Male Infertility Evaluation and Treatment

Males infertility or subfertility is a contributing factor in 50% of couples seeking evaluation and treatment for infertility.

•             20% of infertility cases are caused by the male factor
•             30-40% involve both male and female factors
•             about 50% of infertility cases are attributable to female factors.

Useful Facts about Fertility and Infertility:

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• Peak of fertility occurs in males and females at age 24. Fertility declines after that age in both sexes.
• Most conceptions occur when intercourse occurs 6 days prior to the day of ovulation.   Dr. Shteynshlyuger advises patients to have vaginal intercourse every 2 days.  Sperm lifespan is up to 5 days.
• Normal couple has 20-25% chance of conceiving within 1 month;  75% conceive within 6 months; 90% conceive within 1 year.

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Infertility is classically defined as failure of pregnancy after 1 year of unprotected sex.  About 15% of couples are infertile at 1 year. Usually, a urological evaluation is indicated in all couples who have not been able to conceive after one year of trying to conceive, even in the presence of a known problem in a female as many couples have a co-existing male problem.

Dr. Shteynshlyuger advises that in couples, in particular where the woman is close or over  age 35, earlier evaluation is indicated. It is unwise to wait 1 year as aging works against the odds of conceiving.  Ability to conceive naturally rapidly deteriorates in women after age 35 with each year.

It is important to remember that fertility is a dynamic state.  Of all infertile couples (no conception at 1 year), 25-35% will conceive spontaneously without any treatment with time.  Baseline pregnancy rate in non-azoospermic couples is 1-3% per month. 23% will conceive within the first 2 years, 10% more will conceive in the following 2 years.

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If you have concerns about infertility, make an appointment with Dr. Shteynshlyuger for a thorough and complete evaluation.  We welcome men to bring their significant others to the appointment.

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Male infertility can be classified as

• Reversible – varicocele, infections, obstruction
• non-reversible that can be managed by ART (Assisted Reproductive technologies),
• non-reversible that cannot be managed by ART (azoospermia).  Donor insemination and adoption are viable options.
• Due to underlying medical problems – recent febrile illness impairs spermatogenesis for 1-3 months; testicular cancer, pituitary problems, neurological diseases, renal failure.  60% of patients with testicular cancer/lymphoma have oligospermia.
• genetic/chromosomal abnormalities that affect the patient and/or offspring

Factors that affect male fertility:

• Genes that control male fertility, including androgen receptor genes, are located on the X chromosome.  Relevant family history includes history of infertility in maternal uncles.
• Lubricants – many are spermicidal; others (KY, surgi-lube, saliva) affect sperm motility.  Peanut oil, vegetable oil, egg white do not affect motility.  Avoid lubricants if possible
• Cryptorchidism (undescended testis) –  slight decrease in fertility if unilateral, 90% fertile; significant decrease in fertility if bilateral, 65% are fertile;  timing of orchiopexy does not matter as long as it occurs prior to puberty.  Many men are not aware or only vaguely aware that they had orchiopexy as children.  It may be worthwhile to inquire parents or older family members about this.
• Testicular trauma/Torsion – can lead to testicular atrophy;  predisposition to antisperm antibody formation
• Delayed/absent puberty – androgen receptor defects; endocrine disorders
• Gynecomastia – hyperprolactinemia or estrogen abnormality

 

Surgery can affect man’s ability to reproduce:

• Bladder neck surgery – retrograde ejaculation
• Scrotal surgery – vas deferens/epididymal injury
• Inguinal surgery – vas deferens injury
• Retroperitoneal LN dissection – can injure sympathetic nerves, leads to failure of emission or retrograde ejaculation.
• Sympathectomy: ejaculation / emission problems

 

Infections:

• Prostatitis/UTI/STDs – no evidence for infertility causation
• Mumps – 10-30% of patients age 11+ present with mumps orchitis;  mumps rarely affects testis in prepubertal boys.
• Epididymitis – azoospermia with bilateral epididymal obstruction.

Low Volume Ejaculate:

•  #1 cause – poor collection; repeat with care
• absent vas deferens and/or seminal vesicles
• obstruction of the ejaculatory ducts,
• retrograde ejaculation
• hypogonadism (low testosterone)

 

Social/Behavioral:

• use of hot tobs/spas decreases sperm motility by 10%
• Smoking seems to decrease sperm density
• Obesity – leads to hyperestrogenemia.
• Marijuana use

Ejaculatory dysfunction or ED:

• Diabetes
• Multiple Sclerosis
• Renal Failure / Dialysis
• Other Neurological and Systemic diseases.

 

Medical Treatment:

• Medications:  nitrofurantoin, calcium channel blockers, cocaine, pot, caffeine, anabolic steroids.
• Chemo/radiation: may take 4-5 years for spermatogenesis to resume if germ cells are NOT permanently damaged.  Can predict azoospermia based on medication/doses.

Congenital Diseases:

 

• Immotile Cilia Syndrome (Kartagener’s) – immotile sperm, situs invertus, frequent URI
• Cystic Fibrosis – almost all patients with clinical disease have CBAVD (Congenital Bilateral absence of vas deferens).  Most patients with CBAVD have CF.
• Young’s Syndrome – azoospermia and frequent URI.
• Kallman’s Syndrome – anosmia, hypogonadotropic hypogonadism.

Testicular temperature is 1-2.5F below body temperature. No evidence that underwear affects spermatogenesis.  Frequent use of saunas, hot tubs decreases sperm motility by 10%.

Female Factor Infertility

• present in 75% of infertile couples (40% female only, 30% male + female)
• 30% are due to ovulatory dysfunction
• regular menses 21-35 days suggest normal ovulatory function
• evaluation involves: urinary or plasma FH levels, transvaginal US to evaluate follicles, midluteal phase serum progesterone (from corpus luteum) is used to confirm the diagnosis;  endometrial biopsy several days before onset of menses
• most common treatment involves induction agents such as clomiphene citrate or gonadotropins

25% are due to fallopian tube abnormalities

• Common causes include PID, adhesions
• Hysterosalpingogram (repeated twice) is diagnostic
• Treatment involves laparoscopy, surgical repair or IVF

5% are due to endometriosis – treatment involves laparoscopy

4% are due to hyperprolactinemia

4% are due to cervical mucus abnormalities.

If you have been unable to conceive or have been diagnosed with abnormal semen analysis or infertility and are looking for a thorough male infertility evaluation or a second or third opinion make an appointment with Dr. Alex Shteynshlyuger.