Male Infertility
Background
According to the American Society for Reproductive Medicine, over 6 million couples in the U.S. are faced with infertility. Over 1 million of the women in these couples will be evaluated for infertility. However, of these infertile women, only 20% of their partners will receive a medical evaluation for infertility.
Despite a male factor being present in up to 50% of infertile couples, a formal male infertility evaluation is often overlooked. There are a variety of reasons why this occurs including:
Access to expert fertility care
Limited number of urologists who are trained to take care of male infertility patients
Perception in both the public and medical community that the problem is always due to the female partner
Success of assisted reproductive technologies
Infertile couples are encouraged to journey through the infertility process together. In doing so, the man and the woman can gain a better understanding of the potential factors involved with both male and female infertility, and provide each other with the emotional support through these challenging and stressful periods of their lives.
Simultaneous evaluations of both the man and the woman by experts in male and female reproductive medicine can oftentimes result in more timely and cost-effective strategies that treat the infertile couple as a whole and help them accomplish their hopes and dreams.
Goals of a Male Factor Evaluation
Identify potentially correctable conditions that if treated may allow for conception through intercourse
Identify irreversible conditions that are amenable to IVF/ICSI using the man's sperm
Identify irreversible conditions that are not amenable IVF/ICSI thereby sparing couples the distress of attempting ineffective therapies.
Identify life-threatening or harmful conditions that may be contributing to the man's infertility
Identify genetic abnormalities that may affect the health of offspring. Doing so may allow couples to be informed about the potential to transmit genetic abnormalities and may allow a better understanding of the basis of their infertility
Evaluation of the Infertile Male
Medical History
Questions that are asked during the initial evaluation may pertain to:
Sexual history (Does the couple have intercourse at the right time of the month?)
Pregnancy history (Has he ever initiated a pregnancy before, either with his current partner or a previous partner?)
Current therapy (Has he already been treated by another physician or provider?)
Childhood diseases (Has he had any childhood conditions that may put him at risk for infertility?)
Medical or surgical problems (Does he currently have any medical conditions or has he had any surgeries that might affect his reproductive potential?)
Gonadotoxins (Are there any environmental exposures that are putting his sperm at risk?)
Physical examination
A comprehensive examination by an experienced clinician is critical. Emphasis is placed on the genito-urinary examination including:
Location of the urethral meatus
Testis size, consistency, and location
Presence of varicocele
Presence of abdominal or inguinal scars
Presence of vas deferens
Epididymal congestion
Laboratory evaluation
In general, 2 separate semen analyses and a routine hormone profile (blood tests) are recommended as part of the initial evaluation.
Basic semen analyses typically report the volume of fluid, the sperm count, and what percentage of the sperm seen under the microscope are moving.
Depending on initial test results, more advanced studies may be recommended, and may include tests of sperm morphology, sperm DNA fragmentation, anti-sperm antibodies, and seminal leukocytes (inflammatory cells in the semen).
Genetic tests, such as karyotype, Y-chromosome microdeletion, and cystic fibrosis may also be indicated.
Ultrasound
When there are inconclusive findings on the physical examination, a testicular ultrasound may be recommended to further evaluate for the presence or absence of varicoceles or other testicular pathology.
In the setting of low seminal volume, absence of the vas deferens, or severely impaired sperm motility a trans-rectal ultrasound is recommended to evaluate the prostate gland and seminal vesicles for evidence of ejaculatory duct obstruction.
Treatment of Male Infertility
The treatment of male infertility depends upon a number of factors including what abnormalities, if any, were identified during the evaluation, as well as the presence of any female factors such as advanced reproductive age.
Because it can take up to 3 months for new sperm to be produced in the testis and travel through the male reproductive tract, any treatments geared towards improving the amount or quality of sperm in the semen will take time.
Oftentimes, treatment of male-factor infertility requires the expertise of female fertility specialists who perform intra-uterine inseminations (IUI) and IVF/ICSI.
Thus, the optimal treatment of infertile couples requires a coordinated effort between male and female fertility experts to come up with indiviualized treatment plans that fit their emotional, temporal, and financial needs. Support of the emotional needs of both the man and the woman during this time is as important as any medical and/or surgical treatments involved in their treatment.
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