Male Subfertility

The fertility of a couple depends upon several factors in both the male and female partner. Among all cases of infertility, about 8 percent can be traced to male factors, 37 percent can be traced to female factors, 35 percent can be traced to factors in both the male and female partners, and 5 percent cannot be traced to obvious factors in either partner. When infertility occurs, the male and female partners are evaluated to determine the cause and best treatment options. In the past, men with infertility had few options because there was limited information about causes and even less information about successful treatment. However, new tests have made it possible to determine the causes of male infertility and treatments, and assisted reproductive techniques (ART) offer hope to many couples.

Fertility in men requires normal functioning of the hypothalamus and pituitary gland (hormone-producing glands in the brain), and the testes. Therefore, a variety of conditions can lead to infertility.

  • 30 to 40 percent of cases are due to problems in the testes.
  • 10 to 20 percent are due to a blockage in the pathway that sperm use to exit the testes during ejaculation. This can be caused by prior infection .
  • 1 to 2 percent of cases are due to conditions of the pituitary gland or hypothalamus.
  • 40 to 50 percent of cases have no identifiable cause, even after an evaluation.

Male Subfertility Evaluation

The most important tests for infertile men are – a clinical examination and a semen analysis (sperm count). A normal result tells us that the male partner most likely does not have an fertility problem.

Male Subfertility Treatment

The treatment of male infertility depends upon the underlying cause. Several months to years of treatment are usually necessary to achieve fertility. The treatment often involves both male and female partners. Blockage of the reproductive tract-Men who have a blockage in the ducts conveying the sperm from the testis until ejaculation (so that sperm cannot get out) can undergo surgery to correct the blockage. If it is not successful, another option is assisted reproductive technologies using sperm retrieved from the testes. Vasectomy (male sterilization) is a different type of blockage. Vasectomies can be reversed in up to 85 percent of cases; over 50 percent of couples can achieve pregnancy following vasectomy reversal. However, the more time that has passed since the vasectomy, the less likely vasectomy reversal is to restore fertility. Treatment of hypothalamic or pituitary deficiency- In a small percentage of cases (1 to 2 percent), male infertility is due to problems in the hypothalamus and pituitary gland (parts of the brain that regulate hormone production). In this case, treatment with hCG, human follicle stimulating hormone (FSH)  is often given.

hCG treatment — hCG treatment is started with injections of hCG 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. If sperm cells do not appear in semen after six months of treatment, follicle stimulating hormone (FSH) is added; this is also given by injection. The success rate for this therapy is high as most men will eventually develop sperm in the ejaculate. In many cases, a total of one to two years of treatment is needed to achieve normal fertility. Varicocele — A varicocele is a dilation of a vein (like a varicose vein) in the scrotum. Many men with varicocele have a low sperm count or abnormal sperm morphology (shape). The reason a varicocele affects the sperm may be related to a higher-than-normal temperature in the testicles, poor oxygen supply, and poor blood flow in the testes. Varicocele can be treated surgically by cutting the veins connected to the varicocele. However, surgery does not always improve fertility and is not recommended for most men unless there is a large varicocele. A varicocele that has been present for a long time can cause irreversible damage that cannot be surgically treated. An alternative to varicocele repair is assisted reproductive techniques (ART), such as intracytoplasmic sperm injection (ICSI). With ICSI, only a small number of sperm are needed Other — Treatment is not currently available for most types of male infertility. For example, there is no known treatment when the sperm-producing structures of the testes have been severely damaged or are abnormal. This happens in men with certain chromosomal abnormalities such as Klinefelter syndrome.

Assisted Reproductive Techniques

If the male partner’s semen contains few sperm, no sperm, abnormal sperm, or sperm with poor motility, assisted reproductive techniques can often help. These techniques offer hope to some infertile couples who could not achieve pregnancy without them. In vitro fertilization (IVF) — IVF is a commonly used technique for a variety of infertility problems, including male tubal blockages and unexplained infertility. IVF is usually recommended with ICSI for men with infertility. IVF success rates depend upon a number of variables, including the age and health of the woman, health of the male sperm and female egg. Intracytoplasmic sperm injection (ICSI) — ICSI is a procedure that is performed in conjunction with IVF. With ICSI, a single sperm from the male partner is injected directly into a woman’s egg (oocyte) in the laboratory. This technique can be useful in many cases of low sperm count. The pregnancy rate with ICSI is approximately 20 to 40 percent per cycle. Testicular extraction of sperm (TESE) — If a man’s semen completely lacks sperm in the ejaculate (azoospermia), sperm can sometimes be directly removed from the testes. This is done in a minor surgery or by using a needle to aspirate semen under local anesthesia. If sperm can be found and extracted from the testis, the sperm will be used for ICSI and the fertilization rate of the oocyte is not very different from IVF. Thus, men with no sperm in the ejaculate can have a potential of fathering a child using these techniques. Risks of ART — Most patients who undergo ART have no major complications. There are few to no risks for men, depending upon the procedure used to obtain sperm. Men who must undergo a procedure to retrieve sperm have a small risk of bleeding, damage to the testes, and infection. There is some evidence that children of couples who become pregnant after IVF or ICSI have a slightly higher rate of chromosomal or congenital (birth) abnormalities and may have a higher rate of lower birth weight.

When Infertility Cannot Be Treated

Some treatments for male infertility fail, and some cases of male infertility simply cannot be treated at this time. If this is this case, an infertility specialist can advise the couple of available alternatives. Each couple’s choice is a very personal one. Men with irreversible infertility and testosterone deficiency may benefit from testosterone treatment. 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 bone and muscle mass. Artificial insemination with donor sperm — Some couples affected by irreversible male infertility consider artificial insemination of the female partner with donor sperm. Donor sperm may be obtained from a sperm bank, which screens men for infections, certain genetic problems, and provides a complete personal and family history. The decision to use donor sperm, can be complicated and difficult for a couple. Counseling may be helpful to help both partners discuss their feelings and the potential implications of using donor sperm. The use of donor sperm has a high success rate; pregnancy rates are about 50 percent after six cycles of insemination. Adoption — Some couples affected by irreversible male infertility consider adopting a child. Childfree state — Some couples affected by irreversible male infertility decide to remain childfree. Parents who decide to remain childfree often face questions from friends or family regarding their decision. These questions can be hurtful for couples who have struggled with infertility. Couples often benefit from counseling after they decide to stop infertility treatments; communicating openly is important to maintain a healthy relationship.