“When I wasn’t able to get my wife pregnant, man, that was a gut punch. I questioned my ability to function as a man. There is no 'water cooler talk about fertility among men. We tend to just go inward. ” - a husband on infertility during an interview
The sperm's passage to the egg is a difficult journey. Out of the 100 - 300 million sperm that are ejaculated, only 400 sperm survive the orgasm and then only about 40 sperm survive the challenges posed by the environment to reach the egg. Even under normal conditions, only about 15% of these millions of sperm are strong enough to fertilize an egg (source). It's therefore not surprising, perhaps, that more than 90% of male infertility cases are due to low sperm counts, poor sperm quality, or both.
Contrary to popular belief that fertility issues are found more often in women, according to the American Society of Reproductive Medicine, infertility issues are split evenly between men and women. About a third of infertility problems are due to female infertility, and another third are due to male infertility. In the remaining cases, infertility affects both partners or the cause is unclear. Last week we explored causes and treatments for female-factor infertility (check out the blog here). Today we will review causes and treatment possibilities for male-factor infertility.
Causes of Male-Factor Infertility:
Problem's with sperm health can stem from pre-testicular, testicular or post-testicular factors. In some cases, the sperm may be immature, abnormally shaped or unable to swim. The remaining cases of male infertility can be caused by a range of conditions including anatomical problems, hormonal imbalances, and genetic defects (source).
Sperm Abnormalities (low sperm count, poor sperm mobility, and poor sperm shape)
Sperm abnormalities can be caused by a range of factors, including congenital birth defects, disease, chemical exposure, and lifestyle habits. In many cases, the causes of sperm abnormalities are unknown. Below are the 3 different classifications of sperm abnormalities. As mentioned above, sperm abnormalities represent 90% of infertility cases in men.
Low sperm concentration/count (oligospermia)
A sperm count of less than 20 million/mL is considered low sperm. Azoospermia refers to the complete absence of sperm cells in the ejaculate. Partial obstruction anywhere in the long passages through which sperm pass can reduce sperm counts. Sperm count varies widely over time, and temporary low counts are common. A single test that reports a low count may not be a representative result. For a list of potential causes by the Mayo Clinic click here.
Poor sperm motility (asthenospermia)
Sperm motility is the sperm's ability to move. In order to swim through the cervical mucus and penetrate the hard outer shell of the egg, the sperm need to swim at a certain speed and in a straight line. If 60% or more of sperm have normal motility, the sperm is at least average in quality. If less than 40% of sperm are able to move in a straight line, the condition is considered abnormal.
When considering treatment, keep in mind that sperm that move sluggishly may have genetic or other defects that render them incapable of fertilizing the egg. You may want to ask your doctor about testing the sperm for genetic diseases: poor sperm motility may be associated with DNA fragmentation and may increase the risk for passing on genetic diseases (source).
Abnormal sperm morphology/shape (teratospermia)
Sperm structure should have an oval head and long tail. If the shape, or morphology, is abnormal, the sperm cannot fertilize and egg. A sample will look for about 60% of the sperm being a normal shape and structure which is required adequate fertility.
Treatment for Sperm Abnormalities:
The treatment of male infertility depends upon the underlying cause. Several months to years of treatment may be necessary to achieve fertility depending on the treatment. In most cases of infertility, both partners will need to be involved with the treatment.
Medication: If the semen sample shows low sperm count and also includes too many white blood cells and bacteria, sexually transmitted diseases (STD) or infection may be contributing to the problem. In the case or an STD or infection, medication will be given for treatment (see more on STDs below).
Assisted Reproductive Technologies (ART): If the underlying cause to the male partner's semen containing abnormal sperm can't be treated naturally or with medication, ART can often help. Couples should discuss the pros, cons, and success rates of these techniques with an infertility specialist. Intracytoplasmic sperm injection (ICSI) is an ART procedure that is performed in conjunction with IVF. With ICSI, a single sperm from the male partner is injected directly into a woman's egg (oocyte) in the laboratory. This technique can be useful in many cases of low sperm count. The pregnancy rate with ICSI is approximately 20 to 40 percent per cycle, although the technique is costly.
If a man's semen completely lacks sperm or has very poor sperm quality in the ejaculate, sperm can sometimes be directly removed from the testes via microsurgical epididymal sperm aspiration (MESA and TESA). MESA and TESA are surgical techniques recommended when there are few or no sperm in the ejaculate. If sperm can be found and extracted from the testis, the sperm will be used for ICSI and the fertilization rate of the oocyte is not very different from IVF. Thus, men with no sperm in the ejaculate can have a potential of fathering a child using these techniques.
