Male infertility is any health issue in a man that lowers the chances of his female partner getting pregnant.There are many causes for infertility in men and women. In over a third of infertility cases, the problem is with the man. This is most often due to problems with his sperm production or with sperm delivery.

The process of conception

Male fertility is a complex process. To get your partner pregnant, the following must occur:

  • You must produce healthy sperm.Initially, this involves the growth and formation of the male reproductive organs during puberty. The testicles are in the scrotum, a sac of skin below the penis.At least one of your testicles must be functioning correctly, and your body must produce testosterone and other hormones to trigger and maintain sperm production.When the sperm leave the testicles, they go into a tube behind each testicle. This tube is called the epididymis.
  • Sperms have to be carried into the semen.Just before ejaculation, the sperms go from the epididymis into another set of tubes. These tubes are called the vas deferens. Each vas deferens leads from the epididymis to behind your bladder in the pelvis. There each vas deferens joins the ejaculatory duct from the seminal vesicle. When you ejaculate, the sperm mix with fluid from the prostate and seminal vesicles. This forms semen. Semen then travels through the urethra and out of the penis.Once sperm are produced in the testicles, delicate tubes transport them until they mix with semen and are ejaculated out of the penis.
  • There needs to be enough sperms in the semen.If the number of sperm in your semen (sperm count) is low, it decreases the odds that one of your sperm will fertilize your partner’s egg. A low sperm count is fewer than 15 million sperm per milliliter of semen or fewer than 39 million per ejaculate.
  • Sperm must be functional and able to move.If the movement (motility) or function of your sperm is abnormal, the sperm may not be able to reach or penetrate your partner’s egg.

The system only works when genes, hormone levels and environmental conditions are right.

Causes

  1. Medical causes

1.      Sperm Disorders

The most common problems are with making and growing sperm. The sperms may:

  • not grow fully
  • be oddly shaped
  • not move the right way
  • be made in very low numbers (oligospermia)
  • not be made at all (azoospermia)
  1. Problems with sexual intercourse

These can include trouble keeping or maintaining an erection sufficient for sex (erectile dysfunction), premature ejaculation, painful intercourse, anatomical abnormalities such as having a urethral opening beneath the penis (hypospadias), or psychological or relationship problems that interfere with sex.

3. Varicoceles

A varicocele is a swelling of the veins that drain the testicle. It is the most common reversible cause of male infertility. Although the exact reason that varicoceles cause infertility is unknown, it may be related to abnormal testicular temperature regulation. Varicoceles result in reduced quality of the sperm.Treating the varicocele can improve sperm numbers and function, and may potentially improve outcomes when using assisted reproductive techniques such as in vitro fertilization.

1. Retrograde Ejaculation

Retrograde ejaculation occurs when the semen enters the bladder during orgasm instead of emerging out the tip of the penis. It can be caused by:

  • prostate or bladder surgeries
  • diabetes
  • spinal cord injury
  • anti-depressants
  • certain anti-hypertensives
  • medications used to treat prostate enlargement (BPH)

Retrograde ejaculation can happen when nerves and muscles in your bladder do not close during orgasm (climax). Semen may have normal sperm, but the semen cannot reach the vagina.Signs are cloudy urine after ejaculation and less fluid or “dry” ejaculation.Various health conditions can cause retrograde ejaculation, including diabetes, spinal injuries, medications, and surgery of the bladder, prostate or urethra.Some men with spinal cord injuries or certain diseases can’t ejaculate semen, even though they still produce sperm.

2. Infection

Some infections can interfere with sperm production or sperm health or can cause scarring that blocks the passage of sperm. These include inflammation of the epididymis (epididymitis) or testicles (orchitis) and some sexually transmitted infections, including gonorrhea or HIV. Although some infections can result in permanent testicular damage, most often sperms can still be retrieved.

3. Tumors

Cancers and nonmalignant tumors can affect the male reproductive organs directly, through the glands that release hormones related to reproduction, such as the pituitary gland, or through unknown causes. In some cases, surgery, radiation or chemotherapy to treat tumors can affect male fertility.

4. Undescended testicles

In some males, during fetal development one or both testicles fail to descend from the abdomen into the sac that normally contains the testicles (scrotum). Decreased fertility is more likely in men who have had this condition.

