Male infertility refers to a male’s inability to cause pregnancy in a fertile female. In humans it accounts for 40-50% of infertility.Male infertility is commonly due to deficiencies in the semen, and semen quality is used as a surrogate measure of male fecundity.
Factors relating to male infertility include:
Pre-testicular factors refer to conditions that impede adequate support of the testes and include situations of poor hormonal support and poor general health including:
Hypogonadotropic hypogonadism due to various causesObesity increases the risk of hypogonadotropic hypogonadism. Animal models indicate that obesity causes leptin insensitivity in the hypothalamus, leading to decreasedKiss1 expression, which, in turn, alters the release of gonadotropin-releasing hormone (GnRH).
Strenuous riding (bicycle riding, horseback riding)
Medications, including those that affect spermatogenesis such as chemotherapy, anabolic steroids, cimetidine, spironolactone; those that decrease FSH levels such asphenytoin; those that decrease sperm motility such as sulfasalazine and nitrofurantoin
Genetic abnormalities such as a Robertsonian translocation
Male smokers also have approximately 30% higher odds of infertility. There is increasing evidence that the harmful products of tobacco smoking kill sperm cells. Therefore, some governments require manufacturers to put warnings on packets. Smoking tobacco increases intake of cadmium, because the tobacco plant absorbs the metal. Cadmium, being chemically similar to zinc, may replace zinc in the DNA polymerase, which plays a critical role in sperm production. Zinc replaced by cadmium in DNA polymerase can be particularly damaging to the testes.
Common inherited variants in genes that encode enzymes employed in DNA mismatch repair are associated with increased risk of sperm DNA damage and male infertility. As men age there is a consistent decline in semen quality, and this decline appears to be due to DNA damage. (Silva et al., 2012). These findings suggest that DNA damage is an important factor in male infertility.
Testicular factors refer to conditions where the testes produce semen of low quantity and/or poor quality despite adequate hormonal support and include:
Genetic defects on the Y chromosomeY chromosome microdeletions
Abnormal set of chromosomesKlinefelter syndrome
Neoplasm, e.g. seminoma
Varicocele (14% in one study)
Defects in USP26 in some cases
Acrosomal defects affecting egg penetration
Idiopathic oligospermia – unexplained sperm deficiencies account for 30% of male infertility.
Radiation therapy to a testis decreases its function, but infertility can efficiently be avoided by avoiding radiation to both testes.
Post-testicular factors decrease male fertility due to conditions that affect the male genital system after testicular sperm production and include defects of the genital tract as well as problems in ejaculation:
Vas deferens obstruction
Lack of Vas deferens, often related to genetic markers for Cystic Fibrosis
Infection, e.g. prostatitis
Ejaculatory duct obstruction
The diagnosis of infertility begins with a medical history and physical exam by a physician or nurse practitioner. Typically two separate semen analyses will be required. The provider may order blood tests to look for hormone imbalances, medical conditions, or genetic issues.
The history should include prior testicular or penile insults (torsion, cryptorchidism, trauma), infections (mumps orchitis, epididymitis), environmental factors, excessive heat,radiation, medications, and drug use (anabolic steroids, alcohol, smoking).
Sexual habits, frequency and timing of intercourse, use of lubricants, and each partner’s previous fertility experiences are important.
Loss of libido and headaches or visual disturbances may indicate a pituitary tumor.
The past medical or surgical history may reveal thyroid or liver disease (abnormalities of spermatogenesis), diabetic neuropathy (retrograde ejaculation), radical pelvic orretroperitoneal surgery (absent seminal emission secondary to sympathetic nerve injury), or hernia repair (damage to the vas deferens or testicular blood supply).
A family history may reveal genetic problems.
Usually, the patient disrobes completely and puts on a gown. The physician or NP will perform a thorough examination of the penis, scrotum, testicles, anus and rectum.
