Male Infertility
This is a difficult time for you and your partner, however diagnosing the problem is an important milestone whether the diagnosis is male-related or female-related. You and your partner need to deal with your infertility as a team regardless of the cause.
If you do not have a fertility diagnosis yet, you may be looking for information about the possible causes. If you already have a fertility diagnosis you probably want to know as much as you can about it. Understanding your infertility condition will help you feel more in control and allow you and your partner to ask the right questions regarding your fertility treatment options. You may be referred to an urologist who specializes in male infertility.
Educating yourself may take a little research. The information in this section is a valuable resource. It details 12 diagnoses for male infertility, including their symptoms, causes and how they are typically treated.
Azoospermia
Symptoms
Determining whether a man’s semen is lacking sperm cannot be accomplished simply by viewing the semen with the naked eye. A semen analysis by an experienced laboratory is required to determine if sperm are present or not.
Cause
This rare condition is sometimes symptomatic of testicular disease or blockage. Often, the cause of testicular disease is unknown, but it may be related to mumps or to genetic disorders such as Y chromosome deletions. Azoospermia is also symptomatic of Klinefelter's syndrome. A lack of sperm in the semen can indicate a blockage in the vas deferens.
The cause of the azoospermia needs to be determined before a treatment plan is formulated as sperm are produced in the testes. A testicular biopsy can retrieve those sperm to be used in IVF with ICSI. Surgical correction may correct a blockage if that is determined to be the cause. Retrieval of viable sperm may require a testicular biopsy. Donor sperm may be an option if the condition cannot be corrected.
Bilateral Absence of the Vas Deferens
The vas deferens is a long, tube-like structure that connects the epididymis (the site of sperm storage) to the urethra (the tube that expels sperm). During ejaculation, the sperm flows out of the testicles, through the vas deferens and into the urethra, which leads outside the body through the penis. Congenital bilateral absence of the vas deferens (CBAVD) is a condition present from birth in which the vas deferens is missing. This greatly affects a man’s fertility since the sperm are essentially stuck in the testicles, with no way of reaching the urethra and out of the body.
Symptoms
A complete lack of sperm in the man’s semen - a condition known as azoospermia - can be a symptom of this condition. The inability to conceive is another indication that a man may have a fertility issue such as bilateral absence of the vas deferens.
Cause
This condition is congenital, meaning that it exists at birth. Up to 65% of the men with CBAVD are cystic fibrosis carriers. 40% of men with CBAVD may actually have a mild form that only presents itself as CBAVD. It is imperative that at least one partner is screened for cystic fibrosis to be sure that they are not passing on CF to their offspring. Genetic counseling can help interpret the results. If both are found to be carriers, preimplantation genetic diagnosis (PGD) is an option.
Treatment
If the vas deferens are absent surgery cannot correct the problem, however there are surgical options to retrieve sperm from the body. PESA (percutaneous epididymal sperm aspiration) is a procedure that retrieves sperm from the epididymis. A testicular biopsy can also be performed to retrieve sperm and using IVF and ICSI assist fertilization. Intracytoplasmic sperm injection (ICSI) is the preferred assisted reproductive treatment.
Couples may opt instead for the use of donor sperm.
Cryptorchidism
The scrotum is a muscular structure that houses the testes. In order for normal sperm production to occur the testes must be a few degrees cooler than the rest of the body. For this reason the scrotum is positioned outside the body. Fertility problems can develop if the testes do not descend into the scrotum within the first month or so after birth. Surgery can repair undescended testes, but permanent damage can result if the testes do not descend early enough.
Symptoms
Cryptorchidism is a likely diagnosis when a man’s testes have not descended into the scrotum.
Cause
The cause for cryptorchidism is unknown.
Treatment
Surgery to correct undescended testes is usually performed in childhood, however, the results of the surgery can impact a man’s fertility later in his life.
Epididymitis
Surgery to correct undescended testes is usually performed in childhood; however, the results of the surgery can impact a man's fertility later in his life.
Symptoms
The most obvious signs of epididymitis are swollen, painful testicles.
Cause
Many pathogens can cause epididymitis, including those that cause sexually transmitted diseases (STDs).
Treatment
The treatment for acute epididymitis is well accepted and effective. It includes antibiotic therapy, bed rest, scrotal support ("supporter"), and oral anti-inflammatory drugs (such as Ibuprofen). Each of these modes of treatment is important. Chronic epididymitis is more of a problem (though less severe) because its symptoms seem to persist even after the initial treatment. In these cases a second round of therapy may be helpful. Beyond this, longer term anti-inflammatory medication is recommended. Surgical treatment for chronic epididymitis is an uncommon last resort.