5. Defects of tubules that transport sperm.

Many different tubes carry sperm. Blockage can occur at any level, including within the testicle, in the tubes that drain the testicle, in the epididymis, in the vas deferens, near the ejaculatory ducts or in the urethra.They can be blocked due to various causes, including inadvertent injury from surgery, prior infections, trauma or abnormal development, such as with cystic fibrosis or similar inherited conditions.With a blockage, sperm from the testicles can’t leave the body during ejaculation.

6. Hormone imbalances

Infertility can result from disorders of the testicles themselves or an abnormality affecting other hormonal systems including the hypothalamus, pituitary, thyroid and adrenal glands. Low testosterone (male hypogonadism) and other hormonal problems have a number of possible underlying causes.

7. Chromosome defects

A sperm carries half of the DNA to the egg. Changes in the number and structure of chromosomes can affect fertility. For example, inherited disorders such as Klinefelter’s syndrome in which a male is born with two X chromosomes and one Y chromosome (instead of one X and one Y) cause abnormal development of the male reproductive organs. Other genetic syndromes associated with infertility include cystic fibrosis, Kallmann’s syndrome (caused by lower amounts of gonadotropin-releasing hormone (GnRH)and Kartagener’s syndrome (defect in flagellumof sperm cell affecting sperm motility).

8. Celiac disease

A digestive disorder caused by sensitivity to gluten, celiac disease can cause male infertility. Fertility may improve after adopting a gluten-free diet.

9. Certain medications

Testosterone replacement therapy, long-term anabolic steroid use, cancer medications (chemotherapy), certain antifungal medications, some ulcer drugs and certain other medications used for the treatment of arthritis and depression can impair sperm production and decrease male fertility.

10. Prior surgeries

Certain surgeries may prevent you from having sperm in your ejaculate, including vasectomy, inguinal hernia repairs, scrotal or testicular surgeries, prostate surgeries, and large abdominal surgeries performed for testicular and rectal cancers, among others. In most cases, surgery can be performed to either reverse these blockage or to retrieve sperm directly from the epididymis and testicles.

11. Immunologic Infertility

Sometimes a man’s body makes antibodies that attack his own sperm. Antibodies are most often made because of injury, surgery or infection. They keep sperms from moving and working normally. The mechanism through which antibodies lower fertility is yet unknown. However, there is evidence that antibodies can make it hard for sperm to swim to the fallopian tube and enter an egg. This is not a common cause of male infertility.

  1. Environmental causes

Overexposure to certain environmental elements such as heat, toxins and chemicals can reduce sperm production or sperm function. Specific causes include:

  1. Industrial chemicals

Extended exposure to benzenes, toluene, xylene, pesticides, herbicides, organic solvents, painting materials and lead may contribute to low sperm counts.

  1. Heavy metal exposure

Exposure to lead or other heavy metals also may cause infertility.

  1. Radiation or X-rays

Exposure to radiation can reduce sperm production, though it will often eventually return to normal. With high doses of radiation, sperm production can be permanently reduced.

  1. Overheating the testicles

Elevated temperatures impair sperm production and function. Although studies are limited and are inconclusive, frequent use of saunas or hot tubs may temporarily impair your sperm count.Sitting for long periods, wearing tight clothing or working on a laptop computer for long stretches of time also may increase the temperature in your scrotum and may slightly reduce sperm production.

  1. Health, lifestyle and other causes

Some other causes of male infertility include:

  1. Drug use

Anabolic steroids taken to stimulate muscle strength and growth can cause the testicles to shrink and sperm production to decrease. Use of cocaine or marijuana may temporarily reduce the number and quality of your sperm as well.

  1. Alcohol use

Drinking alcohol can lower testosterone levels, cause erectile dysfunction and decrease sperm production. Liver disease caused by excessive drinking also may lead to fertility problems.

  1. Tobacco smoking

Men who smoke may have a lower sperm count than do those who don’t smoke. Secondhand smoke also may affect male fertility.

  1. Emotional stress

Stress can interfere with certain hormones needed to produce sperm. Severe or prolonged emotional stress, including problems with fertility, can affect your sperm count.