If sperm can not be found or extracted you and your partner can talk to a fertility specialist about other options such as donor sperm or adoption. It is most certainly not easy to learn that having a biological child together may not be a possibility. Couples having gone through sterility recommend seeking the help of a support group or therapist.
Blockage of the Reproductive Tract
Some men are born with a blockage such as scarring or growths or other problems in the epididymis or ejaculatory ducts, that block sperm from getting out. Some men lack the vas deferens, the tube that carries sperm from the testicles out through the penis. Low semen levels in ejaculate may be associated with structural abnormalities in the tubes transporting the sperm.
Men who have a blockage can talk to their doctor about surgery to fix the blockage. If it is not successful or surgery is not preferable, another option is assisted reproductive technologies using sperm retrieved from the testes.
The surgery procedures, MESA and TESA, may be recommended when there are few or no sperm in the ejaculate as a result of vasectomy, congenital absence of the vas deferns or epididymis, prior failed surgery or epididymal scarring from infection. Tissue is collected from the testes and processed in the laboratory to remove healthy sperm for use with intracytoplasmic sperm injection (ICSI). Used with in vitro fertilization (IVF), ICSI involves injection of a single sperm into the core of an egg (source).
Vasectomy (male sterilization) 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.
In a small percentage of cases, only 1 to 2 percent, male infertility is due to problems in the hypothalamus and pituitary gland (parts of the brain that regulate hormone production). Problems with the hypothalamus and pituitary glands can affect sperm production and sexual function.
Thyroid problems also can lead to low levels of testosterone, follicle stimulating hormone (FSH) and luteinizing hormone (LH) required for sperm production.
Hypogonadism is the general name for a severe deficiency in gonadotropin-releasing hormone (GnRH), the primary hormone that signals the process leading to the release of testosterone and other important reproductive hormones. Low levels of testosterone from any cause may result in defective sperm production.
Hypogonadism is uncommon and is most often present at the time of birth. It is usually the result of rare genetic diseases that affect the pituitary gland. These conditions may include selective deficiencies of the hormones FSH and LH, Kallman syndrome, or panhypopituitarism, in which the pituitary gland fails to make almost all hormones. Hypogonadism can also develop later in life from brain or pituitary gland tumors or as a result of radiation treatments.
Medication may be prescribed for certain hormonal imbalances. Blood tests looking for testosterone and follicle-stimulating hormone (FSH) levels are usually taken first. If testosterone levels are low, then luteinizing hormone (LH) is measured.
If there is a thyroid issue, medication typcially helps and fertility is restored.
Human chorionic gonadotropin (HCG) supports the production of testosterone in the male reproductive organs. Clomiphene citrate helps the hypothalamus and pituitary glands produce the chemical that stimulates LH and FSH production. These, in turn, regulate testosterone production and improve sperm 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 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. This may take several years of treatment to achieve normal fertility.
Hormonal Levels. Men produce both male hormones (testosterone) as well as pituitary hormones (FSH and LH). Tests for these hormone levels are indicated if semen analysis is abnormal (especially if sperm concentration is less than 10 million per milliliter) or there are other indications of hormonal disorders.
A varicocele is a dilation of a vein (like a varicose vein) in the scrotum. Varicoceles are found in about 15% of all men and in about 40% of infertile men, although it is not clear how much they affect fertility or by what mechanisms. They can raise testicular temperature, which may have effects on sperm production, movement, and shape. The reason a varicocele affects 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.
Varicoceles large enough to possibly interfere with fertility can be felt during examination of the scrotum. In such cases, they are described as feeling like "a bag of worms." They disappear or are greatly reduced when the patient lies down, so the patient should be examined for varicocele while standing.
Surgery can be used to repair varicoceles and correct any obstructions in the reproductive tract. However, there is some controversy over whether varicocele embolisation or surgery actually improves fertility. Some studies indicate that varicocele treatment may not help improve a couple’s chances of conception.
An alternative to varicocele repair is assisted reproductive technologies (ART), such as intracytoplasmic sperm injection (ICSI). With ICSI, only a small number of sperm are needed.
Some men may produce plentiful, high-quality sperm but they experience problems ejaculating. With premature and delayed ejaculation, timing prevents orgasm and the release of sperm into the vagina during intercourse.