Hyperprolactinemia
Hyperprolactinemia is the excessive production of the hormone prolactin (which produces milk in pregnancy and that suppresses ovulation). In men, abnormal prolactin levels can lead to sexual dysfunction. It can be symptomatic of hypothyroidism (a condition in which the body lacks thyroid hormone).
Symptoms
In men, hyperprolactinemia may be associated with impotence, visual disturbances, sudden weight loss or gain, fatigue or depression.
Causes
Hyperprolactinemia can be triggered by several factors such as:
- Tumors on the pituitary gland (called prolactinomas)
- Thyroid gland disorder
- Surgical scars on the chest wall and other chest wall irritations (such as shingles)
- Medications including some tranquilizers, high blood pressure medications, and antinausea drugs
- Oral contraceptives and recreational drugs (such as marijuana)
Treatment
Both drug and surgical methods are used to treat hyperprolactinemia:
- Bromocriptine is used to reduce excessive prolactin levels
- Surgery is used to remove tumors (a more risky procedure)
Immunological Infertility
Immunological infertility occurs most often in men. The male immune system can react to its own sperm as if they were invading cells and can be caused by an infection, cancer or a vasectomy. The immune system will attack the sperm and render them useless. If the cause of the immunological infertility is female related the current theories are that cervical mucus can kill sperm or the uterus can reject the embryo. However, both theories are unproven.
Symptoms
Although there may not be obvious signs of infection, an old infection may not appear to be present; a past infection that was not successfully treated could still be present in the body.
Cause
The cause of immunological infertility is still unproven.
Treatment
Treatment for this disorder ranges from drug therapy to assisted reproduction:
- Steroids: Cortisone, Prednisone, Dexamethasone can reduce the body's immune system response
- Antibiotics: Antibiotics are used when it is believed the condition is a result of a bacterial infection (theorized by only some healthcare providers)
- Assisted reproductive technologies: Intrauterine insemination (IUI), intratubal insemination (ITI), in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT) are also options
Klinefelter's Syndrome
Klinefelter's Syndrome is a chromosomal disorder in men, characterized by no sperm in the ejaculate or a low sperm count. Klinefelter's is a genetic disorder. In many cases sperm is still produced in the testes and can be retrieved with a testicular biopsy. However, this is an inherited condition and these patients should consult with a genetic counsellor prior to attempting conception since some of the sperm will pass along an extra X chromosome. Chromosomal testing of the embryos is one option to enable these couples to have healthy children.
Symptoms
Several physical symptoms such as small testes and small penis can suggest Klinefelter’s is present. Excess gonadotropins - hormones that in men stimulate testicular function - is another symptom of the condition. Children with Klinefelter's may be slow learners and be tall and thin.
Cause
An extra X chromosome (XXY instead of XY) causes Klinefelter's. Advanced maternal age can increase the risk.
Treatment
Men with this syndrome usually require infertility treatment to have children. The focus of treatments is not to correct the syndrome, but to harvest any sperm the man has for use in assisted reproductive procedures such as intracytoplasmic sperm injection (ICSI). If this is not possible, donor sperm is another option. 7% of infertile men have some form of chromosomal abnormality. 10-15% of men with azoospermia (absence of sperm) will have an abnormality, compared to 5% of men with oligospermia (low sperm count) and only 1% of men with normal sperm counts. Two-thirds of these chromosomal abnormalities are XXY, Klinefelter's Syndrome.
Chromosomal abnormalities can be inherited, so the couple should have genetic counselling to understand the risk of passing this on to their offspring, as well as the increased risk of miscarriages.
Occlusion
Occlusion is the medical term used for any blockage in a woman or man’s reproductive system. In men, a blockage in the duct system (the epididymis or the vas deferens) may prevent sperm from reaching the ejaculate.
Symptoms
This condition can only be diagnosed by transrectal ultrasound, vasography or seminal vesiculography.
Cause
For men, causes include:
- Scar tissue from abdominal surgery
- Congenital conditions
- Sexually transmitted diseases (STDs)
- Hernias
- Vasectomies (commonest)
Treatment
For men the treatment option available is a vosovasostomy – a procedure in which the doctor stitches the inner and outer layers of the vas deferens back together. The procedure restores continuity to the vas deferens, allowing sperm to travel from the testicles to outside of the body. A testicular biopsy can also be performed to retrieve sperm, however since the number of sperm varies the couple may need IVF with ICSI. The cost of this procedure is high compared to IVF and ICSI and very few will consider this option since it does not attract a Medicare rebate from the Australian Government.