  1. Depression

Research shows that the likelihood of pregnancy may be lower if a male partner has severe depression. In addition, depression in men may cause sexual dysfunction due to reduced libido, erectile dysfunction, or delayed or inhibited ejaculation.

  1. Weight

Obesity can impair fertility in several ways, including directly impacting sperm themselves as well as by causing hormone changes that reduce male fertility.

Symptoms

Although most men with male infertility do not notice symptoms other than the inability to conceive a child, signs and symptoms associated with male infertility include:

  1. Problems with sexual function — for example, difficulty with ejaculation or small volumes of fluid ejaculated, reduced sexual desire, or difficulty maintaining an erection (erectile dysfunction)
  2. Pain, swelling or a lump in the testicle area
  • Recurrent respiratory infections
  1. Inability to smell
  2. Abnormal breast growth (gynecomastia)
  3. Decreased facial or body hair or other signs of a chromosomal or hormonal abnormality
  • A lower than normal sperm count (fewer than 15 million sperm per milliliter of semen or a total sperm count of less than 39 million per ejaculate)

Diagnosis

1.      History and Physical Exam

Your health care provider will take your health and surgical histories. Your provider will want to know about anything that might lower your fertility. These might include defects in your reproductive system, low hormone levels, sickness or accidents.

Your provider will ask about childhood illnesses, current health problems, or medications that might harm sperm production. Mumps, diabetes and steroids may affect fertility. Your provider will also ask about your use of alcohol, tobacco, marijuana and other recreational drugs. He or she will ask if you’ve been exposed to ionizing radiation, heavy metals or pesticides. Heavy metals are an exposure issue (e.g. mercury, lead arsenic). All of these can affect fertility.

Your health care provider will learn how your body works during sex. He or she will want to know about you and your partner’s efforts to get pregnant. For example, your healthcare provider may ask if you’ve had trouble with erections.

The physical exam will look for problems in your penis, epididymis, vas deferens, and testicles. Your doctor will look for varicoceles. They can be found easily with a physical exam.

2.      Semen Analysis

Semen analysis is a routine lab test. It helps show the cause of male infertility. The test is most often done twice. Semen is collected by having you masturbate into a sterile cup. The semen sample is studied. It can be checked for things that help or hurt conception (fertilization).

Your health care provider will study your sperm volume, count, concentration, movement (“motility”), and structure. The quality of your sperm tells much about your ability to conceive (start a pregnancy). For instance, semen is normal if it turns from a pearly gel into a liquid within 20 minutes. If not, there may be a problem with the seminal vesicles, your male sex glands. Lack of fructose (sugar) in a sperm-free sample may mean there are no seminal vesicles. Or it may mean there is a blocked ejaculatory duct.

Even if the semen test shows low sperm numbers or no sperm, it may not mean you are permanently infertile. It may just show there’s a problem with the growth or delivery of sperm. More test may be needed.

3.      Transrectal Ultrasound

Your health care provider may order a transrectal ultrasound. Ultrasound uses sound waves bouncing off an organ to get a picture of the organ. A probe is placed in the rectum. It beams sound waves to the nearby ejaculatory ducts. The health care provider can see if structures such as the ejaculatory duct or seminal vesicles are poorly formed or blocked.

4.      Testicular Biopsy

If a semen test shows a very low number of sperms or no sperm you may need a testicular biopsy. This test can be done in an operating room with general or local anesthesia. A small cut is made in the scrotum. It can also be done in a clinic using, a needle through the numbed scrotal skin. In either case, a small piece of tissue from each testicle is removed and studied under a microscope. The biopsy serves 2 purposes:

  1. It helps find the cause of infertility,
  2. It can collect sperm for use in assisted reproduction.

5.      Hormonal Profile

The health care provider may check your hormones. This is to learn how well your testicles make sperm. It can also rule out major health problems. For example, follicle-stimulating hormone (FSH) is the pituitary hormone that tells the testicles to make sperm. High levels may mean your pituitary gland is trying to get the testicles to make sperm, but they won’t.

Treatment

Treatment depends on what’s causing infertility. Many problems can be fixed with drugs or surgery. This would allow conception through normal sex. The treatments below are broken into 3 categories:

  1. Non-surgical therapy for Male Infertility
  2. Surgical Therapy for Male Infertility
  3. Treatment for Unknown Causes of Male Infertility

A.    Non-Surgical Treatment for Specific Male Infertility Conditions

Many male infertility problems can be treated without surgery.

