Infertility was once considered a “female problem”: however, we now know up to half of all cases involve male fertility issues.
A semen analysis is one of the most important fertility tests to assess the causes of infertility and should be completed before beginning any female treatments.
Male fertility for oncology patients can be preserved by freezing sperm prior to cancer treatments, allowing a man to use his sperm in the future to father a genetically related child.
Both environmental and medical factors can contribute to male infertility. Sperm are manufactured in the testicles, become mature in the epididymis, and travel through the vas deferens during ejaculation.
There is no effective drug treatment to improve sperm quality and quantity. To the best of our knowledge, all male infertility products touted on the Internet have little or no clinical effectiveness.
Fortunately, with today’s technologies most men suffering with male infertility, can father genetically related children. Since the advent of intracytoplasmic sperm injection (ICSI), a pregnancy can be initiated when as few as one sperm is obtained. Prior to ICSI, the only option for patients with moderate to severe male infertility was to use a sperm donor.
Causes of Male Infertility
Sperm quality can be reduced if the testicles are exposed to elevated temperatures for prolonged periods. The scrotum expands to cool the testicles by moving them further from the body and it contracts to increase the temperature. Activities like prolonged sitting in a hot tub, wearing clothing that is too tight, or occupations requiring long periods of sitting can interfere with temperature regulation and reduce fertility.
Smoking, excessive drinking, exposure to heavy metals, marijuana, chemotherapy, radiation and other factors can decrease fertility. In most cases of environmentally caused male infertility, normal fertility returns once the cause is addressed. Certain heavy metals, chemotherapy, or radiation may cause permanent damage. We advise freezing sperm prior to cancer treatments.
Medical Causes of Male Infertility
Male infertility can be caused by a varicocele, which is a mass of varicose veins in the spermatic cord. Blood circulates through these veins thus cooling or warming the testicles and a varicocele interferes with this function.
A complete evaluation should be done before concluding that infertility is due to a varicocele. Small to moderate varicoceles often don’t have a significant impact on sperm quality. Large varicoceles may decrease sperm quality and can usually be treated by a urologist (surgery for varicocelectomy) or a radiologist (interventional procedure requiring spring placement).
A man may develop antibodies to his sperm (rarely) usually as a result of testicular trauma or a vasectomy. When this occurs, the immune system tries to destroy sperm as if they were bacteria or viruses.
Diagnosing Male Infertility
The semen analysis is one of the most important fertility tests since up to half of all cases have a male infertility component. Given the extreme importance of ruling out subtle male infertility, it is best to have the analysis done at a reproductive medicine laboratory. These laboratories hire laboratory directors and technicians who are specialists in the evaluation of sperm who usually have years of clinical experience in identifying all types of semen abnormalities.
While a semen analysis can be performed at most hospital laboratories, it is recommended this test be performed at our laboratory so specialized testing can be performed on the same sample.
We have two private rooms for collecting alone or together with a spouse. We will provide instructions on how to collect the sample. It is possible to collect at home or at a nearby hotel using a sterile container or a special condom in certain circumstances. If the sample is collected out of the office, we prefer that it be delivered within 30 minutes of collection. The sample should be kept at body temperature during transit. Special collection condoms can be purchased through our office (less than $15/condom) or they can be purchased through www.INGFertility.com by ordering the “Pre~Seed Semen Collection Kit” that includes: 1 tube “Pre~Seed “sperm-friendly” Intimate Moisturizer” and 1 non-spermicidal Male Factor Condom.
The sample should be collected after two – three days of abstinence, but preferably not more than four-five days unless there is a known history of low sperm concentration. The sample is collected into a sterile plastic container using no lubricants including hand creams, K-Y jelly, Surgilube, saliva, or any others that can interfere with the accuracy of the sample. If a lubricant is necessary, “His~Seed Semen Collection Facilitator” may be used. This lubricant is available through our office.
Sperm require three months to develop so a semen analysis done today is reflective of conditions that affected the sperm during the previous three months.
Kruger Strict Criteria
There are different laboratory criteria for the semen analysis and ours uses the Kruger Strict Criteria for determining the percent of sperm with normal morphology (shape of the sperm). The sample is evaluated as follows:
- Volume – the milliliters (ml) of fluid which comprise the sample.
- Sperm count (technically it is the concentration) is the number of sperm in a standard given volume (ml) and 20 million/ml is considered normal.
- Motility is the percent of sperm that are moving in the sample. Above 50% is considered normal. The percent of sperm swimming forward in straight lines (progressive motility) is also determined.
- Viability is the percent of sperm that are alive. This test using special stains is completed if the percent of sperm that are motile is very low.
- Sperm morphology (shape) using Kruger strict criteria. Greater than 14% normal forms usually predicts excellent fertilization capability in vitro (>60-70%) if the other test parameters are normal.
- Less than five round cells (may be white blood cells which can indicate an infection) per high power field (or 3 million/ml).Factors Affecting Sperm Quality
Factors Affecting Sperm Quality
Sperm are fragile cells and are easily damaged by a number of environmental and life style factors. Increased testicular temperature resulting from sitting in hot tubs, saunas or spas, wearing excessively tight clothing, or other conditions can affect sperm quantity and quality.
