The Other Half of the Fertility Equation: Male Infertility

By Dr. Elena Yanushpolsky, an infertility specialist with the Center for Infertility and Reproductive Services at Brigham and Women’s Hospital (BWH) and the Director of the BWH Center for Infertility and Reproductive Services at South Shore Hospital in South Weymouth. Dr. Yanushpolsky is a speaker at RESOLVE New England’s upcoming 20th Annual Fertility Treatment, Donor Choices, and Adoption Conference on Saturday, November 2, 2013.

A couple, both about 33 years old, recently came to my clinic after trying to conceive for 18 months without success. After evaluating both of them, we learned that their inability to conceive was due to the husband’s infertility. This couple’s situation is not unusual. In 20-25% of cases, infertility can be attributed exclusively to male factor problems and an additional 10% of couples have male infertility in addition to other factors.

The first step in evaluating whether male infertility is a factor is a detailed health history. Once adequate sexual performance has been confirmed, the next step is a semen analysis. This test measures several characteristics of a man’s sperm including the number of sperm (volume and concentration), the shape of the sperm (morphology), and the ability of sperm to move (motility). If the results of the semen analysis are abnormal, the test is repeated in three to four weeks. If the second test is abnormal, a man will be referred to a urologist for further evaluation.

Male infertility may be due to a complete lack of sperm in the semen (azoospermia) or abnormalities in sperm characteristics. Azoospermia occurs in up to 10% of patients with male infertility. It may be caused by obstruction or absence of ducts that transport sperm (ejaculatory ducts), failure of sperm production in the testes or the result of chemotherapy for cancerous conditions.

Abnormalities in sperm characteristics occur much more commonly than azoospermia. These abnormalities include low sperm concentrations in the semen (oligospermia), low movement of sperm (asthenospermia), or abnormal sperm shape (teratospermia).

Unfortunately, in most cases, no specific cause can be identified to explain sperm abnormalities; however, a thorough health evaluation is recommended to rule out treatable conditions before beginning fertility treatments.

Causes of male infertility include:

  • Obstruction of Ejaculatory Ducts: Blockages in the ducts that transport sperm can be caused by infection and/or inflammation, but also may not have any obvious cause.
  • Genetic Factors: Chromosome abnormalities can be associated with low sperm counts. Y-chromosome gene deletions and cystic fibrosis gene mutations may be associated with azoospermia. Cystic fibrosis gene mutations may also result in an absence of the ducts that transport sperm. Genetic testing is recommended for all men with a lack of sperm (azoospermia) or low sperm counts.
  • Hormonal Abnormalities: Testing blood levels of testosterone, follicle stimulating hormone and luteinizing hormone will help your doctor identify possible causes of sperm abnormalities.
  • Health Conditions: Male infertility may be the result of minor health conditions, such as an enlargement of the veins in the scrotum (varicoceles), or more serious illnesses such as cancer or diabetes. Evaluation by a urologist or primary care provider is recommended for all men experiencing infertility.

Other factors that can affect the number and quality of sperm are marijuana use, heavy cigarette smoking, heavy alcohol intake, use of illegal drugs, prolonged heat to the testicles (hot tubs) and use of testosterone products (testosterone injections, or androgel topical treatments, or anabolic steroids). All of these practices should be stopped before starting fertility treatments.

There are several options for successfully managing male infertility. The highest pregnancy success rates are achieved through in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). In the most serious cases, such as men with azoospermia, sperm can be surgically extracted from a man’s testes and injected into his partners’ eggs in the laboratory to achieve fertilization. For men with very low sperm count, sperm can be collected from the semen. Even very small numbers of sperm can be sufficient for successful IVF/ ICSI procedures.

For men with milder cases of infertility, intrauterine inseminations (IUI) with sperm that has been washed, spun down to extract the best moving sperm, and injected directly into the female partner’s uterus can also be effective. For these patients IUI is attempted first, followed by IVF/ICSI.

As for my patients, further testing revealed that the husband tested positive for cystic fibrosis gene mutations. A testicular biopsy produced enough sperm for IVF/ICSI and the couple became parents after a successful pregnancy. You can learn more about male infertility at the BWH Center for Infertility and Reproductive Surgery.

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