The volume of the semen sample, approximate number of total sperm cells, sperm motility/forward progression, and % of sperm with normal morphology are measured. This is the most common type of fertility testing. Semen deficiencies are often labeled as follows:
Oligospermia or Oligozoospermia – decreased number of spermatozoa in semen
Aspermia – complete lack of semen
Hypospermia – reduced seminal volume
Azoospermia – absence of sperm cells in semen
Teratospermia – increase in sperm with abnormal morphology
Asthenozoospermia – reduced sperm motility
There are various combinations of these as well, e.g. Teratoasthenozoospermia, which is reduced sperm morphology and motility. Low sperm counts are often associated with decreased sperm motility and increased abnormal morphology, thus the terms “oligoasthenoteratozoospermia” or “oligospermia” can be used as a catch-all.
Common hormonal test include determination of FSH and testosterone levels. A blood sample can reveal genetic causes of infertility, e.g. Klinefelter syndrome, a Y chromosome microdeletion, or cystic fibrosis.
Some strategies suggested or proposed for avoiding male infertility include the following:
Avoiding smoking as it damages sperm DNA
Avoiding heavy marijuana and alcohol use.
Avoiding excessive heat to the testes.
Sperm counts can be depressed by daily coital activity and sperm motility may be depressed by coital activity that takes place too infrequently (abstinence 10–14 days or more).
When participating in contact sports, wear a Protective Cup and Jockstrap to protect the testicles. Sports such as Baseball, Football, Cricket, Lacrosse, Hockey, Softball,Paintball, Rodeo, Motorcross, Wrestling, Soccer, Karate or other Martial Arts or any sport where a ball, foot, arm, knee or bat can come into contact with the groin.
Treatments vary according to the underlying disease and the degree of the impairment of the male fertility. Further, in an infertility situation, the fertility of the female needs to be considered.
Pre-testicular conditions can often be addressed by medical means or interventions.
Testicular-based male infertility tends to be resistant to medication. Usual approaches include using the sperm for intrauterine insemination (IUI), in vitro fertilization (IVF), or IVF with intracytoplasmatic sperm injection (ICSI). With IVF-ICSI even with a few sperm pregnancies can be achieved.
Obstructive causes of post-testicular infertility can be overcome with either surgery or IVF-ICSI. Ejaculatory factors may be treatable by medication, or by IUI therapy or IVF.
The off-label use of Clomiphene citrate, an anti-estrogen drug designed as a fertility medicine for women, is controversial. Vitamin E helps counter oxidative stress, which is associated with sperm DNA damage and reduced sperm motility. A hormone-antioxidant combination may improve sperm count and motility. The Low dose Estrogen Testosterone Combination Therapy may improve sperm count and motility in some men. including severe oligospermia.
Oral antioxidants e.g. brand name Maxoza-L given to males in couples undergoing in vitro fertilisation for male factor or unexplained subfertility result in significantly higher live birth rate.
Infertility means that couples have been trying to get pregnant with frequent intercourse for at least a year with no success. Female infertility, male infertility or a combination of the two affects millions of couples in the United States. An estimated 10 to 15 percent of couples have trouble getting pregnant or getting to a successful delivery.
Infertility results from female infertility factors about one-third of the time and male infertility factors about one-third of the time. In the rest, the cause is either unknown or a combination of male and female factors.
The cause of female infertility can be difficult to diagnose, but many treatments are available. Treatment options depend on the underlying problem. Treatment isn’t always necessary — many infertile couples will go on to conceive a child spontaneously.
The main symptom of infertility is the inability of a couple to get pregnant. A menstrual cycle that’s too long (35 days or more), too short (less than 21 days), irregular or absent can be a sign of lack of ovulation, which can be associated with female infertility. There may be no other outward signs or symptoms.
When to see a doctor
When to seek help depends, in part, on your age.
If you’re in your early 30s or younger, most doctors recommend trying to get pregnant for at least a year before having any testing or treatment.
If you’re between 35 and 40, discuss your concerns with your doctor after six months of trying.
If you’re older than 40, your doctor may want to begin testing or treatment right away.
Your doctor also may want to begin testing or treatment right away if you or your partner has known fertility problems, or if you have a history of irregular or painful periods, pelvic inflammatory disease, repeated miscarriages, prior cancer treatment, or endometriosis.
To become pregnant, each of these factors is essential:
You need to ovulate.Achieving pregnancy requires that your ovaries produce and release an egg, a process known as ovulation. Your doctor can help evaluate your menstrual cycles and confirm ovulation.
