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Male Infertility: The Other Half Of The Equation

Posted Aug 21 2009 12:25pm
By: Sunita Kulshrestha MD, FACOG Reproductive Endocrinologist

When a couple has trouble getting pregnant, there is about a 50% chance that there is a male factor causing or contributing to their infertility. In order to achieve pregnancy, a man must deliver into the vagina healthy sperm that are able to reach, penetrate and fertilize the egg.

The first test to assess male fertility potential typically is a semen analysis. Semen is the fluid that contains both the sperm and the secretions from glands that nourish and protect the sperm. A normal ejaculate contains more than 40 million sperm! A semen analysis measures several factors, including: the amount of semen produced (volume); the total number of sperm in each milliliter of semen (concentration); the percentage of sperm moving (motility), and the percentage of sperm that are normally shaped (morphology). Abnormalities seen in the analysis may include too few sperm (oligospermia), sperm that are not motile and do not move the way they should (asthenospermia), abnormally shaped sperm (teratozospermia) or a combination of all of the above. The number of sperm and the percentage of those sperm that are motile influence how many sperm are able to reach the vicinity of the egg. Sperm motility and morphology determine the ability of the sperm to penetrate the egg.

Historical risk factors for infertility and abnormal semen analysis include a history of sexual/erectile dysfunction, history of sexually transmitted diseases, exposure to environmental toxins including tobacco, drug use, and alcohol, prolonged exposure of the testes to high heat, history of undescended testes, history of mumps, chronic medical conditions such as diabetes, a family history of cystic fibrosis, urological procedures including inguinal hernia repair, history of cancer treatment, use of anabolic steroids, and the use of certain types of medications.

If a semen analysis is abnormal, another test should be performed at least three weeks later to confirm the findings. For any given man, semen quality can be quite variable and simple environmental effects (such as a fever, excess alcohol use, medications) can temporarily decrease the quality of the semen. If an abnormality persists, a urological evaluation can be informative. A physical exam can evaluate the size and location of the testes and the presence of a varicocele. A varicocele is a dilated testicular vein that can compromise fertility. The physical exam can also determine the presence of a patent vas deferens, the duct through which sperm flow from the testes to the penis.

Additional testing for the male may include a blood hormonal profile. Total testosterone and FSH (follicle stimulating hormone) are both indicators of testicular function. A prolactin excess or thyroid abnormality can also be evaluated with blood tests and can affect fertility. If the sperm concentration is less than 5 million/ml, genetic blood testing such as a chromosomal analysis (karyotype) and testing for missing segments of the Y chromosome (Y deletion) is recommended. A karyotypic abnormality can not only cause infertility, it can increase the risk of miscarriage and an abnormal pregnancy.

The treatment for male infertility is based on the suggested cause. Some causes of infertility can be accurately defined and effectively treated. Lifestyle changes such as avoiding smoking, excess alcohol, and heat to the scrotum can improve semen quality. Medication can help men with erectile or sexual dysfunction. Varicoceles can be treated through outpatient procedures. Hormone treatment can be instituted if there is a hormonal insufficiency of the thyroid gland or the signals from the brain that control sperm production (FSH, LH). Antibiotics can be given for prostatitis or other infection.

Most causes of male infertility, however, do not have an identifiable cause. For mild to moderate abnormalities in sperm numbers, sperm motility or morphology, an intrauterine insemination (IUI) can improve fertility. An IUI delivers a higher concentration of sperm closer to the egg and improves the efficiency of the process.

For moderate to severe abnormalities, in vitro fertilization with ICSI (intracytoplasmic sperm injection) can be performed with great success. IVF involves the female partner taking hormones to stimulate the ovaries, collecting eggs through an office procedure called an egg retrieval, and then injecting a single sperm directly into each egg (ICSI) to create embryos. These embryos then grow in the lab and are transferred back into the female's uterus. IVF with ICSI has revolutionized the treatment of male infertility because the vast majority of problems that lead to male infertility can be completely bypassed, as long as just a small amount of normal sperm is present (rather than the normal millions).

Sperm can be obtained for IVF/ICSI from an ejaculate or directly from the testes/epididymides using the techniques of testicular biopsy, epididymal sperm aspiration and non-surgical sperm aspiration (NSA). An NSA can be performed in a simple medicated procedure in the office at the time of the egg retrieval. This procedure can also be used to obtain sperm from men who have had vasectomies.

For men who are azoospermic (no sperm produced at all), the use of donor sperm offers an option for achieving pregnancy. Donor sperm can be obtained from either a known donor or an anonymous donor (or both) and can be used with both IUI and IVF.
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