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Male Infertility

The incidence of infertility in newly married couples is approximately 10-15 percent. Ninety percent of "normal" couples who are attempting to conceive a child will be successful within one year. Approximately 20 percent of cases of infertility are due exclusively to a "male factor", and in 30-40 percent of cases, both male and female factors will affect fertility. In women fertility peaks at age 24 and thereafter declines with advancing age.

The goals of male infertility evaluation

  • Identify correctable conditions:
    Many causes of male infertility are correctable, and with appropriate treatment normal reproductive potential can be restored. Correctable conditions should be identified and treated as promptly and economically as possible.

  • Identify irreversible conditions:
    In some patients infertility is not treatable, and natural conception cannot occur under any circumstances. It is important to identify such patients so that couples can move on to assisted reproduction if they so desire.
  • Identify life or health threatening conditions:
    Occasionally infertility may be the initial sign of a more serious condition such as a pituitary tumor or testicular cancer. These diagnoses should always be kept in mind when performing a male infertility evaluation.
  • Identify genetic abnormalities:
    Genetic abnormalities may be responsible for infertility in up to 20% of male patients. While fertility can frequently be restored with assisted reproductive techniques the genetic abnormality may be passed on to offspring. It is important to identify such patients so that genetic counseling can be offered prior to assisted reproduction.

Timing of an infertility evaluation

The timing of the decision to proceed with an infertility evaluation varies from couple to couple. While there are no “rules” regarding the length of time a couple should attempt conception naturally, it is generally accepted that an infertility evaluation should be performed when pregnancy fails to occur after one year of unprotected intercourse. However an evaluation should be performed prior to one year if a known male factor, such as undescended testicles or prior cancer treatment, or female factor, including advanced reproductive age (over 35 years), exists.

The initial male infertility evaluation

The initial evaluation for male infertility consists of a detailed history, physical examination, and two semen analyses. The essential elements of each are listed below.

Medical History

  • Coital frequency/timing:
    • Is sexual intercourse occurring during the fertile interval (days 11-15 if a 28 day cycle)?
  • Duration of infertility/previous fertility:
    • How long has this couple been attempting to conceive a child?
    • Have there previously been any suspected or confirmed pregnancies for either partner?
  • Childhood illnesses/developmental history:
    • History of birth defects such as undesdcended testicles
    • Is there a history of mumps after puberty (can affect testicular function)
  • Medical illnesses:
    • Urinary tract infections
    • Respiratory infections
    • Diabetes
  • Surgical history:
    • Repair of a hydrocele or hernia
    • Surgery on the urethra, prostate or bladder
  • Sexual history:
    • Sexually transmitted diseases
    • Difficulty in obtaining or maintaining an erection
    • Failure to ejaculate
  • Exposure to toxins:
    • Heat
    • Medications
    • Steroids
    • Recreational drugs
  • Family history:
    • History of infertility in siblings
    • History of cystic fibrosis (almost always associated with infertility)

Physical Examination

  • General
    • Muscle mass, hair distribution, breast developmentetc.
  • Genitalia
    • Penis/urethral opening
    • Testicular size and consistency
    • Vas deferens(presence/absence)
    • Varicocele
  • Digital rectal examination of the prostate

The Semen Analysis

  • The semen analysis is the cornerstone of the male infertility evaluations. Therefore proper collection technique is critical. Since semen values can vary significantly from one test to the next, at least two semen analyses, separated by one month, are recommended for the initial evaluation. The following are recommendations for the proper collection of semen specimens:
    • Patients should abstain from ejaculation for 48-72 hours prior to collection.
    • Collection by masturbation is common, but collection through intercourse is acceptable as long as condoms without spermicidal substances are used.
    • If the semen specimen is collected at home, it should be delivered to the laboratory within one hour of collection and maintained at room or body temperature during transport.
       
  • The semen analysis provides information on several parameters including semen volume, semen viscosity (thickness), semen pH (acidity or alkalinity), sperm count, sperm motility (movement), and sperm morphology (appearance). The World Health Organization has established normal values for each. However, it should be emphasized that men with values outside these ranges may be fertile and men with values inside these ranges may still be infertile.
     
  • Normal values:
    • Semen Volume : 1.5-5cc
    • pH: over 7.2
    • Sperm Concentration: over 20mil/cc
    • Sperm Motility: over 50%
    • Sperm Morphology: over 30 14%
    • Semen Viscosity (scale 0-4): over 3

Additional tests for male infertility

  • Hormonal: Sperm production is under the control of two hormones produced in the pituitary gland (brain), lutenizing hormone (LH) and follicle stimulating hormone (FSH). LH stimulates the testicles to produce the male hormone, testosterone. Sperm are produced under the influence of FSH and high concentrations of testosterone. Therefore measurement of levels of FSH, LH, and testosterone can be helpful in the evaluation of male infertility, particularly in patients with sperm counts less than 10 million/cc or a history of impaired sexual function. Since the levels of these hormones fluctuate during the day, it is recommended that these tests be performed on blood samples drawn in the morning.
     
  • Post-ejaculatory urinalysis: In some patients, particularly diabetics, ejaculation occurs in a retrograde (backward) fashion. In such cases, examination of urine following ejaculation will reveal the presence of sperm. Sperm can be retrieved with a catheter and used for in-vitro-fertilitzation (IVF).
     
  • Ultrasound: Ultrasound can occasionally be helpful in the evaluation of the infertile male. In a patient with absent semen, transrectal ultrasound may reveal swelling of the seminal vesicles which can indicate obstruction of the ejaculatory ducts. Scrotal ultrasound can be used to confirm inconclusive scrotal findings on physical examination.
     
  • Antisperm antibody testing: Antisperm antibodies are found in 3-12% of infertile men. Antisperm antibodies are commonly found in men after a vasectomy, but can be seen following testicular injury, torsion (“twisting” of the testicle), or in men with genitor-urinary infections. It is thought that antisperm antibodies may interfere with the sperm-cervical mucus interaction or with the interaction of sperm with the egg. Testing for antsperm antibodies should be considered when marked reduction in sperm motility is present, when sperm agglutination (sperm stick together) is noted, or when an abnormal post-coital test occurs.
     
  • Post-coital test: Testing of the interaction of sperm and cervical mucus is known as the post-coital test. An abnormal post-coital test can indicate the presence of antisperm antibodies (see above) as well as cervical factors contributing to infertility. Although the results of post-coital testing are subjective, the test may be useful in directing infertility therapy.
     
  • Genetic testing: Genetic abnormalities are now a well recognized cause of male infertility. A small percentage of infertile men are born with congenital absence of both vas deferens. Many of these men will carry a gene mutation for cystic fibrosis, a fatal respiratory disease. Seven percent of infertile men have chromosomal abnormalities resulting in abnormal testicular function. Ten to fifteen percent of men with marked reduction in sperm count will have abnormalities of the “Y” chromosome. Since many of these abnormalities will be passed on to offspring, genetic testing and counseling should be performed prior to initiating assisted reproduction.