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 trying. 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 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 male partner should be evaluated by a urologist with expertise in male infertility, and the evaluation should 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).
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. Men should abstain from ejaculation for at least two days before the semen collection.
- 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 the source of the imbalance, either within the testicles 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.
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 Infection: 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 (broken up) 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: Some men with no sperm in the ejaculate may still have a small amount of sperm produced by their testes. A new surgical technique uses a microscope to find some sperm within the testicular tissue, and can provide new hope for some 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 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, more efficacious treatments such as IVF with ICSI are 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.
Dr. Charles Obasiolu is a board-certified obstetrician and gynecologist and a subspecialist in reproductive endocrinology and infertility. Dr. Obasiolu received his medical degree from the University of Utah College of Medicine. He completed his residency and internship at Hutzell Hospital – Wayne State University Affiliated Hospitals in Detroit, Michigan and completed his fellowship at the University of Illinois Hospital in Chicago.
Prior to joining Harvard Vanguard, Dr. Obasiolu was an Assistant Professor in the Department of Obstetrics and Gynecology at the University of Illinois at Chicago. His areas of clinical interest include assisted reproductive technologies, polycystic ovarian syndrome and minimally invasive pelvic surgery. He also publishes and lectures on many of these topics.
Dr. Obasiolu is an active member of the American Society of Reproductive Medicine, Society of Reproductive Endocrinology and Infertility, the Endocrine Society and New England Fertility Society. Dr. Obasiolu is the Chief of the Department of Fertility and Reproductive Health at Harvard Vanguard Medical Associates.
Dr. Stephen Lazarou is a board-certified urologist and a Clinical Instructor of Urology at Harvard Medical School. He completed his fellowship in male infertility and sexual medicine (andrology) at the Beth Israel Deaconess Medical Center in Boston. He is board certified by the American Board of Urology.
Dr. Lazarou specializes in the full range of evaluations and treatments of male reproductive issues with an emphasis on fertility preservation for cancer patients, treatment of severe male factor infertility, treatment of men with clinical hypogonadism (symptoms of low testosterone), as well as sexual dysfunction. He is trained in advanced microsurgery of the male reproductive system.
He has also lectured nationally and internationally on various topics in male reproductive and sexual medicine before medical and patient groups.
Dr. Lazarou is a member of several professional organizations, including the American Urological Association, the American Society of Reproductive Medicine, The New England Fertility Society, The Society for the Study of Male Reproduction, and The Sexual Medicine Society. He has written numerous medical articles and recently co-authored a book chapter on the effect of advancing age on male reproduction.