Drugs (including alcohol, marijuana and nicotine) have been proven to decrease male infertility and should be minimized or avoided while attempting to achieve pregnancy. Commercial or industrial chemicals such as DBCP, lead, carbon disulphide, benzene, and mercury can have an adverse effect on sperm.
Various pharmacologic compounds have been linked to male infertility by decreasing spermatogenesis (production of sperm) fertilizing capacity:
- Spironolactone (part of many anti-hypertensive regimens)
- Sulfasalazine (treatment of inflammatory bowel disease)
- Colchicine (acute and chronic control of gout and suppression of familial Mediterranean fever)
- Allopurinol (alters uric acid metabolism)
- Anabolic steroids (weight lifters and body building)
- Cyclosporin (component of immunosuppressive regimens used in renal and liver transplant recipients)
- Chemotherapeutic agents (treatment of malignant or cancerous conditions).
Natural Ways to Increase Sperm Quality
- Take a low cost multivitamin to assist with sperm function.
- Try to get 6 to 8 hours of sleep at night.
- Eat a balanced diet and exercise regularly.
- Decrease or minimize caffeine to two cups of coffee a day or no more than two cans of caffeinated beverages.
- Limit alcohol to less than 2 ounces a day.
- Decrease stress in your life as much as possible because stress can have an adverse effect on sperm.
- Avoid all possible gonadotoxins as mentioned above.
- Time intercourse every other day while in the time of ovulation or use ovulation predictor kit testing. For optimal sperm production ejaculation 3-4 times each week throughout the month is optimal. Ejaculation too frequently can reduce sperm concentration and too infrequently can reduce sperm motility.
Mild male infertility can often be treated with intrauterine insemination (IUI).
Intrauterine insemination (IUI) is a painless procedure where a small catheter is used to pass concentrated sperm through the vagina, past the cervix, and into the uterus.
The semen analysis is crucial to documenting the sperm’s ability to fertilize an egg. Our andrology laboratory uses the “Kruger Strict Criteria” to evaluate semen, unlike most commercial laboratories. This testing helps predict IUI success and indicates if more advanced treatments like IVF, using ICSI are needed.
Invitro Fertilization (IVF) Intracytoplasmic Sperm Injection (ICSI)
Moderate to severe male infertility is usually treated with invitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI).
In vitro fertilization occurs when eggs are fertilized in petri dishes leading to the formation of embryos. The embryos are later transferred to the uterus. Sperm are collected and washed before exposure to the eggs. Intracytoplasmic sperm injection (ICSI) is often used in cases of male infertility. ICSI involves injecting a single sperm into the egg. Some men with severe male infertility may have no viable sperm in the ejaculate. In these cases, sperm can be taken from the testicles (TESA) or the vas deferens (MESA). The patient could also opt to use a sperm donor.
Vasectomy Reversal and Intracytoplasmic Sperm Injection (ICSI)
Men wanting to restore fertility using their own sperm after vasectomy have two options:
- A vasectomy reversal surgically reconnects the vas deferens tubes. This is an invasive procedure and is not always successful. There must be enough tube remaining to perform the connection and tubes must be free of scar tissue that can prevent sperm passage. Typically, the longer it has been since the vasectomy, the lower the chance of success with a reversal as antisperm antibodies may contribute to decreasing pregnancy rates with time.
- Invitro fertilization uses testicular or epididymal sperm extraction through ICSI. This is a much less invasive procedure for the man and has a higher success rate than a vasectomy reversal. Normally, in vitro fertilization involves obtaining sperm from the ejaculate and combining it with the partner’s eggs in the laboratory. Frequently, intracytoplasmic sperm injection (ICSI) is used in help insure egg fertilization. Using ICSI, a single sperm is collected and injected directly into the egg. The injection procedure usually does not damage the egg. For men who have had a vasectomy, there are no sperm in the ejaculate to use for ICSI even though sperm continues to be produced in the testicle and can be found in other parts of the reproductive tract. In this case, a non-surgical testicular sperm extraction (TESE) is used to gather sperm. TESE is a “closed procedure” (no incision is made in the scrotum). Testicular tissue is obtained using a small thin needle similar in size to one used for drawing blood. This procedure is usually performed under IV anesthesia for optimal comfort but can be performed under local anesthesia if preferred. The small sample obtained is examined under the microscope in the laboratory for viable sperm. Identified sperm are extracted and injected into the egg using ICSI. Most of the time, small numbers of sperm can be obtained. The likelihood of not finding viable sperm from the testicle of a previously fertile male after vasectomy is less than 5%. If desired, a trial testicular aspiration can be performed prior to ovarian stimulation and egg retrieval. Another alternative is to have donor sperm available in the unlikely event sperm is not retrieved.
Most patients can expect good results combining IVF/ICSI with testicular sperm aspiration after vasectomy as long as there are no additional severe causes of female infertility.
An alternative option for having a child after vasectomy not utilizing the partner’s sperm is use of a sperm donor for IUI or IVF.
An issue to consider in determining which option to pursue in situations when pregnancy is desired after vasectomy is the female partner’s age. It usually takes longer to conceive following vasectomy reversal compared to IVF. This may be a concern if the woman is over 35 years of age or has decreased ovarian reserve. In many cases in vitro fertilization (IVF) offers the best chance for pregnancy success following a vasectomy.
Our facility specialists are available to discuss all potential post vasectomy procedures in detail with each patient.