm’s fertilization ability which includes: Total progressive counts and total motile counts.  These counts can be used to identify which treatments will be effective in achieving fertilization of an egg.

When an abnormality in the sperm is identified, a repeat semen analysis to confirm this finding is frequently recommended.  Semen analysis parameters can vary from ejaculate to ejaculate and can be affected by events that occurred while the sperm was being produced and stored prior to ejaculation. For example, illness, exposure to extreme environments (hot or cold), extreme stress (both physical or mental) can all cause temporary abnormalities that can resolve themselves.  Frequently it is recommended that the semen analysis be repeated approximately 60 days apart to verify if the abnormality holds or is corrected by time removed from the incident that caused the original abnormality.  However, your provider will assist you with the appropriate timing recommendation for repeating a semen analysis. 

Depending on the abnormality identified in the semen analysis further evaluation may be recommended.  This can include, hormonal evaluation, genetic evaluation, physical examination and ultrasound to better identify the cause of the abnormality.  This is frequently carried out by a specialist trained in male infertility.

In some cases, the underlying cause of the abnormal semen analysis parameters are not identified, which can be extremely frustrating to the couple. Depending on other findings in the evaluation, treatments focused specifically on enhancing male fertility can be initiated with the goal of improving semen analysis parameters. These treatments could include supplements, direct hormone treatment with gonadotropins, human chorionic gonadotropin, selective estrogen modulators, aromatase inhibitors. Typically, these treatments are initiated and carried out by a specialist trained in male infertility. If a couple decides to directly treat male infertility it is important to note that treatments often require many months (3-9 months) of treatment to enhance male fertility to the point that allows conception to occur. 

The good news related to male infertility is that the vast majority of couples can be effectively treated and achieve a successful pregnancy through the technologies available today! If there is a subtle abnormality or borderline parameters, intrauterine insemination (IUI) can be effective in overcoming the low concentration or motility.  The basic premise of the IUI is to prepare sperm, load it into a small catheter and release it high in the uterus near the fallopian tubes. The sperm must then propel themselves down the fallopian tubes to locate the egg. This allows more sperm to be available to fertilized the egg. With normal sexual intercourse sperm is released in the vagina and must traverse the vagina, cervix, uterus and fallopian tubes to locate the egg. In this journey many sperm are lost and not enough sperm arrive at the egg to allow for effective fertilization. Although only 1 sperm is required to fertilized the egg, hundreds of thousands to millions of sperm are required to be present for that 1 sperm to enter the egg.

In many cases the semen analysis parameters are too low to be effective for intrauterine insemination. Or they exist in combination with other female factors contributing to infertility. In this case, in vitro fertilization (IVF), a procedure which removes eggs from the woman’s ovaries, is combined with intracytoplasmic sperm injection (ICSI). ICSI is an extremely effective technology that allows for a single sperm to be selected and injected directly into the egg. This process allows the sperm and egg to be used in a one-to-one ratio, thus eliminating the need for millions or even hundreds of thousands of sperm required for natural fertilization to occur. The results of ICSI are nothing short of miraculous, with extremely high fertilization rates. In most cases of male infertility, once the egg is fertilized embryo development and pregnancy often follows a normal course.

For some men, sperm must be located and removed directly from the testical using aspiration procedures or surgical techniques. For example, men who have had a prior vasectomy can elect to have a vasectomy reversal or percutaneous epididymal sperm aspiration (PESA), where a needle is inserted into the epididymis and sperm is aspirated. The sperm is then used to fertilize the egg with ICSI. Additionally, a variety of surgical techniques to retrieve sperm directly from the testicle are available and used depending on the particular circumstances. Although these sperm retrieval techniques are more invasive than ejaculation, they allow couples who would not otherwise conceive to becomes successfully pregnant. 

The most challenging male fertility diagnosis is azoospermia, which is the complete absence of sperm. These patients require additional testing and evaluation, and in some cases surgical evaluation of the testes to identify the presence or absence of sperm. If sperm cannot be identified within the testicles, then the couple’s options include the use of donated sperm or the adoption of an embryo or child.

In the last decades, great progress has been made in the treatment of male infertility, which has allowed millions of couples to build sounds who otherwise would not have been able to.

There are over three million infertile couples in the United States. Factors affecting men account for about 40% of the causes. Until the past few years, many of these couples were only able to become parents through using donor sperm or adoption. Fortunately, increased focus on male infertility has led to a series of recent advances in the medical world. Now, virtually all forms of male infertility are treatable.