1.      Anejaculation

Anejaculation is when there’s no semen. It is not common, but can be caused by:

  • spinal cord injury
  • prior surgery
  • diabetes
  • multiple sclerosis
  • abnormalities present at birth
  • other mental, emotional or unknown problems

Drugs are often tried first to treat this condition. If they fail, there are two next steps. Rectal probe electroejaculation (RPE, better known as electroejaculation or EEJ) is one. Penile vibratory stimulation (PVS) is the other.

  1. Rectal probe electroejaculation is most often done under anesthesia. This is true except in men with a damaged spinal cord. RPE retrieves sperm in 90 out of 100 men who have it done. Many sperm are collected with this method. But sperm movement and shape may still lower fertility.
  2. Penile vibratory stimulationvibrates the tip and shaft of the penis to help get a natural climax. While non-invasive, it doesn’t work as well as RPE. This is especially true in severe cases.

Assisted reproductive techniques like in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) are of great value to men with anejaculation.

2.      Congenital Adrenal Hyperplasia (CAH)

CAH is a rare cause of male infertility. It involves flaws from birth in certain enzymes. This causes abnormal hormone production. CAH is most often diagnosed by looking for too much steroid in the blood and urine. CAH can be treated with hormone replacement.

3.      Genital Tract Infection

Genital tract infection is rarely linked to infertility.Antibiotics are often given for full-blown infections. But they are not used for lesser inflammations. They can sometimes harm sperm production. Inflammation from causes other than infection can also affect fertility. For example, chronic prostatitis, in rare cases, can also block the ejaculatory ducts.

4.      Hyperprolactinemia

Hyperprolactinemia is when the pituitary gland makes too much of the hormone prolactin. It is a factor in infertility and erectile dysfunction. Treatment depends on what is causing the increase. If medications are the cause, your health care provider may stop them. Drugs may be given to bring prolactin levels to normal. If a growth in the pituitary gland is found, you may be referred to a neurosurgeon.

5.      HypogonadotropicHypogonadism

Hypogonadotropichypogonadism is when the testicles don’t make sperms due to poor stimulation by the pituitary hormones. This is due to a problem in the pituitary or hypothalamus. It is the cause of a small percentage of infertility in men. It can exist at birth (“congenital”). Or it can show up later (“acquired”).

The congenital form, known also as Kallmann’s syndrome, is caused by lower amounts of gonadotropin-releasing hormone (GnRH). GnRH is a hormone made by the hypothalamus. The acquired form can be triggered by other health issues such as:

  • pituitary tumors
  • head trauma
  • anabolic steroid use.

If hypogonadotropichypogonadism is suspected, your health care provider may want you to have a MRI. This will show a picture of your pituitary gland. You will also have a blood test to check prolactin levels. Together, a MRI and blood test can rule out pituitary tumors. If there are high levels of prolactin but no tumor on the pituitary gland, your provider may try to lower your prolactin first. Gonadotropin replacement therapy would be the next step. During treatment, blood testosterone levels and semen will be checked. Chances for pregnancy are very good. The sperm resulting from this treatment are normal.

6.      Immunologic Infertility

In vitro fertilization with Intracytoplasmic Sperm Injection (ICSI) is now preferred for fertility problems caused by the immune system. This abnormality is very rare.

7.      Reactive Oxygen Species (ROS)

ROS are small molecules found in many bodily fluids. They are in white blood cells. They are also in the sperm cells in semen. ROS can help prepare the sperm for fertilization. But too much ROS can hurt other cells. Sperms are easily harmed by ROS. Recent studies have shown more ROS molecules in the semen of infertile men. Antioxidant therapy may help lower ROS.

8.      Retrograde Ejaculation

Retrograde ejaculation is found by checking your urine for sperm. This is done under a microscope right after ejaculation. Drugs can be used to correct retrograde ejaculation.

B.     Surgical Therapy for Male Infertility

1.      Varicocele Treatments

Varicoceles can be fixed with minor outpatient surgery called varicocelectomy. Fixing these swollen veins helps sperm movement, numbers, and structure.

