Although having a problem conceiving can feel very isolating fertility issues are common: about one in six couples are unable to conceive after one year of unprotected intercourse. About 30% of the time, a problem with the male partner’s fertility is the single contributing factor to the couple’s inability to conceive.

The good news is that many of these conditions are potentially reversible or respond well to treatment options. If the problem is not reversible, assisted reproductive techniques such as sperm retrieval in combination with in vitro fertilization (IVF), sperm injection (ICSI), or intrauterine inseminations (IUI) are possible options.

A couple attempting to conceive should both have an evaluation if they are unable to get pregnant within one year of regular unprotected intercourse or if there is suspected history of reduced fertility in either partner. The evaluation of the male should be performed by a urologist with expertise in male infertility and include a complete reproductive/medical history, physical examination, and at least two semen analyses. Based on the results of the evaluation, the urologist may recommend other tests followed by treatment(s).

Screening

A good understanding of these tests and treatments can reduce a couple’s anxiety: let us take a look at what they entail.

• Physical examination: this is important to assess for general sex characteristics and scrotal contents. Important parts of the exam include looking for abnormal hair patterns, enlargement of the breasts, and palpation for abnormal size, shape, and location of testicles along with surrounding structures.
• Semen Analysis: A semen analysis helps to provide information on semen volume as well as sperm concentration, motility and shape. An abstinence period of at least two days is necessary before semen can be collected by masturbation or by special collection condoms.
• Hormone Evaluation: Hormonal imbalances are well known causes of male infertility. When there is an abnormal semen analysis, impaired sexual function, or other clinical findings suggestive of a specific hormone imbalance, these tests are the next step. A blood test can measure the amounts of serum follicle-stimulating-hormone (FSH), luteinizing hormone (LH), testosterone and prolactin. The relationship between these hormone levels help to identify whether the imbalance is due to an issue within the testicle or the pituitary gland.
• Post-ejaculatory urinalysis: Little or no fluid during ejaculation may suggest semen going back into the bladder instead of out the urethra, also called “retrograde ejaculation.” Diabetic men are often affected. An analysis of a urine sample after ejaculation can determine if there is sperm in the urine.
• Imaging: Scrotal ultrasonography can help identify varicoceles (dilated veins in the scrotum), tumors, and other abnormalities. Ultrasound is also used to detect other potential problems such as blockages or cysts of the structures that produce or transport semen.
• Genetic screening: Genetic abnormalities may alter fertility by affecting sperm production or transport, such as cystic fibrosis, Y chromosome deletions, and other chromosomal abnormalities. Couples should consider genetic counseling whenever a genetic abnormality is found.

Treatments

There are several effective treatment options for men with infertility. Hormonal abnormalities can often be treated with medications for prolactin-producing tumors of the pituitary gland, thyroid imbalances, or low testosterone conditions.

• Removal of Toxic Agents: A wide range of chemical substances can affect sperm quality and/or quantity, including various medications and steroid supplements. The male partner should be carefully screened for these.
• Treatment of Genital Infections: Some men may have infections of the urogenital tract found by the presence of white blood cells in the semen. A course of antibiotics generally can address this problem.
• Retrograde ejaculation: Intrauterine insemination (IUI) can be performed using semen collected after alkalinization of the urine and washing of the sperm. The washed sperm can also be used for in vitro fertilization or ICSI procedures.
• Varicoceles: These enlarged veins in the scrotum can be treated surgically or embolized radiologically.
• Obstructed ducts/Vasectomy reversal: Men who have a blockage, such as after a vasectomy, may have it surgically reversed. Another option is to bypass the blockage and remove sperm directly from the testis or epididymis and proceed with IVF.
• Testicular Microdissection (“micro-TESE”): Some men with no sperm in the ejaculate may still have a small amount of sperm produced by their testes. A new surgical technique using a microscope to find some sperm within the testicular tissue provides new hope for couples.

ART (Assisted Reproductive Technology)

Results of the semen analysis can be used to categorize the severity of male infertility from mild to moderate to severe. This is typically done using the degree of deficit in count, motility and morphology.

Mild to moderate male infertility can be treated successfully with intrauterine insemination (IUI) using the male partner’s sperm. Occasionally, fertility medications are given to the female partner during these cycles to improve the likelihood of success.

With severe male infertility (sperm counts of less than 5 million/cc or absence of sperm), more efficacious treatments such as IVF with ICSI (direct injection of sperm into an egg) is warranted. Typical fertilization rates with ICSI are 60% with pregnancy rates in the range of 20% to 30% depending on the age of the female partner.

Intrauterine insemination with donor sperm is a proven, time-tested treatment choice for irreversible male infertility due to azoospermia (total absence of sperm) and results in good pregnancy rates when there are no female infertility factors—50% pregnancy rate with 6 cycles of insemination.

Finally, alternatives such as adoption and childlessness should be discussed with couples with severe male infertility.

It is important to realize that infertility could be secondary to a male factor. In the past, men with infertility had relatively few options. In this era, it is often possible to provide treatment options which offer help to many couples.