Another problem is retrograde ejaculation which is when semen is released backward, into the bladder. This can be caused due to trauma, nerve damage, birth defects and diseases including diabetes and multiple sclerosis. Retrograde ejaculation also is linked to certain prescription drugs, including those for depression and high blood pressure.
Hypospadias is a birth defect in which the urinary opening is on the underside of the penis. It can prevent sperm from reaching the cervix if not surgically correct.
Premature ejaculation is only a problem of fertility if ejaculation occurs before entering the vagina and/or has had a negative impact on a couple's intimate life. Premature ejaculation can be due to anxiety, over-excitement, prostate health issues, prescription medications, cold medications and some depressive conditions can cause premature ejaculation. Some men are simply super sensitive and tend to arouse easily. Treatment may involve sex therapy (ie: start-stop method) or medications to treat the underlying cause (source).
In cases involving retrograde ejaculation, sperm may be found in the urine. If healthy sperm can be extracted, insemination is an option. In cases where timing is the problem, a collection of sperm and insemination may be recommended. Oral medications may be effective in improving retrograde ejaculation by helping the bladder neck close during ejaculation.
Hypospadias may be fixed via surgery or insemination via ART.
Male sexual dysfunction can be related to medical conditions and psychological issues including stress. In some cases, age plays a part. Although age-related changes in male fertility are not as pronounced as those in the female, sex drive, sexual function and the ability to conceive can be diminished by changes in the testes, the quality of sperm and hormone-related problems.
Medication may be available to address sexual dysfunction depending on the nature of the problem and the cause. Fertility medications can be prescribed to restore hormonal balance, increase the sex drive, restore sexual function or improve performance.
If“performance anxiety” is an issue or as mentioned above, premature ejaculation, therapy can be a helpful treatment. Therapy can help to reduce stress and restore sexual confidence and function.
Age-related sperm changes in men are not abrupt but are a gradual process. Aging can adversely affect sperm counts and sperm motility (the sperm's ability to swim quickly and move in a straight line). The genetic quality of sperm declines as a man ages but does not impact fertility to near the extent of women.
There is no treatment for age-related infertility.
Sexually Transmitted Diseases
Repeated Chlamydia trachomatis or gonorrhea infections are the sexually transmitted diseases most often associated with male infertility. Such infections can cause scarring and block sperm passage. Human papillomaviruses, the cause of genital warts, may also impair sperm function.
In many cases, infertility due to STDs can be treated. In one study. after treating 95 infertile men with antibiotics for four months, the researchers found that their sperm DNA fragmentation improved 36% - during this time 13% of them managed to get their partners pregnant. By the end of the treatment period, 86% of the couples became pregnant (source).
A man can make small changes immediately to naturally improve sperm quality and quantity. Semen is continuously being produced in the male body, and takes approximately 74 days to mature, meaning that positive lifestyle changes today can result in improvements in sperm quantity and/or quality in as little as 2 to 3 months time. Here are a list of lifestyle factors that can decrease sperm quality.
Testicular Overheating. Overheating, such as from high fevers, saunas, and hot tubs, may temporarily lower sperm count.
Substance Abuse. Cocaine or heavy marijuana use can temporarily reduce the number and quality of sperm. Chemical compounds in marijuana may impair sperms' ability to swim and also inhibit their ability to penetrate the egg. Anabolic steroid use can shrink testicles and decrease sperm production. Heavy drinking may also impair fertility.
Smoking. Cigarette smoking may affect sperm quality.
Obesity. Obesity may impair hormonal levels and adversely affect fertility.
Bicycling. Prolonged bicycling may affect erectile function. Pressure from the bike seat can sometimes damage blood vessels and nerves that are responsible for erections. Mountain biking, which involves riding on off-road terrain, exposes the perineum (the region between the scrotum and the anus) to more extreme shocks and vibrations and increases the risk for injuries to the scrotum.
Emotional Stress. Stress may interfere with certain hormones involved with sperm production but doctors are not sure if stress plays an important role in infertility.
Environmental Factors. Toxins in everyday household products may impact hormonal health. Try switching to non-toxic cleaners, skin products, and avoid processed foods.
Occupational or other long-term exposure to certain types of toxins and chemicals: Toxins such as herbicides and pesticides, may reduce sperm count by either affecting testicular function or altering hormone systems. Chemicals in these products are known as endocrine distruptors and little is known about the negative effects on reproduction. While trying to conceive and once pregnant, it is best to avoid toxins if possible.
