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You’re a modern male. You understand that infertility, while no one’s fault, is a puzzle involving both partners. Dr. Philip Werthman, Director of the Center for Male Reproductive Medicine in Century City, California, states, “Experience shows that male factor will be a contributing cause to a couple’s infertility in 30-40% of cases, and the sole cause in about 20%.”

If one were to put this in some historical perspective, Henry VIII had six wives, one son who didn’t survive adolescence, two daughters, and many miscarriages. He tried to blame his wives however, history has shown that his health was a factor in his reproductive difficulties. Unlike King Henry, you know this is not solely a woman’s issue and you’re ready to have an evaluation to determine if your reproductive capacity is compromised. You’ve had unprotected intercourse for a year, your partner isn’t pregnant and you’ve had your sperm tested. (To learn more about sperm testing, refer to Focus On Fertility fact sheet, “Swimming Toward Conception: The Semen Analysis” by visiting http://www.focusonfertility.org.) The next step your doctor tells you is to see a urologist.

As soon as the words are uttered, most men feel the panic rising. Unlike King Henry, the conventional wisdom is that infertility, or the possibility of it, has nothing to do with your manhood or anything else that makes you who you are. There’s nothing wrong with your virility or masculinity.

Still, the sense of dread can be pretty overwhelming. “Most men come in reluctantly,” observes Dr. Mark Licht, of Boca Urologists in Florida. “With many guys, I hear, ‘my wife wanted me to come,’ or, ‘I don’t know why I’m here.’ Most of them have a very hard time dealing with the fact that an issue relating to fertility has anything to do with them.”

“Whatever the cause, once men realize there are options and there is hope to have their own biological child, they deal with it differently,” says Licht. “Yes it may take help, surgery or IVF (in vitro fertilization) however, the odds are reasonable even for the most difficult cases.”

Typically, initial results of the semen analysis have shown something unusual in your sperm count, motility (swimming ability), or morphology (shape). The results may suggest agglutination (the sperm are clumping together), white blood cells in semen or few or no sperm. Any number of things, including simple, treatable infections, can cause some of these results. To determine the cause and treatment, a urologist is the doctor for you.

“Urologists will treat the male as not just a producer of sperm but as a whole person,” explains Dr. Eric Seamen, of the St. Barnabas Institute for Reproductive Medicine and Science in Livingston, NJ. “The urological examination may uncover an underlying condition causing the low sperm count. It is possible that treatment may allow a couple to conceive without resorting to assisted reproductive techniques.”

Equally important, the urologist will be aware of the latest research in genetics and reproductive technology and its implications for you and your partner. According to Dr. Peter Schlegel, chairman of the Urology Department at the Weill-Cornell Medical Center, recent research has identified areas of the Y chromosome that affect sperm production. He also mentions another promising area of investigation into the DNA content of the sperm itself and how that may affect embryo growth and implantation. Research is underway about the semen content as well.

The goal, remarks Schlegel, is new tests that will guide your doctors, you and your partner to the most effective and efficient treatments and avoid unnecessary and sometimes invasive surgeries. Often, the test results can lead a couple and their doctors away from complex assisted reproductive techniques that have no chance of working and exact a high emotional, social and financial toll.

Of course, different urologists do things differently, and some semen analysis results will suggest different tests. But generally, here’s what you can expect at the urologist’s office.

A Complete Physical Exam

Your urologist will put you through a full-body exam, but will focus on the genitals, says Dr. Sarah Girardi of Urological Associates in Manhasset, NY explains, “That’s the part most men are concerned about. It takes about a minute. And it’s pivotal because it involves determining that there are no structural abnormalities.”

Your urologist will be looking at size and shape of the penis, including any curvature, and testicles. The physical exam concludes with a rectal exam. That’s key, too, says Dr. Girardi, because it may reveal other structural abnormalities, most of which are congenital. For example, there’s the Mullerian cyst, a remnant of female tubal structures present in all early fetuses, that can cause a blockage if it doesn’t disappear the way it normally would. “If you can successfully relieve the cyst there is usually a nice improvement in semen analysis,” notes Girardi.

A complete history will be taken including childhood illnesses and accidents. Think back. If you had undescended testicles, any kind of genital trauma, or went through puberty either early or late, you may be experiencing the effect now. Your doctor will discuss the frequency and timing of sexual intercourse with your partner. You should mention any previous pregnancies you may have achieved with other partners, even those that ended with a miscarriage or an abortion.

Your urologist will ask about your work and workplace. There will be questions about exposure to toxic substances including alcohol and marijuana. This is a place where total honesty is essential. Remember, this is between you and your urologist, and it is the place to mention and discuss, any STDs you’ve had and any drugs you may be currently taking or taken in the past including steroids and herbal supplements. Your candor here can make a significant difference in the diagnosis.