2.      Azoospermia Treatments

If your semen lacks sperm (azoospermia) because of a blockage, there are many surgical choices.

        i.            Microsurgical Vasovasostomy

Vasovasostomy is used to undo a vasectomy. It uses microsurgery to join the 2 cut parts of the vas deferens in each testicle.

      ii.            Vasoepididymostomy

Vasoepididymostomy joins the upper end of the vas deferens to the epididymis. It is the most common microsurgical method to treat epididymal blocks.

3.      Transurethral Resection of the Ejaculatory Duct (TURED)

Ejaculatory duct blockage can be treated surgically. A cystoscope is passed into the urethra (the tube inside the penis) and a small incision is made in the ejaculatory duct. This gets sperm into the semen in about 65 out of 100 men. But there can be problems. Blockages could come back. Incontinence and retrograde ejaculation from bladder damage are other possible but rare problems.

C.    Treatment for Unknown Causes of Male Infertility

Sometimes it is hard to tell the cause of male infertility. This is called “non-specific” or “idiopathic” male infertility. Your health care provider may uses experience to help figure out what works. This is called “empiric therapy.” Because infertility problems are often due to hormones, empiric therapy might balance hormone levels. It is not easy to tell how well empiric treatments will work. Each case is different.

1.      Assisted Reproductive Techniques

If infertility treatment fails or isn’t available, there are ways to get pregnant without sex. These methods are called assisted reproductive techniques (ARTs). Based on the specific type of infertility and the cause, your health care provider may suggest:

i.                    Intrauterine Insemination (IUI)

For IUI, your health care provider places the sperm into the female partner’s uterus through a tube. IUI is often good for low sperm count and movement problems, retrograde ejaculation, and other causes of infertility.

ii.                  In Vitro Fertilization (IVF)

IVF is when the egg of a female partner or donor is joined with sperm in a lab Petri dish. For IVF, the ovaries must be overly stimulated. This is often done with drugs. It allows many mature eggs to be retrieved. After 3 to 5 days of growth, the fertilized egg (embryo) is put back into the uterus. IVF is used mostly for women with blocked fallopian tubes. But it is being used more and more in cases where the man has very severe and untreatable oligospermia (low sperm count).

iii.                Intracytoplasmic Sperm Injection (ICSI)

ICSI is a variation of IVF. It has revolutionized treatment of severe male infertility. It facilitates conception in infertile couples. A single sperm is injected into the egg with a tiny needle. Once the egg is fertilized, it’s put in the female partner’s uterus. Your health care provider may use ICSI if you have very poor semen quality. It is also used if you have no sperm in the semen caused by a block or testicular failure that can’t be fixed. Sperm may also be taken from the testicles or epididymis by surgery for this method.

Sperm Retrieval for ART

Many microsurgical methods can remove sperm blocked by obstructive azoospermia (no sperm). The goal is to get the best quality and number of cells. This is done while trying not to harm the reproductive tract. These methods include:

1.      Testicular Sperm Extraction (TESE)

This is a common technique used to diagnose the cause of azoospermia. It also gets enough tissue for sperm extraction. The sperm taken from the testicle can be used fresh or frozen (“cryopreserved”). One or many small biopsies are done.

2.      Testicular Fine Needle Aspiration (TFNA)

TFNA was first used to diagnose azoospermia. It is now sometimes used to collect sperm from the testicles. A needle and syringe puncture the scrotal skin to pull sperm from the testicle.

3.      Percutaneous Epididymal Sperm Aspiration (PESA)

PESA, like TFNA, can be done many times at low cost. There is no surgical cut. More urologists can do it because it doesn’t call for a high-powered microscope. PESA is done under local or general anesthesia. The urologist sticks a needle attached to a syringe into the epididymis. Then he or she gently withdraws fluid. Sperm may not always be gotten this way. You may still need open surgery.

4.      Microsurgical Epididymal Sperm Aspiration (MESA)

With MESA, sperm are also retrieved from the epididymal tubes. This method uses a surgical microscope. MESA yields high amounts of motile sperm. They can be frozen and thawed later for IVF treatments. This method limits harm to the epididymis. It keeps blood out of the fluid. Even though MESA calls for general anesthesia and microsurgical skill, it has a lower problem rate. It is also able to collect larger numbers of sperms with better motility for banking.