Mount Sinai Male Infertility Program
One out of five couples will have difficulty establishing a pregnancy. In 40% of these cases the man will be identified as the sole or contributing cause. Today, new innovative treatments offer more hope to these men than ever before.
Normal Male Reproduction
Male fertility depends on the adequate production of sperm and its proper deposition into the female reproductive tract. Sperm development begins within the testicles with the process called spermatogenesis. Sperm cells called spermatozoa are generated by a complicated process of cell division that occurs over a 3 month period. Upon leaving the testicles, sperm are stored in the epididymis where they further mature and acquire motility. During ejaculation the sperm travel through the vas deferens and urethra. The production and maturation of sperm requires a favorable environment including a normal genetic profile, adequate levels of the male hormone testosterone and a slightly decreased scrotal temperature.
Definition of male infertility
Male infertility is a condition where the man is identified as adversely affecting the chances of initiating a pregnancy with his female partner. In the majority of cases this involves abnormalities in sperm quantity, quality and delivery.
Causes of Male Infertility
Dilated scrotal veins, the most common treatable cause of male-factor infertility, are present in approximately 15% of men but observed in up to 40% with infertility. Treatment options include several types of surgical repair. The current treatment of choice is Subinguinal Microscopic surgical repair because of the thoroughness of the procedure, minimal recurrence and complication rate as well as a short post-operative recovery period.
The release of semen back into the bladder instead of the usual route through the penis. The cause is failure of the nerves and muscles in the bladder neck to properly close during organism. As a result sperm isn't properly deposited into the vagina during sexual activity. Signs include cloudy urine after ejaculation and a diminished or dry ejaculation with orgasm. Previous surgery, medications or diseases affecting the bladder or prostate as well as ones affecting the nervous system like diabetes are often the root cause.
An immune response to a man's sperm, producing antibodies that attach to the sperm's surface and interfere with fertilization. Usually associated with a history of scrotal injury, surgery or infection.
The obstruction of the normal passage of sperm along the male reproductive tract. Any section of the male reproductive tract can be obstructed, preventing normal transport of sperm. This can be due to a number of factors, including:
- Repeated infections
- Prior surgery (including vasectomy)
- Inflammation or congenital conditions.
A low testosterone level associated with low serum levels of luteinizing hormone (LH) and FSH, is the cause of infertility in a small percent of men.
Genetics play a key role in male fertility. Abnormalities in the number of chromosomes as well as deletions of critical sections of the Y chromosome are all causes of genetic infertility.
Various medications can impair sperm production, function and ejaculation. Medications that are prescribed to treat conditions like arthritis, depression, digestive problems, infections, hypertension (calcium channel blockers) and cancer are the most common.
Signs and Symptoms
Male infertility doesn't usually have features easily discernable. You might have difficulty with sexual function. If the cause is hormonal, you may note a change in your voice or hair growth pattern, enlargement of breasts. Infertility in women may be signaled by irregular periods or associated with conditions that cause pain during menstruation or intercourse.
When to Seek Medical Advice
Medical help should be sought if you've been trying for a year and haven't been able to conceive on your own. The waiting period is less if your partner is over 30 or if you know of a preexisting medical condition.
Unlike female infertility, the cause of which is often easily identified, diagnosing male factors can be more difficult. The problems, however, usually fall into two areas — sperm production and/or delivery.
Because male infertility results from such varied factors, you will need to see your physician to sort out the possibilities. A primary care doctor can often locate the problem by completing an initial evaluation. Further evaluation by an urologist or reproductive specialist may be necessary if you and your partner have been trying unsuccessfully for a year to get pregnant or if you have a known male, such as an undescended testicle.
In any case, the evaluation usually includes medical and surgical histories. The doctor will want to know about childhood diseases (e.g., mumps), current health problems (e.g., diabetes), or even medications (e.g., anabolic steroids) that might interfere with the formation of sperm. Your physician will also ask about your use of alcohol, marijuana and other recreational drugs, as well as your exposure to such the occupational hazards of ionizing radiation, heavy metals and pesticides. All affect fertility.
Every evaluation will also include an assessment of your sexual performance, along with you and your partner's joint efforts to achieve pregnancy. For instance, your doctor will investigate whether you've had difficulty with erections and if your ejaculate has sufficient quality and volume. Such factors can adversely affect your sperm's effectiveness for pregnancy.