Your partner needs sperm. For most couples, this isn’t a problem unless your partner has a history of illness or surgery. Your doctor can run some simple tests to evaluate the health of your partner’s sperm.
You need to have regular intercourse. You need to have regular sexual intercourse during your fertile time. Your doctor can help you better understand when you’re most fertile during your cycle.
You need to have open fallopian tubes and a normal uterus. The egg and sperm meet in the fallopian tubes, and the pregnancy needs a healthy place to grow.
For pregnancy to occur, every part of the complex human reproduction process has to take place just right. The steps in this process are as follows:
One of the two ovaries releases a mature egg.
The egg is picked up by the fallopian tube.
Sperm swim up the cervix, through the uterus and into the fallopian tube to reach the egg for fertilization.
The fertilized egg travels down the fallopian tube to the uterus.
The fertilized egg implants and grows in the uterus.
In women, a number of factors can disrupt this process at any step. Female infertility is caused by one or more of these factors.
Ovulation disorders, meaning you ovulate infrequently or not at all, account for infertility in about 25 percent of infertile couples. These can be caused by flaws in the regulation of reproductive hormones by the hypothalamus or the pituitary gland, or by problems in the ovary itself.
Polycystic ovary syndrome (PCOS). In PCOS, complex changes occur in the hypothalamus, pituitary gland and ovaries, resulting in a hormone imbalance, which affects ovulation. PCOS is associated with insulin resistance and obesity, abnormal hair growth on the face or body, and acne. It’s the most common cause of female infertility.
Hypothalamic dysfunction. The two hormones responsible for stimulating ovulation each month — follicle-stimulating hormone (FSH) and luteinizing hormone (LH) — are produced by the pituitary gland in a specific pattern during the menstrual cycle. Excess physical or emotional stress, a very high or very low body weight, or a recent substantial weight gain or loss can disrupt this pattern and affect ovulation. The main sign of this problem is irregular or absent periods.
Premature ovarian insufficiency. This disorder is usually caused by an autoimmune response where your body mistakenly attacks ovarian tissues or by premature loss of eggs from your ovary due to genetic problems or environmental insults such as chemotherapy. It results in the loss of the ability to produce eggs by the ovary, as well as a decreased estrogen production under the age of 40.
Too much prolactin. Less commonly, the pituitary gland can cause excess production of prolactin (hyperprolactinemia), which reduces estrogen production and may cause infertility. Most commonly this is due to a problem in the pituitary gland, but it can also be related to medications you’re taking for another disease.
Damage to fallopian tubes (tubal infertility)
When fallopian tubes become damaged or blocked, they keep sperm from getting to the egg or block the passage of the fertilized egg into the uterus. Causes of fallopian tube damage or blockage can include:
Pelvic inflammatory disease, an infection of the uterus and fallopian tubes due to chlamydia, gonorrhea or other sexually transmitted infections
Previous surgery in the abdomen or pelvis, including surgery for ectopic pregnancy, in which a fertilized egg becomes implanted and starts to develop in a fallopian tube instead of the uterus
Pelvic tuberculosis, a major cause of tubal infertility worldwide, although uncommon in the United States
Endometriosis occurs when tissue that normally grows in the uterus implants and grows in other locations. This extra tissue growth — and the surgical removal of it — can cause scarring, which may obstruct the tube and keep the egg and sperm from uniting. It can also affect the lining of the uterus, disrupting implantation of the fertilized egg. The condition also seems to affect fertility in less-direct ways, such as damage to the sperm or egg.
Uterine or cervical causes
Several uterine or cervical causes can impact fertility by interfering with implantation or increasing the likelihood of a miscarriage.
Benign polyps or tumors (fibroids or myomas) are common in the uterus, and some types can impair fertility by blocking the fallopian tubes or by disrupting implantation. However, many women who have fibroids or polyps can become pregnant.
Endometriosis scarring or inflammation within the uterus can disrupt implantation.
Uterine abnormalities present from birth, such as an abnormally shaped uterus, can cause problems becoming or remaining pregnant.
Cervical stenosis, a cervical narrowing, can be caused by an inherited malformation or damage to the cervix.
