Male Infertility

In the past, the female was the main focus of the infertility evaluation. It is now recognized that male fertility is a common cause of sub fertility and is implicated in up to 47% of infertile couples. This means that the semen analysis is one of the most important tests conducted in the fertility evaluation. Most specialists agree that treatment of the female should not begin without the male evaluation.

Tragically, some physicians (non infertility specialists) prescribe fertility medications, like Clomid, without the male evaluation. If male fertility is present, treatment of the female can never be successful and extended use of fertility medications can produce side effects.

Unlike women, whose fertility declines dramatically with age, most men are capable of fathering children until much later in life. Age related male infertility is usually not an issue before age 55.

Sperm are produced in the seminiferous tubules of the testicles under the influence of the hormone testosterone. The testicles are composed of these tubules and the epididymus, which stores and transports sperm.

Sperm travel from the epididymus to the vas deferens (small tubes), past the seminal vesicle and prostate where seminal fluid is added, and ultimately out the urethra at ejaculation. This path must be free of obstructions.

The testicles are suspended in the scrotum which serves as a temperature regulating organ. When the testicular temperature is elevated, the scrotum expands increasing the distance of the testicles from the body thus lowering temperature. Conversely, when the temperature of the testicles drops, the scrotum contracts drawing them closer to the body.

Factors that tend to increase the testicular temperature, such as prolonged sitting in hot tubs, occupations such as a long distance truck driver where the scrotum cannot perform its cooling function, can lower sperm count. Sperm take approximately three months to mature so changes in habits that could affect sperm count are not immediately apparent.

The semen analysis involves evaluation of numerous sperm characteristics and is best conducted by a reproductive medicine laboratory. Most of these laboratories use the Kruger Strict Criteria; however, some still use the World Health Organization criteria. The Kruger Strict criteria evaluate the following semen characteristics.

• Semen volume - the amount of fluid which makes up the semen.
• Sperm count- the number of sperm present in a standard volume. A normal sample contains more than 20 million sperm per milliliter.
• Motility- the percent of sperm moving when the semen is examined under the microscope. Normal is defined as >50% motile.
• Progression - the forward movement of sperm cells.
• Viability- the percent of live sperm.
• Sperm morphology or shape- Normal is > 14% "highly normal."
• Additional semen contents, such as white blood cells, an indication of infection. Less than five white blood cells per high power field is considered normal.

Various fertility medications, such as Clomid and FSH, have been used to treat male infertility. Unfortunately, they are limited in usefulness and require extended therapy which can be extremely expensive.

Some health products boast that they can increase sperm quality and quantity; however, to date, no study has demonstrated a statistically significant advantage to using these "enhancers".

When there is mild male infertility, intrauterine insemination (IUI) or artificial insemination is often the treatment of first choice. In IUI, the sperm are collected via masturbation then washed and concentrated. The concentrated sample is placed directly into the uterus using a small catheter. Unprepared sperm must never be inserted directly into the uterus as very serious allergic reactions and severe uterine cramping can result.

In the past men, with moderate to severe male factor had no hope of producing a genetically related child. Due to recent advances in in vitro fertilization and intracytoplasmic injection (ICSI), a pregnancy can be produced even when very small numbers of sperm are present. A single sperm is inserted directly into the egg in the ICSI procedure.

This sperm can be collected from ejaculation or, if the male has had a vasectomy, sperm can be extracted directly from the male's testicle using Testicular/Epididymal Sperm Aspiration (TESA), or from the epididymus using Microsurgical Sperm Aspiration (MESA). This means a pregnancy can be produced even if no ejaculate can be produced.

In some cases couples choose to use a sperm donor. Fortunately, most sub fertile men can now be effectively treated though surgery or by using assisted reproductive technologies.