Your doctor will draw blood for many tests including a hormone profile, as your reproductive capabilities depend on a functioning endocrine system. The blood work will also reveal any recent sexually transmitted diseases.

“I always ask for a second semen analysis, and often a third,” says urologist Dr. Philip Werthman. “You never hang your hat on one or two. If someone had a cold or a fever a few months ago they may have a poor sample. Sperm production is really affected by environment. Even men who present with no sperm in one analysis can turn out to have normal semen analysis a month or two later.”

Anxiety can also affect the results. You will be asked to avoid ejaculation for 2-3 days prior to the test. Be careful as you collect the ejaculate. It should be in a sterile container and the volume is an important factor that needs to be measured. The analysis has to be done within two hours of collection, so you may be asked to go to a lab to provide a sample, or commonly to provide the sample in the doctor’s office.

Your urologist may consider genetic screening critical to rule out causes based on ethnicity or your past history. A blood screen will help determine if you’ve got a heritable condition that’s impeding conception, such as Kleinfelter’s Syndrome (absence of sperm). Furthermore, about two-thirds of men missing a semen duct (vas deferens) also carry a mutation of the cystic fibrosis gene. If you are one of these men, your partner will also be checked before you begin assisted reproductive therapy, so you can discuss with a genetic counselor the risk of passing cystic fibrosis to your offspring.

Another test that may be performed is a testicular sonogram, an imaging procedure used to get a clear picture of the testicles. The procedure is really pretty simple: A technician spreads warm gel on the scrotum then gently passes a light transducer over the scrotum. The technician (and you, if you ask) can view the image on a screen, and the images may be printed or stored for further review. A rectal sonogram might be needed to view the prostate and internal structures.

Once the testing is complete and the blood and semen analysis results are available, your urologist may make a diagnosis. Remember Henry VIII? Dr. Seaman says, “I’d tell him to lose weight. And he also would need to have the syphilis treated.” Yes, King Henry probably had syphilis that was undiagnosed and it undoubtedly affected his reproductive life. Fortunately, we live in the age of antibiotics. You may have an infection or other condition that can be treated fairly simply with the appropriate drugs. You may have a hormonal condition. This is fairly rare, however, in some cases the testes can be hormonally stimulated to produce more sperm.

Other conditions such as blockages, may need surgical correction with a simple procedure. One condition that is commonly found is a varicocele, or varicose vein around the spermatic cord. Varicoceles, according to Dr. Werthman, appear in 15% of all men and 40% of infertile men. A duct may be blocked. Or you may have had a vasectomy. Of course the thought of surgery, even minor, in the genital area is hard to think of as “simple.” But Dr. Werthman says, “People undergo cosmetic surgery to fix varicose veins all the time. If you’re going to do it for vanity, you ought to do it for a good reason. It’s a 20-minute operation with a one and a half-inch incision. We don’t cut through any muscle, just go under the skin with a microscope. This operation is not on the testicle or the scrotum.” Vasectomies too can be surgically reversed, though it’s a slightly more complicated operation. All of these surgeries are outpatient surgeries, meaning that they can be done in the doctor’s office and that you can go home the day of the surgery.

For a small number of men there may be less happy news. Some men with genetic disorders like Klinefelter’s Syndrome are unable to produce sperm. You may be missing the duct that carries the sperm from the testicles to the ejaculate. If you have taken or are taking steroids or herbal preparations with androgenic properties, you may have interfered with your reproductive capacity. This interference is usually -but not always - reversible. Remember the honest discussion? It’s much better to disclose it.

In other, rarer cases, there may be a more complex underlying medical condition that is contributing to the semen analysis results that needs treatment. Approximately one in 100 men seeking assessment as part of a couple’s quest for fertility will have a testicular mass that needs evaluation, says Dr. Girardi. Urologists can identify testicular cancers - and may save your life by providing a quick evaluation.

Whatever the cause of the infertility in many cases it is correctible. In the vast majority of men with infertility problems, once there’s a clear diagnosis, there’s usually an assisted reproductive technique that will likely work for you. The most important thing is that you contribute to the reproductive equation by going to see the urologist.

Having support, a place to discuss your concerns, and gather information can take some of the sting out of that first visit to the RE. So contact the American Fertility Association, toll-free at 1-888-917-3777 or log on to http://www.theafa.org or visit http://www.focusonfertility.org. We’ve been through it. We know exactly how you feel. We can help

For more information about fertility and infertility diagnosis and treatment, visit http://www.focusonfertility.org, http://www.theafa.org or contact The AFA directly at 1-888-917-3777.

This fact sheet is part of the Focus On Fertility campaign (http://www.focusonfertility.org) and is sponsored by OrganonUSA (http://www.organonusa.com).