Infertility in men

Introduction
Causes Of Male Infertility
Evaluation Of Male Infertility
Treatment Of Infertility
Assisted Reproductive Techniques
Options For Couples In Whom Male Infertility Cannot Be Treated

Introduction

Infertility is defined as a couple's inability to become pregnant after one year of unprotected intercourse. In any given year, about 15 percent of the couples in North America and Europe who are trying to conceive are infertile.

The fertility of a couple depends on several factors in both the male and female partner. Among all cases of infertility, about 20 percent can be traced to male factors, 38 percent can be traced to female factors, 27 percent can be traced to factors in both the male and female partners, and 15 percent cannot be traced to obvious factors in either partner.

When infertility occurs, doctors involve both the male and female partners in evaluation and treatment. In the past, male infertility was often frustrating because many cases had no identifiable cause and many men could not be treated. However, new tests have made it possible to pinpoint previously unidentified causes of male infertility, and new treatments and assisted reproductive techniques (ART) offer hope to many couples.

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Causes Of Male Infertility 

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Evaluation Of Male Infertility

History — Your doctor may be able to get some clues about the cause of infertility by discussing your past health and medical history with you. He or she will ask about your childhood growth and development; sexual development during puberty; sexual history; illnesses and infections; surgeries; medications you take; exposure to certain environmental agents (alcohol, radiation, steroids, chemotherapy, and toxic chemicals); and any previous fertility assessments that you may have had.

Physical examination — A physical examination usually includes a general medical examination, with special attention to any signs of testosterone deficiency or other conditions that might impair fertility. Your doctor will measure your height and weight, assess your body fat and muscle distribution, inspect your skin and your hair pattern, and look for possible breast development. Your doctor will also perform a genital exam, which can identify abnormalities of the reproductive tract.

Semen analysis — A semen analysis (sperm count) is a central part of the evaluation of male infertility. This analysis can provide information about the volume and pH of semen and the number, motility, and shape of sperm. Your doctor will usually request that you abstain from sex for two to seven days before providing the sample. Ideally, a sample should be produced in your doctor's office by masturbation, but if that is not possible, you may be allowed to collect a sample at home in a physician's laboratory-provided container or chemical-free condom and deliver it to the lab within one hour of collection. If your initial result is abnormal, your doctor will request two additional samples one to two weeks apart to confirm the initial results.

Blood tests — Blood tests can provide information about the levels of hormones that play a role in male fertility. If your sperm concentration is low or if your doctor suspects you might have a hormonal deficiency, blood tests to measure testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH), and prolactin (a pituitary hormone) will be ordered.

Genetic tests — If your doctor suspects genetic or chromosomal abnormalities, he or she may order specialized blood tests to check for absent or abnormal regions of chromosomes.

Other tests — If your doctor suspects an obstruction of the reproductive tract (epididymis or vas deferens), he or she may order a transrectal ultrasound test. This test can identify areas of blockage in the male reproductive tract. Your doctor may also request that you collect a post-ejaculation urine sample if he or she suspects retrograde ejaculation (movement of semen in the wrong direction in the reproductive tract). In addition, your doctor may recommend a testicular biopsy (collection of a small tissue sample) to examine the microscopic architecture of the testes and to check for sperm production.

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Treatment Of Infertility

Treatment of hypothalamic or pituitary deficiency — Male infertility can occur when the hypothalamus and pituitary gland fail to produce normal levels of hormones. In this case doctors recommend treatment with human chorionic gonadotropin (hCG) and human menopausal gonadotropin (hMG) (also called gonadotropin therapy) or gonadotropin-releasing hormone (GnRH).

The hCG is given by injection 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. In cases where sperm counts do not recover after six months of treatment, the hormone hMG (given by injection under the skin) is added. In many cases, a total of one to two years of treatment is needed to achieve normal fertility.

GnRH treatment requires the ongoing use of a portable pump and is currently available only in research centers. Although it has been shown to be as effective as hCG and FSH injections, FDA approval has not yet been sought for this indication. The pump is attached to a catheter and needle that is left in place under the skin continuously. This treatment also requires up to two years of therapy before normal fertility is restored.

Treatment of other conditions — Treatments are available for certain other conditions (listed below), but their role in reversing infertility and their effectiveness are still being studied. The pregnancy success rate of these treatments can vary from couple to couple. Your doctor may be able to predict the likelihood that these treatments will work for you and your partner.

