Male Factor

There are many factors that can contribute to male infertility. Some of these problems can be structural abnormalities, sperm production disorders, ejaculatory disturbances and congenital disorders. Perhaps it is best to break them out into 2 categories: Productive Factors and Obstructive Factors. In some cases of male infertility, the production of sperm is impacted whereas in obstructive issues cause problems with transporting the sperm to the semen.

Here’s a breakdown of the many different types of male factor problems that can pose an issue to conceiving:

• Structural abnormalities
  It is possible that there can be an abnormalities of the reproductive tract, leading to potential obstructions that partially or totally block the flow of sperm and/or seminal fluid. Some of these abnormalities may be present at birth (congenital), others may have occurred after infection of the urogenital tract, whereas others may have resulted from previous surgery.
• Sperm production disorders
  This occurs when the production or quality of the sperm is limited. These disorders include
  • hormonal abnormalities
  • infections
  • prior medical treatments
  • varicocele
  • genetic/congenital disorders
  • and other sperm production problems, the cause of which may not be identifiable

  Complete evaluation of the man may also identify medications, environmental exposures or dietary changes that can enhance sperm production and/or quality.

• Ejaculatory disorders
  These prevent sperm from reaching the female. These disorders include
  • sexual or erectile disfunction
  • abnormalities of the penis/urine passage and
  • retrograde ejaculation

Set up a consult with your doctor or urologist. For many men that is the hardest part of the process. An evaluation of the man must be performed by a urologist or other reproductive expert with a special background and interest in male infertility. The reason for this is that new diagnostic and treatment methods including technically challenging sperm retrieval procedures require special training and expertise. Best to stick with the pros who know what they are doing.

If you think you may have male factor, ask your doctor for a referral to a urologist/ male infertility specialist so both partners will have a necessary and timely diagnostic work-up before beginning any treatment for infertility.

We all know it takes a sperm and an egg to make a baby, at least we should know that. Then why is it so unlikely to happen when men release millions of sperm with each ejaculation? According to ASRM, did you know that out of the 1 in 6 couples with infertility, roughly 20% of the time it’s completely due to sperm issues? Sperm problems are also a contributing factor in an additional 30-40% of couples.

10 facts about male infertility that you should know:

1) Causes: Male infertility can be a result of

• physical
• hormonal
• toxic exposures,
• genetic
• a chronic illness or a sexual condition preventing semen from being deposited in the vagina (ICMART glossary)

With so many possibilities, no wonder it’s such a common cause of infertility. Most of these issues result in no direct symptoms. This means many couples try for years until they see a fertility specialist and get tested.

2) Speaking of testing, a semen analysis is the first step to see if there is male factor infertility. The semen analysis is a test that looks at volume of ejaculate (the whole sample), number of sperm in each milliliter of ejaculate, the percentage of moving sperm, and the shape of a representative sample of sperm. It basically looks at how many sperm are living and moving, called a “total motile count”. This is a good test but not a perfect one because men with infertility often have low total motile counts but not all men with low numbers are infertile.

3) Getting a sample to analyze. While most guys masturbate into a cup to produce a sperm sample, did you know you could also use a special condom during sex? The sample needs to be collected without contamination from jellies or spermicide so don’t try just any condom, your doctor will have the one designed for the test. This can be an option if you have personal or religious prohibitions against masturbation.

4) Although you are trying for a baby, sometimes it’s best to not have sex; at least abstain for a few days before the semen analysis. The rationale: sperm is continuously made fresh however daily ejaculation results in samples with lower amounts of sperm in each. This could make the results of the analysis look abnormal even though you are making enough sperm. On the other hand, while attempting to conceive, more frequent intercourse often provides better quality sperm even if sperm production is limited.

Waiting too long is not great though. Longer than 5-6 days abstinence for most men results in the number of living sperm to seem low. Why is that? Because sperm are not only being made but they also die in the ejaculate. The semen analysis measures the percentage of sperm that are living and moving and so if more are dead than alive, the sample looks bad.

5) Is this why my doctor said have sex every 1-2 days? In part, but the whole answer is found in the numbers. A typical “normal” number of sperm in one ejaculation is more than 48 million (ASRM). When a guy ejaculates into a woman’s vagina, relatively few of the sperm travel through her cervix into her uterus and then down her tubes. It's estimated that only about 1 in 14 million ejaculated sperm make it from the uterus to the fallopian tubes where egg fertilization normally occurs. Ejaculated sperm can live in the woman’s tubes for 2-3 days.

