Male infertility is common, being present in up to half of all infertile couples. Infertility is certainly not just a “female problem” rather it is a "couples” problem. Fertility in men appears to decline with age, but the effects of age are not as distinct compared to menopause in women. With age, there are declines in the quality and quantity of sperm. The semen analysis is the cornerstone male infertility test and must be completed before any female treatment begins.
Male infertility has several causes. Sperm require three months to develop and mature, so a semen analysis done today reflects conditions affecting sperm three months ago. For example, a high fever or binge drinking that happens today, will affect sperm quality for three months. Also, any changes made today, such as removal of a varicocele may not affect the semen analysis for three months.
Male infertility can result when one or more processes are affected. During ejaculation the sperm travel from the testicles through the epididymis, into the vas deferens, past the seminal vesicles, into the urethra and are then ejaculated from the penis. Conditions such as retrograde ejaculation prevent sperm delivery into the vagina.
A man may develop antisperm antibodies to his own sperm, usually as a result of testicular trauma or a vasectomy with reversal, resulting in male infertility due to reduced sperm motility.
Male infertility can occur as a result of numerous environmental factors. Sperm are manufactured in the testicles and the temperature must be regulated within a relatively narrow margin. The scrotum serves a heating/cooling function for the sperm by moving them farther from the body to decrease temperature or “pulling” them closer to raise temperature. Activities that interfere with the scrotum's heating/cooling functions can lead to male infertility.
Other activities that might abnormally raise the testicular temperature include repetitive soaking in a hot tub, and wearing clothes that are too tight thus forcing the testicles too close to the body. Some occupations, such as long distance truck driver, require prolonged sitting and can raise testicular temperature. Activities that abnormally increase testicular temperature can result in some degree of male infertility.
A varicocele can interfere with testicular temperature regulation. A varicocele is a collection of congested veins in the spermatic cord that interferes with blood flow to the testicles. The resultant change in blood flow interferes with the heating/cooling functions and can lead to decreased sperm quality. Varicoceles, particularly large ones that are detected by physical exam, may be treated surgically by a urologist with improvement in the sperm quality.
Vasectomy is performed for elective sterilization. Sometimes men seek vasectomy reversals. While a vasectomy reversal is sometimes successful, vasectomy should be considered a permanent means of birth control. In many cases, obtaining sperm from testicular biopsy for use with intracytoplasmic sperm injection (ICSI) in an IVF cycle produces much higher per cycle success rates than a vasectomy reversal.
Male fertility can also be influenced by smoking, excessive drinking, exposure to heavy metals, infections, marijuana, chemotherapy, radiation and other environmental factors.
In most cases of environmentally caused male infertility, such as prolonged sitting in a hot tub, normal fertility returns once this activity is stopped. On the other hand male infertility caused by certain heavy metals, chemotherapy, or radiation therapy may be permanent.
Male infertility ranges from mild count decreases to the total absence of sperm. In the past, the only option for couples with severe male infertility was to use a sperm donor. Nowadays, a pregnancy can often be initiated even in the absence of sperm in the ejaculate using intracytoplasmic sperm injection (ICSI), TESE or MESA, and IVF. Using ICSI, a single sperm is injected directly into the eggs using a microscopic needle.
When there are no sperm in the ejaculate, they can often be withdrawn directly from the male reproductive tract using testicular sperm extraction (TESE) or micro epididymal sperm aspiration (MESA).
Most cases of male infertility do not respond to fertility medications and none of the “sperm enhancers” have been proven to significantly increase sperm quality or quantity. One exception is the infertile male who has extremely low levels of FSH and LH a rare condition known as hypogonadotropic hypogonadism. These patients often do well with FSH injections, and sometimes clomiphene, but the treatment period is long and very expensive.