Retrograde Ejaculation
Retrograde ejaculation is a condition in which semen is ejaculated into the bladder instead of exiting the body through the penis. Anatomically, the spermatic duct joins the path of the urethra for semen to exit the body. Caused by a malfunction in the valves that control the flow of urine versus semen through the urethra, this rare condition is sometimes the result of diabetes or the removal of the prostate gland. Normally, the valve between the bladder and the urethra constricts during ejaculation or conversely, the valve between the vas deferens and the urethra closes during urination. For men diagnosed with retrograde ejaculation, sperm may be retrieved from collected urine processed by the andrology laboratory. Because the acidity of urine can be detrimental to sperm, a man may take sodium bicarbonate to neutralize the acidity of the urine and allow collection of more viable sperm from the urine. Alternatively, a man can empty his bladder; have a catheter inserted to fill the bladder with laboratory solution. After ejaculation, the fluid is collected, the liquid removed and the sperm harvested.
Retrograde ejaculation occurs when a man’s semen moves backward into his bladder, rather than out of the body through the penis.
Symptoms
No ejaculate indicates retrograde ejaculation.
Cause
The most common reason for retrograde ejaculation is previous prostate surgery. Other possible causes are cancer, diabetes, multiple sclerosis and surgeries involving the abdomen, pelvic or genital areas. Also, certain medications used to treat heart disease and high blood pressure can cause the bladder neck to relax. In some cases, the exact source of the problem is unknown.
Treatment
Healthcare providers commonly approach this condition in one of two ways -- through the use of drugs or assisted reproductive technologies.
Antihistamine drugs are used to tighten the bladder opening in an attempt to prevent the sperm from flowing backwards. Various assisted reproductive procedures can bypass the normal way sperm is deposited into the vagina, such as intracytoplasmic sperm injection (ICSI), in vitro fertilization (IVF) and zygote intrafallopian transfer (ZIFT).
Sperm Problems
The odds of conception are lowered when sperm concentrations are lower than normal, a condition known as oligospermia. If sperm have poor swimming ability (astenozoospermia) (motility) or are misshapen (teratozoospermia) (morphology), the sperm’s ability to fertilize the egg is compromised.
Symptoms
Semen analysis is the only way to detect these abnormalities.
Cause
Sperm problems can be caused by hormonal imbalances and genetic abnormalities. Physical causes such as a blockage in the vas deferens can prohibit sperm transport. Diabetes, which in some cases leads to retrograde ejaculation, can also lead to sperm problems.
Environmental conditions may play a role as well. Smoking, alcohol and the use of recreational drugs may all be contributing factors. Also frequent exposures to high temperatures, found in saunas, for instance, can cause these abnormalities.
Treatment
Treatment options depend on the cause:
- Ovulation inducing drugs
- IVF with intracytoplasmic sperm injection (ICSI)
- Donor sperm
Varicocele
Varicoceles are enlarged veins inside the testicle. The prevailing theory on the effects of varicoceles on fertility is that these enlarged veins may increase the temperature of the testicles, resulting in impaired sperm production.
Symptoms
A smaller left testicle may be a sign of varicocele. An ultrasound can determine if a vein is enlarged.
Cause
Currently there is no known cause for varicocele.
Treatment
Varicocele can be surgically repaired through balloon surgery and microsurgery. An assisted reproductive procedure called intracytoplasmic sperm injection (ICSI) can circumvent any of the problems varicocele might create.
There is no evidence that correction of varicocoele improves fertility. They should be ignored from a reproduction point of view.
Vasectomy Reversal
Vasectomy reversals are not always successful and depend on when the vasectomy was performed, the amount of vas removed and circulating antibody levels. The procedure can cause a man to develop other problems such as blockages, immunological problems and an infertility condition called azoospermia.
Symptoms
None
Cause
Some men who've had vasectomies change their minds and want the condition reversed.
Treatment
For men the treatment option available is called a vasovasostomy or reversal of vasectomy, a procedure in which the doctor stitches the inner and outer layers of the vas deferens together. The procedure restores continuity to the vas deferens to restore sperm in the ejaculate. Success of the procedure depends on a number of factors and should be discussed with an urologist or fertility specialist. It is expensive, takes time and has a lower level of success compared with IVF. In Australia there is no Medicare support for reversal of vasectomy. There are Medicare rebates for IVF and testicular sperm retrieval.
It is not uncommon for men to develop antisperm antibodies in the years after vasectomy. If a man has had a vasectomy for more than ten years, it's possible his body will not produce viable sperm.