Treatment of genital infection — If semen analysis reveals many white blood cells, your doctor may suspect an infection of the reproductive tract and may prescribe antibiotics. However, only certain sexually transmitted diseases have been clearly linked to infertility, and antibiotic treatment may therefore be ineffective at restoring fertility.

Treatment of infertility due to retrograde ejaculation — Certain conditions cause sperm to move in the wrong direction in the male reproductive tract and to be deposited in the urinary tract. In many cases, retrograde ejaculation is a permanent condition. However, sperm can be retrieved from a specially treated urine sample, washed, and used to achieve pregnancy by assisted reproductive techniques.

Treatment of varicocele — A varicocele is a dilation of a vein (like a varicose vein) in the scrotum. Varicoceles are associated with elevated testicular temperature, poor oxygen supply, and poor blood flow in the testes. These dilated veins can be repaired surgically, but it is not known whether this procedure improves fertility. Surgery appears to be more likely to restore fertility if it is done before longstanding damage affects the testes. Some couples affected by this type of infertility may also consider assisted reproductive techniques.

Treatment of obstruction in the male reproductive tract — Surgery is sometimes performed to open or bypass obstructions of various parts of the male reproductive tract. Vasectomy is one type of obstruction that can be reversed in up to 85 percent of cases; over 50 percent of couples can achieve pregnancy following this procedure. However, the longer the time elapsed since the vasectomy, the less likely this procedure is to restore fertility. Other types of obstructions (such as obstructions in the epididymis caused by past infections) tend to be more difficult to treat. Treatment options include surgery to correct the obstruction or assisted reproductive technologies.

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Assisted Reproductive Techniques

Some infertile men may have abnormalities of the chromosomes or specific genes on the chromosomes. Although assisted reproductive techniques may be able to overcome this type of infertility, there is a possibility of transferring the gene or chromosome abnormalities to a child. Doctors therefore recommend genetic counseling for couples with this type of infertility, prior to proceeding with assisted reproductive techniques.

In vitro fertilization (IVF) — IVF is a commonly used technique for a variety of infertility problems, including tubal blockages and unexplained infertility. During IVF, the female partner receives daily injections under the skin of FSH (for 5 to 12 days) to stimulate the ovaries to produce multiple eggs. When the eggs appear to be mature by pelvic ultrasound and blood tests for estrogen, she undergoes a surgical procedure (under light sedation) to remove the mature eggs from the ovaries. The eggs are placed in a dish in the laboratory (in vitro), and sperm from the male partner are added to the dish for fertilization to occur. If fertilization occurs, the embryos are placed back into the woman's uterus several days later (using a small catheter inserted through the cervical canal). IVF success rates have been improving because laboratory techniques now permit the embryos to be more mature when they are placed back in the uterus.

Intracytoplasmic sperm injection (ICSI) — While IVF can be somewhat helpful for couples with male factor infertility due to a low sperm count, ICSI is a new procedure that can be performed in conjunction with IVF. With ICSI, a single sperm from the male partner is injected directly into the cytoplasm of one of the eggs in the laboratory dish. This technique can be useful in many but not all cases of low sperm count. If a man's semen completely lacks sperm (azoospermia), sperm can sometimes be directly removed from the testes (with a needle under local anesthesia). The pregnancy rate of ICSI is approximately 20 to 40 percent per cycle, but the technique is expensive and carries the same medical risks as IVF for the female partner.

There is some evidence that IVF or ICSI pregancies have a slightly higher rate of birth defects. This potential risk should be discussed with your doctor.

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Options For Couples In Whom Male Infertility Cannot Be Treated

Doctors may also recommend testosterone treatment for some men with irreversible infertility and testosterone deficiency. Although this treatment may not address a couple's goal of having a child, it can improve the male partner's sexual function and mood and help increase and maintain his bone and muscle mass.

Artificial insemination with donor sperm — Some couples affected by irreversible male infertility consider artificial insemination with donor sperm. This procedure has a pregnancy rate of about 50 percent after six cycles of insemination. The children that are conceived using this approach develop normally, both physically and psychologically.

Adoption — Some couples affected by irreversible male infertility consider adopting a child. Your doctor can suggest resources if you decide to pursue this option.

Childlessness — Some couples affected by irreversible male infertility may decide to remain childless. They may explore alternate ways of enjoying children, enriching their relationship, creating a support network, and building a personal legacy.

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20/1/04

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