Male Infertility Overview
Male Infertility Clinic in San Diego
Getting Started
Abnormal Semen Analysis
Varicocele
Unexplained Infertility
Treatment Options
Genetic Concerns
Conclusions
The old saying that "it takes two to Tango" is especially true for couples trying to conceive. The importance of a complete and thorough evaluation of both partners in the relationship cannot be overestimated. After a complete diagnostic evaluation of both partners, the incidence of male factors accounts for 30-50% of the problems identified.
GETTING STARTED
The evaluation of the male partner begins with a simple laboratory test called a complete semen analysis, commonly known as a "sperm count." Semen analysis is done on a sample of seminal fluid collected after masturbation. It is best to do this test after a couple has abstained from sexual activity for 3-5 days. The test can be thrown off if there has been recent ejaculation (counts too low) or if ejaculation has not occurred in a long time (many dead sperm). Once the fluid has been taken to the laboratory it is analyzed for many different things, including; fluid volume, sperm numbers, sperm motility (the number of moving sperm) and sperm morphology (the shape of the sperm head). Variations always occur from test to test, even in the same man, and sometimes the test needs to be repeated.
ABNORMAL SEMEN ANALYSIS
If the test comes back abnormal, the first step is to repeat it!! Every man is entitled to a bad day and sometimes a single semen analysis is not a true reflection of his fertility. If the test is consistently abnormal this represents a significant factor in the fertility of the couple. There are many different ways to perform a semen analysis and not all laboratories perform the test in the same way. Sometimes your physician will recommend an expanded semen analysis looking for subtle changes in the shape of the sperm head, which might predict an abnormality of sperm function. This test uses very strict criteria for normal (Kruger criteria) and is done under high-powered microscopy. The results of this Kruger test can help predict whether the sperm will fertilize eggs normally. Unfortunately, this test is not widely available and is not always covered by insurance plans. The test is available through the San Diego Fertility Center.
VARICOCELE
A urologist is often consulted after an abnormal semen analysis is obtained. The most common abnormality discovered by the urologist is a "varicocele." A varicocele is a dilated vein around the testicle, which raises the core temperature of the testicle and can impair the process of making sperm. Although abnormalities of sperm motility and morphology are the most common abnormalities associated with a varicocele, any abnormality can occur.
The correction of a varicocele involves a minor surgical procedure. The procedure ties off the dilated vein. Tying off the vein (ligation) improves the blood flow around the testicle and can improve the semen analysis. This is where the controversy begins!
Although we are fairly certain that varicoceles impair testicular function, they do not always cause infertility. There are many men in the world with varicoceles and a house full of children. In this instance, the varicocele may have diminished testicular function, but not to the extent of infertility. Or, alternatively, they may have married women of extraordinary fertility, who were capable of "overcoming" the mild deficit in sperm quality. Sorting out which varicoceles cause infertility and which ones are less important is a difficult (and sometimes impossible) task.
Surgical repair of varicoceles is usually successful in eliminating the abnormality and is a safe and effective procedure. After repair of a varicocele the testicle needs to heal and the process of spermatogenesis (making sperm) gradually improves. The full benefit of a varicocele repair may not be seen for up to three months. Unfortunately, not all successful varicocele repairs result in an improvement in sperm counts or motility. Neither the urologist who performs the procedure nor the reproductive endocrinologist coordinating the care of the infertile couple can accurately predict which man will have an improvement in his semen analysis and which will not. Maybe more frustrating is our inability to determine if varicocele repair will improve the chances for pregnancy.
Sometimes varicocele repair improves sperm, but pregnancy still does not occur. Varicoceles and the surgical repair of varicocele can also lead to the production of antisperm antibodies. These antibodies can also impair sperm motility and sperm binding to egg. Needless to say, the book on varicoceles is still wide open.
UNEXPLAINED MALE INFERTILITY
Sometimes a man has consistently abnormal semen analyses and nothing can be found to explain to problem. This happens more often than we would like and can be frustrating to both the doctor and patient. There is an evolving body of literature that suggests there may be very subtle genetic mutations of the Y chromosome which can account for some of these abnormalities. These mutations are usually random occurrences that lead to impaired testicular function. All other bodily functions are normal. Only a few research centers in the world are equipped to hunt for these mutations and they do not necessarily change the treatments recommended.
TREATMENT OPTIONS
Intrauterine Insemination (IUI)
Separating motile sperm from the seminal fluid and placing these sperm high into the uterus (next to the fallopian tubes) can improve fertility by increasing the number of motile sperm that reach the tubes. The sperm washing procedure separates the motile sperm from the seminal fluid, activates sperm motility and may disassociate antisperm antibodies from the sperm cells. This treatment is commonly combined with fertility drugs to enhance female fertility.
In vitro Fertilization (IVF)
Directly placing eggs and sperm together in the laboratory increases the chances of successful fertilization. The resulting embryos are then transferred into the uterus.
Intracytoplasmic Sperm Injection (ICSI)
This technique maximizes fertilization rates by directly injecting a single sperm into an egg. This is done in conjunction with in vitro fertilization and has revolutionized the options available for couples with the severest forms of male factor infertility.
GENETIC CONCERNS
Rarely, the cause for abnormal sperm is the result of a genetic abnormality in the chromosomes of the male. In men with extremely low sperm counts (or the complete absence of sperm) about 10% have a deletion of part of the Y chromosome. It is possible to send a sample of blood from the man to a reference laboratory to test for these deletions. If an abnormality is found it can explain why the sperm counts are so low, but it is impossible to change the genetics to change the sperm making process. If a genetic abnormality is found, it could be passed on to male offspring resulting in infertility in their sons. Genetic counselors are available to explain the risk of this occurrence.
CONCLUSIONS
Male infertility is a common problem in couples trying to conceive. Although the exact cause of the problem often is not known, there are a variety of effective treatments available. Using the right technology, even couples with severe male factor infertility now have options that are very successful. After a thorough diagnostic evaluation, your doctor will be able to create an effective treatment strategy to maximize your fertility.
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Last updated:
October 26, 2005
Authors: Dr. William Hummel and Dr. Michael Kettel