In addition to conducting a general exam, your doctor will look for any penile abnormalities.
Semen analysis is a routine test that is the single most important lab indicator for male infertility. Completed twice, it helps urologists define each factor and its severity. In addition to the above screens, other tools to assess fertility, including transurethral ultrasonography, which detects ejaculatory duct obstructions, and testicular biopsies which substantiate any reproductive, may be used.
Getting a complete evaluation should help you and your partner understand your infertility issues and make better decisions about treatment.
Your treatment options will depend entirely on the factors causing your infertility. The good news is that few medical fields have progressed as dramatically during the past decades as reproductive medicine, particularly as it pertains to men.
Today, many conditions can be corrected with drugs or surgery thus enabling conception to occur through normal intercourse.
Diagnosis of Male Infertility
The initial male fertility evaluation consists of a thorough history and physical examination. The couple's marital history including prior marriages and sex partners are examined. All miscarriages, elective terminations, and pregnancies are studied to establish if the problem is primary or secondary infertility. Primary infertility is indicated if neither partner has been able to initiate any pregnancy. Secondary infertility implies that they have been unable to initiate a subsequent pregnancy.
Childhood and developmental conditions that may have an impact on fertility include:
- A history of undescended testicles, testicular torsion, trauma, and precocious or delayed puberty.
- Systemic illnesses such as diabetes mellitus, multiple sclerosis, and spinal-cord injury
- Prior exposure to sexually transmitted diseases leading to reproductive tract scarring.
- Exposure during the past several months to systemic illness, fevers, excessive heat, or various medications which can affect the 74 day cycle of sperm maturation.
- Prior exposure to gonadotixins such as chemotherapy, radiation, exogenous androgenic steroids, as well as excessive alcohol use, cigarette or marijuana smoking and other recreational drug use.
Finally, it's important to inquire about the couple's sexual habits including the frequency and timing of intercourse. To achieve conception, sexual intercourse should be initiated prior to ovulation and continued at a frequency of every other day during the ovulatory period.
A thorough physical examination should ascertain overall physical health. The urologic examination focuses on accurately determining testicular size and evaluating possible detrimental conditions. From a semen sample the physician will be able to assess factors such as volume, count, concentration, movement and structure as well as the bearing of these factors on initiating conception.
Your physician may order an imaging test known as a transrectal ultrasound to determine if the prostate's ejaculatory ducts and seminal vesicles are properly developed and unobstructed by cysts, calcifications or other blockages.
A testicular biopsy is performed when a semen analysis shows very low number of sperm or no sperm at all. Performed in an operating room under general or regional anesthesia through a small cut in the scrotum, this test may also be done in a clinic. A small piece of tissue is removed from each testicle for microscopic evaluation. The biopsy serves two purposes: to determine the cause of infertility, and, if necessary, to retrieve sperm for assisted reproduction. Besides a semen analysis, a hormonal profile to discover the testicles' sperm-producing abilities may be required. This will also serve to rule out other adverse conditions.
Disorders of sperm production and development are the most common causes of male infertility. Sperm disorders include:
- Diminished concentration (Oligospermia)
- Poor motility (Asthenospermia)
- Abnormally shaped sperm (Teratospermia)
- Combinations of the above are often seen as well
- The absence of any sperm in the ejaculate is termed Azoospermia
Semen analysis forms the basis of the initial evaluation for assessing male infertility. Two to three semen analyses should be performed. Multiple analyses are necessary because semen findings normally fluctuate for a given individual. For each analysis, patients are instructed to abstain from intercourse for 2 to 3 days. It is critical that the specimen is:
- Collected in a nontoxic container
- Not decreased due to spillage
- Analyzed within 2 hours of collection.
A properly performed semen analysis evaluates several parameters including:
- Ejaculate volume
- Sperm count
- Sperm motility
- Forward progression
- Sperm morphology
- pH Balance
- Sperm agglutination
- White blood cell presence
- Sperm Concentration
The most common factor evaluated for male infertility is sperm count. A low sperm count doesn't mean sterility. Sterility is an absence of all sperm. Other factors in Male Infertility that can be evaluated are:
- Semen volume
- pH balance
Incontinence & Pelvic Organ Prolapse
Maternal Fetal Medicine
Prenatal Care & Childbirth Preparation
Reproductive Endocrinology and Infertility