Historically, male factor infertility has largely been neglected. This accounts for the many treatment options available for the management of female-related infertility, but few for men. Interestingly, in 1677 the sperm was the first microscopic organism ever seen. Yet, except for the use of sperm banks, which surprisingly have been around since the late 1800’s, many men could not become fathers and couples become parents because of the lack of other available treatments. During the 1950s and 1960s, techniques were developed to cleanse sperm from semen and capacitate them. This enabled couples to undergo intrauterine inseminations. In 1978, the first in-vitro fertilized (IVF) baby was born. IVF was designed primarily to help women with tubal factor infertility to become pregnant. It was finally in the early 1990’s, that techniques were created that helped men with very low sperm counts. The impact of these techniques on the treatment of male-related infertility is comparable to the impact antibiotics had on infectious disease 60 years ago.

Male factor infertility centers on the sperm. Sperm are very simple creatures. They are the smallest cells in the human body composed basically of encapsulated DNA (i.e., genetic blueprint) with a “propeller.” They resemble tiny tadpoles. Difficulty conceiving results from any disorder that limits the sperm reaching and fertilizing the egg. Some of these disorders include poor sperm production by the testicles, blockage of the passageway that carry sperm out, destruction of sperm by forces in the female tract, and inability of the sperm to recognize and fertilize an egg. A very common cause of male infertility is a defect with the “propeller” (i.e., poor motility). This naturally does not allow the DNA package to be delivered to the awaiting egg. Fortunately, defects with the propeller do not correlate with defects in the DNA. Thus, if we can help deliver the DNA package by another means we can restore that sperm’s capacity of fertilizing an egg.

The average ejaculate contains over 100 million sperm. A common question is: Why are so many required for conception to occur? The reason lies in the tremendous journey sperm must make from the top of the vagina (after penile emission) to the end of the fallopian tube where the egg awaits. Relative to a grown man’s size, he must swim across the Pacific Ocean to match the distance. If there were 100 million of him, perhaps some would make it. However, if there are fewer numbers or half are crippled, the likelihood is much smaller. The World Health Organization recommends there be a minimum of 20 million sperm available for effective conception to occur with intercourse. Male factor infertility occurs when the numbers are less than this.

The treatment for male factor infertility then is simply to help the sperm reach and fertilize the egg. If a lower number of available sperm is the problem, we can help this by decreasing the distance they must swim. Intrauterine insemination (IUI) places a sperm sample half way up the female reproductive tract, essentially starting them from Hawaii in their quest across the Pacific Ocean. The advanced reproductive techniques, like Gamete intra-fallopian transfer (GIFT) and IVF, places them as far as the opposite shore. By cutting the distance, the minimum numbers required decrease substantially such that only about 10 million are desired for IUI and 1 – 2 million for GIFT or IVF. These treatments have greatly reduced the threshold of sperm needed to achieve conception and have helped tens of thousands of couples worldwide to become parents.

What about those individuals whose sperms are a fewer than a million and for the many men who have no sperm at all released due to obstruction or non-development of the passageway? In 1992, a revolutionary technique called intracytoplasmic sperm injection (ICSI) was first used to help four couples have babies. The technique uses micromanipulation so that a single sperm can be handled to fertilize a single egg. Thus, if a man produces any sperm, he is capable of becoming a genetic father. Over the past five years, thousands of healthy babies have been born as a result of ICSI. And for the many men who have no sperm released, newer techniques of sperm retrieval have been developed to precede any obstruction. We can even take sperm directly from the testicle and apply ICSI to achieve conception. These newer techniques have an alphabet soup of acronyms: Percutaneous and Microsurgical Epididymal Sperm Aspiration (PESA and MESA), Testicular Sperm Extraction (TESE). These techniques are commonly used for men who are born without a vas deferens or who have had vasectomies but later desire children. PESA and MESA allow men to avoid surgical reconstruction of the blocked vas and still maintain contraception after their baby is born. Finally, we have learned to identify viable sperm even if they do not move at all. No movement was the previous definition of a dead sperm, but with the hypoosmotic-swelling test (HOS) we can pick individual living sperm and apply ICSI to help these couples conceive.

There are treatments currently available to overcome virtually all forms of male factor infertility. From andrology to technology, improvements have been made that enable infertile men with any viable sperm to become genetic fathers. For the few men who never made or no longer make any viable sperm, the remaining options are to use donor sperm or adoption to become parents. Given the rate of progress over the past two decades, there may eventually be treatments available for these men also. It is exciting to review how far we have come and where we might be in the future. Infertility, whatever the cause, is a disease that can severely cripple the lives of many people. Fortunately, there are effective means now available for male factor which may foster hope and alleviate the distress it adds to one’s life.