This means you don’t need to replenish the sperm supply every day in order to have enough around to fertilize the egg. For many couples, having sex everyday while struggling with infertility is just one more major stressor to add to the list. Keeping it casual can restore some of your sanity without lowering your odds of success, if you have a normal sperm count.

6) Does this mean we shouldn’t have sex every day? Not exactly, but it depends on who you ask. A small study looked at the quality of sperm rather than the quantity in samples taken daily compared to samples produced every other day. It seems that although the amount of living sperm drops with daily ejaculation, the quality of the sperm in those samples seems to be better, suggesting having sex daily is OK. This is debated, and evidence on the amount of abstinence recommended to have the best quality sperm is evolving, so take your doctor’s advice as the final word. The take-home message is don’t over think it and just have sex.

7) We are what we eat, and breathe, and drink, inhale… Your health is tied to the quality and quantity of your swimmers. Chronic illness such as obesity, diabetes, and others can impact sperm production, as does smoking and drinking large amounts of alcohol.

The good news is sperm are created new every day. This means improving your health, habits and diet can result in improvements in sperm production, but not right away. It takes 72 days for a sperm to go from a little germ cell to a full grown mature sperm that can fertilize an egg. So when you decide on New Years day its time to become a new man, wait until St. Patrick’s day to get a repeat semen analysis.

8) While the semen analysis is the first test for male infertility, if the numbers are low more advanced testing (e.g. hormone or genetic tests) can help uncover the cause. The testicles make sperm but the testes are told to make sperm by the brain. Hormones from the brain signal the testes to make sperm and measuring these hormones can give a clue to the cause of the semen analysis problems.

For some guys, the brain hormones are low meaning the problem is from the top, and this sometimes can be treated with medication. For others, the problem is at the factory and the brain is sending a really loud signal (hormone levels are high) but the testes aren’t responding. This situation calls for finding and using rare sperm, usually with IVF or other forms of assisted reproduction or an alternative factory (aka using donor sperm).

9) Sometimes you can blame your father for your poor sperm count. This may sound one sided but one cause of very low sperm counts (less than 5 million) is a genetic mutation called “Y-microdeletion.” The Y chromosome is always passed on from the father to the son (women have two X chromosomes, so daughters get the X from dad). If a small part of the Y chromosome is damaged this can result in very low sperm production and infertility. This is why if your numbers are very low, your doctor may suggest genetic testing before trying to get sperm other ways.

10) Depending on how low your numbers are, different treatments can be used to help you have a baby. With slightly low sperm counts, concentrating the sperm into a smaller volume and placing directly into a woman’s uterus can be an option. This is called an “intrauterine insemination” or “IUI”. This same technique is used with donor sperm for those trying to become pregnant without a partner or who’s can’t provide sperm. If the sperm numbers are very low or the quality is extremely poor, the odds of enough sperm swimming from the uterus to fertilize the egg are very small. In this case the sperm needs to be combined directly with the egg using in vitro fertilization.

“This is ‘her’ problem—I don’t need to be an active participant.”

Busted: Having a baby, whether it is the result of GOFI (good old fashioned intercourse) or with the help of a reproductive doctor can be one of the most intimate, connecting experiences a couple has.

The Hollywood image of a magical night of lovemaking yielding a positive pee stick result is simply replaced by an extra squeeze of your wife’s hand during an ultrasound, a quick breakfast date and kiss before the morning blood draw, and an extra long hug after an embryo transfer.

When your wife is stressed out waiting for the results of that pregnancy test you can field the insurance questions, be attentive to her preoccupation with whether “this time” a baby is growing inside of her, and be a shoulder to cry on if the pregnancy results come back with a “big fat negative.”

Of course, it might not be just “her problem”, which brings us to the next myth…

“I don’t need to get checked—my boys are just fine.”

Busted: According to RESOLVE, at least 30% of infertility is due to male factor. Maybe it’s all the preservatives in food, the chemicals in the air, the consequence of putting off child bearing beyond the years that nature designed for conception to be easiest to accomplish—or maybe a combination of all of the above.

Not “checking your boys” after one year of trying to have a baby on your own is like ignoring the “check engine” light when it first goes on. It could be nothing, but if you let it go, it could cost you far more in the long run that if you just take care of it soon after that warning signal first appears.

