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In the past, infertility was considered primarily a “female problem” but we now know that up to half of all infertile couples will have a male infertility component. This fact makes the semen analysis one of the most important initial fertility tests. Surely, no treatment of the female should begin until male infertility has been “ruled out”.
Unlike women, who have a finite reproductive life span, most men can father children throughout their adult lives. Sperm are "manufactured" in the testicles and travel through the epididymus and the vas deferens when ejaculated. Interestingly, sperm require three months to fully develop so a semen analysis conducted today is reflective of “sperm conditions” over the past three months.
Sperm are sensitive to heat and cold and nature devised the scrotum to help control temperature. When the testicles become too hot the scrotum expands moving them further away from the body, thus lowering temperature. Prolonged high temperatures can lead to decreases in sperm quality and quantity. When the testicles become “too cool” the scrotum contracts bringing them closer to the body.
Men trying to initiate a pregnancy should not engage in activities, such as prolonged sitting in a hot tub, which will cause testicular temperature increases. Clothing that is too tight may also interfere with scrotal function. Some occupations that require prolonged sitting can cause declines in sperm count and/or quality. Smoking, excessive drinking, exposure to heavy metals, marijuana, chemotherapy, radiation and other environmental factors can negatively affect sperm.
Rarely, a man will develop antibodies to his own sperm usually as a result of testicular trauma or a vasectomy. When this occurs, his immune system seeks to destroy sperm as if they were invading bacteria or viruses. More commonly, the female will develop antisperm antibodies to the male partner’s sperm.
Sometimes a man will develop a large varicocele, which is a mass of varicose veins in the spermatic cord. It is most common on the left side. Veins carry heat from the testicles by circulating blood. When the veins are dilated, as occurs with a varicocele, it interferes with the cooling/heating functions. Varicoceles can have a variable impact on sperm quality and a complete evaluation should be completed prior to attributing the major problem to a varicocele. Small to moderate varicoceles often do not have a significant impact on sperm quality. On the other hand large varicoceles may decrease sperm quality but fortunately, large varicoceles can usually be effectively treated surgically by a urologist (surgery for varicocelectomy) or radiologist (interventional procedure requiring spring placement).
 Since the advent of intracytoplasmic sperm injection (ICSI), a pregnancy can be initiated when as few as one sperm can be obtained. Prior to ICSI, the only option for couples with mild to moderate male factor was to use a sperm donor. In ICSI, the sperm is injected directly into the egg as a part of an IVF cycle. Sperm can be obtained from an ejaculate, by testicular biopsy or needle aspiration, or from other parts of the reproductive tract such as the epididymis. This breakthrough technology has allowed most men to have genetically related children.
We often see men who wish to have a surgical vasectomy reversed. While a skilled surgeon can often reconnect the tubes, a vasectomy must be considered a permanent means of birth control not to be undertaken lightly. We strongly encourage vasectomy patients to freeze their sperm prior to the procedure in case there are future changes in their life situations. Generally, per cycle success rates in men with vasectomies are higher for IVF than surgical reversal. Another option to vasectomy reversal that many patients prefer is IVF with testicular aspiration and ICSI. Usually IVF success rates are much higher per cycle than after vasectomy reversal.
Unfortunately, there is no effective drug treatment to improve sperm quality and quantity. Clomid® and FSH have been used but they must be administered for at least three months, are extremely expensive, and improvements in sperm parameters are often minor. The exception is the rare male that has severe deficiencies of FSH and LH, a condition known as hypogonadotropic hypogonadism. To the best of our knowledge, all of the male fertility products touted on the Internet have little or no scientific verifiability of clinical effectiveness.
Fortunately, with today’s technologies most men can father genetically related children. It is also possible for men to freeze sperm thus preserving their fertility. This is especially important for men who will undergo cancer treatments.
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