Infertility affects 15% of all couples (an estimated 9 million) in their reproductive years. As a result, one in eight couples will struggle with infertility regardless of whether the diagnosis is primary or secondary. Despite 40% of infertility causes attributed to the male and 30% due to both the male and female, most men are reluctant to appreciate the high prevalence of their contribution. This distribution of etiologies maintains across cultural and ethnic boundaries. Following a complete evaluation, an exclusive male cause for infertility is 20%. Most male infertility physicians today are urologists with additional years of in fellowship for specialized training in the field.
The simplest testing of a male is the semen analysis (SA). The World Health Organization classifies as normal: sperm density greater than 20 million/mL; motility greater than 50%, and morphology (greater than 30%. The SA correlates with sperm fertilization potential. A persistently abnormal SA (two occasions obtained one month apart), particularly if severely low, warrants a genital examination by an experienced male reproductive specialist. An abnormal SA may be the first sign of significant pathology that may be life threatening in 2% of cases.
The diagnosis of infertility may not only indicate a problem with the husband but also may put the health of his offspring at risk. With a growing understanding about the genetics behind male infertility, a genetic cause may exist in up to 20% of patients. This is usually Kinefelter’s syndrome 47, XXY) but also microdeletions in the Y-chromosome.
The primary goal of the evaluation is to determine the cause of the problem and to exclude life threatening pathology. To accomplish this all males will require at least a history, physical examination, hormonal testing in addition to the semen analyses. Other studies may be indicated but usually occur after the core evaluation.
The secondary goal of the male evaluation is to determine if the infertility is treatable. The leading causes of male infertility are scrotal varicocele (10-30%), idiopathic (23%), obstruction (14%) and cryptorchidism (3%). A varicocele appears as a “bag of worms” in the scrotum resulting in increased testicular temperature thereby damaging sperm. This venous congestion is usually present in tall men and dominant on the left due to testicular vein drainage into the renal vein at a 90 degree angle. The American Urology Association considers a varicocele as clinically significant when it is palpable on clinical examination as opposed to sonogram, the semen parameters are abnormal, and infertility is present.
Once a diagnosis is made treatment options are reviewed. Problems are categorized into: 1) Hypogonadotropic hypogonadism (HypoH); 2) Hypergonadotropic hypogonadism (HyperH); and 3) Obstruction, including retrograde ejaculation (RE). Once pituitary pathology is excluded, HypoH has been well established to be responsive to hCG and/or FSH injections. HyperH usually requires testicular aspiration (TESA) with the advanced fertilization technique of IVF-ICSI or donor sperm. Genetic consequences of infertility or sex chromosomal aneuploidy apply to the offspring, particularly males so a karyotype and Y-chromosome microdeletion testing is recommended. Testicular sperm do not have mature fertilization capability and require ICSI. Obstructive causes may be surgically corrected or treated by TESA as above. Because of the association, men with Congenital Bilateral Absence of the Vas Deferens should be tested for Cystic Fibrosis. RE is easily managed by pre-ejaculation alkalinization of the urine then voiding for sperm collection followed by intrauterine insemination of the washed sperm. The empiric use of clomiphene citrate, antioxidants, and protein supplements has not been demonstrated to improve sperm parameters or pregnancy rates. Importantly, testosterone supplementation can actually suppress pituitary FSH and lower sperm production.
Special consideration is given to the vasectomy reversal. Physicians have long believed a reversal is usually unsuccessful when the vasectomy was performed more than 10 years prior. Actually, recent evidence reveals reasonable pregnancy rates when the reversal is performed in experienced hands and the female partner is less than 35 years old.
Today more options exist that were previously unavailable. Despite severe male factor infertility, pregnancy may still be achieved. The other unique feature of infertility treatment is the shared nature of the decision making process between the physician and the couple. Not only must the status of the wife be factored into the treatment decision but the couple’s psychological, ethical and financial concerns as well. It is imperative during the male evaluation that the wife have completed her evaluation and that an open dialogue exists between the treating physicians of both the husband and the wife.
A couple experiencing infertility should not underestimate the significance of the problems that can exist in the male. These problems may be the sole or contributing reason for the couple’s failure to conceive and are best identified by a male infertility specialist. Care and attention in looking for and identifying disease processes in both the man and woman will prevent missed opportunity for a potential cure and give the couple the timeliest and most efficient pathway to start or expand their family.
Dr. Witt is one of a few fellowship trained male infertility specialist and is on staff at Fertility C.A.R.E. Dr. Mark P. Trolice is the Director of Fertility C.A.R.E. and is Board-certified in Reproductive Endocrinology and Infertility (REI). Please direct any inquiries by calling 407-672-1106 or email