In a nut-shell for healthy sperm:
- Lose weight and exercise
- Maintain a healthy diet with foods rich in antioxidants
- Don’t smoke or use recreational drugs
- Reduce your intake of alcohol to fewer than 5 drinks per week
- Take a daily multivitamin
- Don't overheat your sperm and avoid hot tubs and prolonged bike rides.
Sometimes treatment is not currently available for some types of male infertility or infertility can not be explained. For example, there is no known treatment when the sperm-producing structures of the testes have been severely damaged such as during active duty, cancer treatments or a car accident. Other issues happen in men with certain chromosomal abnormalities such as Klinefelter syndrome and small deletions in the Y (male-specific) chromosome where no known treatment is available yet (source).
Medical conditions also can affect male fertility and include any severe injury or major surgery, diabetes, HIV, thyroid disease, Cushing syndrome, heart attack, liver or kidney failure, and chronic anemia. Certain types of medications can impair sperm production.
Infections in the Urinary Tract or Genitals. Infections that may affect fertility include prostatitis (inflammation in the prostate gland), orchitis (in the testicle), semino-vesculitis (in the glands that produce semen), or urethritis (in the urethra), perhaps by altering sperm motility. Even after successful antibiotic treatment, infections in the testes may leave scar tissue that blocks the epididymis.
To determine if there is a potential fertility issue, a semen analysis is the most useful investigation and is able to detect 9 out of 10 men with a genuine problem of male infertility. It is a simple test that assesses the sperm health but analyzing the formation and maturity of sperm and how the sperm interacts in the seminal fluid. It also provides insight on sperm count, and quality (motility, morphology) (source).
Denny Ceizyk, who writes about infertility after his own journey with low sperm count, says, "Not 'checking your boys' after one year of 'trying to have a baby on your own is like ignoring the 'check engine' light when it first goes on. It could be nothing, but if you let it go, it could cost you far more in the long run that if you just take care of it soon after that warning signal first appears," he explains.
In addition to a medical history and physical exam, specific tests for male infertility include:
- Semen analysis to evaluate the quantity and quality of sperm
- Blood tests to evaluate hormone levels
- Imaging tests to look for structural problems
- Genetic testing to identify sperm DNA fragmentation, chromosomal defects, or genetic diseases
In any fertility work-up, both male and female partners are tested if pregnancy fails to occur after a year of regular unprotected sexual intercourse. It should be done earlier if a woman is over age 35 or if either partner has known risk factors for infertility. A work-up can not only uncover the causes of infertility but also detect other potentially serious medical problems, including genetic mutations, cancer, or diabetes.
The basic test to evaluate a man's fertility is a semen analysis. The sperm collection test for men who can produce semen involves the following steps:
A man should abstain from ejaculation for several days before the test because each ejaculation can reduce the number of sperm by as much as a third. To ensure an accurate sample, most doctors recommend abstaining from ejaculation for at least 2 days, but not more than 5 days, prior to semen collection.
A semen analysis should be repeated at least three times over several months. Please note that a semen analysis alone is not necessarily a definitive indicator of either infertility or fertility.
A semen analysis will provide information on:
- Amount of semen produced (volume)
- Number of sperm per milliliter of semen (concentration)
- Total number of sperm in the sample (count)
- Percentage of moving sperm (motility)
- Shape of sperm (morphology)
- Semen Volume and Concentration. The seminal fluid (semen) itself is analyzed for abnormalities. The color is checked and should be whitish-gray.
The amount of semen is important. Most men ejaculate 2.5 - 5 milliliters (mL) (1/2 - 1 teaspoon) of semen. Either significantly higher or lower amounts can be a sign of prostate problems, blockage, or retrograde ejaculation.
Other factors may also be measured:
- An absence of semen fructose (sugar) may indicate obstruction in the vas deferens or epididymis.
- Low levels of a substance called inhibin B, which is produced only in the testes, may indicate blockage or other defects in the seminiferous tubules.
- Low levels of another compound, alpha-glucosidase, may also indicate blockage in the epididymis.
Check out the parameters for the analysis here.
The good news is there are many options for treating most male-factor infertility. Treatment, of course, depends on the issue and may require medication and surgery. If it's simply low sperm count or mobility than IVF may be a good option. Should you seek fertility help, always ask 1) if your condition can be treated in other ways 2) know why a test or procedure is recommended 3) what the results could mean and, 4) and the statistical success rate.
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