A plastic cup, a brown paper bag and about fifteen minutes of your time is all you’ll need to diagnose your contribution to that trouble code description.

“I’m less of a man because I can’t get my wife pregnant.”

Busted: This is probably the by product of the expression “what’s the matter, you shootin’ blanks” so many guys hear as part of the standard locker room insult fests uttered when a guy of child bearing maturity has not conceived and makes the unfortunate decision to confide in guys that seem to get their wives pregnant by looking at them.

This is really a myth of perspective. You just haven’t gotten your wife pregnant yet, in the way that you hoped it would happen. The most virile man with multi-million sperm count won’t necessarily have a better chance of conceiving if there are complex fertility hurdles to overcome.

You can become more of a man to your wife during the fertility process by learning the lingo and the acronyms for the next procedure so you don’t don that deer in the headlight look when you are in the next consult with your fertility doctor. You can provide an emotional defense system to counter the inevitable insensitive “you just need to relax” or “why don’t you just adopt” comments. You can be the exit strategist at a family gathering, giving the “time to go” sign when things get to an emotional breaking point.

“Something must be wrong with our marriage if my wife wants a baby so bad.”

Busted: For many women, having a baby is as biologically necessary as breathing. Feeling a child grow inside of our body is simply something men were not designed to do.

Once a woman has found her soulmate, the natural progression for her is going to be to find her soul baby. It doesn’t come from something lacking in the marriage. In fact it is how fulfilled she is in your marriage that produces the strong urge to see what the miracle of creation will yield—your eyes, her smile, your patience, her temper.

Guys forget that the ability to satisfy the need to have a child started with a marriage where you and your wife declared mutual love for each other. A baby is the ultimate consummation of that love—truly the definition of two souls becoming one.

“I don’t need to talk to anyone about this. It’s private.”

Busted: Dealing with infertility requires that guys evolve beyond the ‘strong silent type.’

Finding another couple—especially another guy—who has gone down the infertility path can normalize the experience. RESOLVE statistics show that 1 in 8 couples trying to have a baby will experience some form of infertility. This means an understanding sounding board may be closer than you think.

Support groups, or even therapy with a psychologist who specializes in infertility can be a great benefit to helping adjust to the realities of medically assisted baby making.

“I can’t let her see how upset I am that this cycle didn’t work.”

Busted: Most guys think they have to be the proverbial rock of Gibraltar emotionally. But truly being present in the medically assisted baby making efforts sometimes means showing sadness when a cycle doesn’t work.

If you open up and let in the potential for fatherhood—the vision of a future filled with that first bike ride, that first daddy/daughter dance, that afternoon playing ball in the yard as the sun sets and fire flies start to appear, then it is only natural that a negative outcome from a cycle would be disappointing.

Just like shedding tears when a relative or friend of your wife’s dies, the loss of the potential of a cycle is something that can be shared with an open show of emotion. While a medical professional may try to soften the blow saying “it was just a clump of cells” and relatives and friends will try to comfort you with “it just wasn’t meant to be,” it is perfectly normal to view this as the loss of the promise of a child.

Crying, ranting, raving and screaming at the universe alongside your wife can often help connect you both, and release the energy from a negative outcome, allowing you to store up positive energy for the next try.

Contributed by: Marc Goldstein, MD, DSc (hon), FACS

The most commonly identified treatable cause of infertility in men is a varicocele (pronounced VAR-ih-koe-seel)), an abnormally enlarged vein draining the testicles. Approximately one third of infertile men who have never fathered a child have a varicocele, and 50 to 80% of men who were once fertile, but are now infertile, also have a varicocele. This means that varicocele effects may increase as time goes by.

Varicocles are just like varicose veins in the legs or hemorrhoids. They cause pooling of blood in the scrotum and a rise in testicular temperature. Even a one degree rise in testicular temperature can have an adverse effect on sperm production and testosterone function.

The good news is that varicoceles are treatable. Dozens of reports have been published demonstrating the benefit of varicocele surgery to improve sperm counts. Yet, varicocele repair remains controversial, particularly for small varicoceles that cannot be seen or felt on a physical exam. Studies have known greater improvements in semen quality for repair of large varicoceles compared with smaller ones.