Sometimes the cervix can’t produce the best type of mucus to allow the sperm to travel through the cervix into the uterus.
Certain factors may put you at higher risk of infertility, including:
Age. With increasing age, the quality and quantity of a woman’s eggs begin to decline. In the mid-30s, the rate of follicle loss accelerates, resulting in fewer and poorer quality eggs, making conception more challenging and increasing the risk of miscarriage.
Smoking. Besides damaging your cervix and fallopian tubes, smoking increases your risk of miscarriage and ectopic pregnancy. It’s also thought to age your ovaries and deplete your eggs prematurely, reducing your ability to get pregnant. Stop smoking before beginning fertility treatment.
Weight. If you’re overweight or significantly underweight, it may hinder normal ovulation. Getting to a healthy body mass index (BMI) has been shown to increase the frequency of ovulation and likelihood of pregnancy.
Sexual history. Sexually transmitted infections such as chlamydia and gonorrhea can cause fallopian tube damage. Having unprotected intercourse with multiple partners increases your chances of contracting a sexually transmitted disease (STD) that may cause fertility problems later.
Alcohol. Heavy drinking is associated with an increased risk of ovulation disorders and endometriosis.
Tests and diagnosis
If you’ve been unable to conceive within a reasonable period of time, seek help from your doctor for further evaluation and treatment of infertility.
Fertility tests may include:
Ovulation testing. An over-the-counter ovulation prediction kit — a test that you can perform at home — detects the surge in luteinizing hormone (LH) that occurs before ovulation. If you have not had positive home ovulation tests, a blood test for progesterone — a hormone produced after ovulation — can document that you’re ovulating. Other hormone levels, such as prolactin, also may be checked.
Hysterosalpingography. During hysterosalpingography (his-tur-o-sal-ping-GOG-ruh-fee), X-ray contrast is injected into your uterus and an X-ray is taken to determine if the uterine cavity is normal and whether the fluid passes out of the uterus and spills out of your fallopian tubes. If abnormalities are found, you’ll likely need further evaluation. In a few women, the test itself can improve fertility, possibly by flushing out and opening the fallopian tubes.
Ovarian reserve testing. This testing helps determine the quality and quantity of eggs available for ovulation. Women at risk of a depleted egg supply — including women older than 35 — may have this series of blood and imaging tests.
Other hormone testing. Other hormone tests check levels of ovulatory hormones as well as thyroid and pituitary hormones that control reproductive processes.
Imaging tests. Pelvic ultrasound looks for uterine or fallopian tube disease. Sometimes a hysterosonography (his-tur-o-suh-NOG-ruh-fee) is used to see details inside the uterus that are not seen on a regular ultrasound.
Depending on your situation, rarely your testing may include:
Other imaging tests. Depending on your symptoms, your doctor may request a hysteroscopy to look for uterine or fallopian tube disease.
Laparoscopy. This minimally invasive surgery involves making a small incision beneath your navel and inserting a thin viewing device to examine your fallopian tubes, ovaries and uterus. Laparoscopy may identify endometriosis, scarring, blockages or irregularities of the fallopian tubes, and problems with the ovaries and uterus.
Genetic testing. Genetic testing helps determine whether there’s a genetic defect causing infertility.
If you’re a woman thinking about getting pregnant soon or in the future, you may improve your chances of having normal fertility if you:
Maintain a normal weight. Overweight and underweight women are at increased risk of ovulation disorders. If you need to lose weight, exercise moderately. Strenuous, intense exercise of more than seven hours a week has been associated with decreased ovulation.
Quit smoking. Tobacco has multiple negative effects on fertility, not to mention your general health and the health of a fetus. If you smoke and are considering pregnancy, quit now.
Avoid alcohol. Heavy alcohol use may lead to decreased fertility. And any alcohol use can affect the health of a developing fetus. If you’re planning to become pregnant, avoid alcohol, and don’t drink alcohol while you’re pregnant.
Reduce stress. Some studies have shown that couples experiencing psychological stress had poorer results with infertility treatment. If you can, find a way to reduce stress in your life before trying to become pregnant.
Limit caffeine. Some physicians suggest limiting caffeine intake to less than 200 to 300 milligrams a day.