Microscopes were not used in older surgical procedures to repair varicoceles, which made it extremely difficult to locate the tiny arteries that provide the major source of nourishment for the testicles. These arteries were often tied off, which is unlikely to enhance testicular function. Tiny lymph ducts were also inadvertently tied off, often causing a condition called hydrocele, which is a bag of fluid that develops around the testicle.

New Microsurgical Repair Techniques

These results led to the development a technique of varicocele repair using an operating microscope. This enables the identification and preservation of the arteries and lymph ducts, eliminating potential damage to the testicle as well as virtually eliminating the complication of hydrocele. Using this technique in several thousands of patients the average healthy sperm count after repair of large varicoceles has been shown to increase 128%. Microsurgical repair of varicoceles improves semen parameters and fertility with less postoperative pain and fewer complications and failures compared to non-microsurgical techniques.

Additional Benefits of Varicocele Repair

In addition, varicocele repair decreases sperm DNA fragmentation, or the breaking up of DNA strands into pieces. Sperm parameters are significantly improved, and sperm DNA fragmentation is significantly decreased, after varicocele repair. This leads to improved clinical pregnancy rates and live birth rates, even when IVF with intracytoplasmic sperm injection (ICSI) is employed in infertile couples in which the male partner has a clinical varicocele (a varicocele that can be easily felt by the urologist).

What’s more, microsurgical varicocelectomy may induce spermatogenesis and help achieve pregnancy for couples in which the man has a zero sperm count (azoospermia), although treatment of varicocele in these men may not be better than direct treatment of the azoospermia with sperm retrieval surgery and IVF.

Varicocele repair has another important function. The testicles have two purposes: one is the production of the sperm, and the other is to produce testosterone. Testosterone is the male hormone necessary for a normal sex drive, erections, muscle strength, energy levels and bone health. The presence of varicocele causes significantly lower testosterone levels, and following microsurgical varicocele repair, testosterone levels are greatly improved in more than two-thirds of men.

In conclusion, varicocele repair is a cost-effective treatment for infertility. Men can upgrade to normal semen, which can allow for a natural pregnancy, or upgrade to semen of adequate quality for intrauterine insemination. Men with azoospermia may produce ejaculated sperm adequate for ICSI. Even if a man remains azoospermic, varicocele repair may enhance spermatogenesis allowing enough sperm production for ICSI. Finally, microsurgical varicocelectomy will improve testosterone levels in a majority of men, which is a men’s health issue aside from infertility.

Recommended Reading:

1. Rosenwaks Z, Goldstein M, Fuerst M. A Baby at Last! Simon & Schuster, New York. 2010.
2. Gorelick JI, Goldstein M. Loss of fertility in men with varicocele. Fertil Steril 1993, Mar; 59(3): 613-16.
3. Tanrikut C, Goldstein M, Rosoff JS, Lee RK, Nelson CJ, Mulhall JP. Varicocele as a risk factor for androgen deficiency and effect of repair. BJU International 2011; 108:1480-84.
4. Esteves SC, Oliveira FV, Bertolla RP. Clinical outcome of intracytoplasmic sperm injection in infertile men with treated and untreated clinical varicocele. J Urol 2010, Oct; 184: 1442-46.
5. Marmar JL, Agarwal A, Prabakaran S, et al. Reassessing the value of varicocelectomy as a treatment for male subfertility with a new meta-analysis. Fertil Steril 2007, Sept; 88(3): 639 – 46.
6. Goldstein M, Tanrikut C. Microsurgical management of male infertility. Nature Clinical Practice Urol 2006, Jul; 3(7): 381 – 91.

Contributed by: Marc Goldstein, MD, DSc (hon), FACS, is the Matthew P. Hardy Distinguished Professor of Reproductive Medicine and Urology at the Weill Cornell Medical College of Cornell University, and Surgeon-in-Chief, Male Reproductive Medicine and Surgery at the New York Presbyterian Hospital, Weill Cornell Medical Center in New York.

Male infertility sometimes is the only initial symptom of significant medical problems such as brain tumors, thyroid gland disease, diabetes, multiple sclerosis, and genetic diseases. There has been a growing concern that infertility may actually be a forerunner to testicular cancer, and men with severe male infertility problems are actually life-long risk of developing other cancers. Needless to say, male infertility is a harbinger of other medical problems, so infertility in a male should result in evaluation of the entire man, not just analysis of sperm test results.

It’s all about being proactive and advocating that you/ your male partner is tested for possible male factor disorders by a reproductive expert or urologist.