Male infertility is a broad and complex area. The following information is intended only as a very general introduction to the subject of male fertility and infertility. We strongly encourage you to find a specialist in your area to fully evaluate your particular situation. There are a variety of male infertility treatments to help a couple reach their goals.

ON THIS PAGE: Likelihood of Occurrence Causes Testing Treatment

Likelihood of Occurrence A male factor is involved in 60% of cases of couples' infertility. Forty percent are primarily male and 20% are combined male and female. Thus, when a couple is having trouble conceiving, it makes sense not only to evaluate the woman but to evaluate the man as well.

Sperm takes 3 months to produce and mature and there is often a 4 to 6 month delay between treatment of the man and resulting changes in the sperm. Since the evaluation of the woman may take several months, it is recommended that a comprehensive and accurate semen analysis be scheduled at the outset in order to evaluate the male partner. Treatment of the man can then occur at the same time as treatment of the woman and there will be no additional delay once the woman's treatment is completed.

Causes Varicoceles
Varicoceles are dilated veins in the scrotum (similar to varicose veins in the legs). These veins are dilated because the blood does not drain properly from them. These dilated veins allow extra blood to pool in the scrotum, which has a negative effect on sperm production. This condition is the most common reversible cause of male factor infertility and may be corrected by minor outpatient surgery.

Most experts perform this surgery microscopically to preserve the arterial supply and lymphatics. A sub-inguinal incision (about one inch above the penis and one inch from the midline) is usually used, as this avoids incising the abdominal muscles and creates less post-operative pain.

Seminal Fluid Abnormalities
If the seminal fluid is very thick, it may be difficult for the sperm to move through it and into the woman's reproductive tract. Often, the semen can be processed to separate the moving sperm from the surrounding debris, dead sperm, and seminal fluid. The processed sperm is usually placed directly inside the uterus with a small tube. This is called intrauterine insemination (IUI).

Ductal System Problems
Sperm carrying ducts may be missing or blocked. A patient may have bilateral (both sides) congenital (from birth) absence of the vas deferens. He may have obstructions either at the level of the epididymis (the delicate tubular structure draining the testes) or higher up in the more muscular vas deferens. He may have become mechanically blocked during hernia or hydrocele repairs. He may have become blocked by scar tissue as a response to an infection.

Sperm are stored in sacs called the seminal vesicles and are then deposited in the urethra, which is the tube through which men urinate and ejaculate. The sperm must pass through the ejaculatory ducts to get from the seminal vesicles to the urethra. If these are blocked on both sides, no sperm will come through.

In some situations, the ducts may be repaired or unblocked to allow them to flow through the man's reproductive tract. If this is not possible, the sperm may be harvested to allow them to flow through the man's reproductive tract. Because they are obtained in lower numbers, this procedure must be used in conjunction with advanced reproductive techniques to attempt a pregnancy.

Immunological Infertility
Men can develop an immunological response (antibodies) to their own sperm. The causes for this may include testicular trauma, testicular infection, large varicoceles, or testicular surgery. Sometimes, there are unexplained reasons for this occurrence.

These antibodies have a negative effect on fertility although the exact reason why this is the case is unclear. Most likely, these antibodies act negatively at several points along the pathway to fertilization. They make it more difficult for the sperm to penetrate the partner's cervical mucous and make its way into the uterus. They make it more difficult for the sperm to bind with the zonapellucida (the external membrane or shell of the egg). Also, the antibodies make it more difficult for the sperm to fuse with the membrane of the oocytes (eggs) themselves.

The treatment for anti-sperm antibodies is somewhat controversial. Men may be treated with corticosteroids. However, this can lead to significant morbidity in the man. The most significant is aseptic necrosis of the hip (noninfectious destruction of the joint), requiring hip replacement.

Most of the time, the first level of intervention includes intrauterine insemination. If the couple is planning in-vitro fertilization (IVF), the presence of anti-sperm antibodies is usually an indication to inject the sperm directly into the egg (ICSI) instead of conventional IVF.

Difficulties with Erections and Ejaculations
About five percent of couples with infertility have factors relating to intercourse. This includes the inability to obtain or maintain an erection, premature ejaculation, lack of ejaculation, retrograde (backwards) ejaculation, lack of appropriate timing of intercourse, and excessive masturbation. Interestingly, the most common problem is infrequency of intercourse. Many men will have difficulty with erections under the pressure of trying to achieve conception. These couples can easily learn the technique of self-insemination. Studies have shown that five out of six previously fertile couples having intercourse four times per week will conceive over six months, while only one out of six with intercourse once per week during the same period will conceive.

Testicular Failure
This generally refers to the inability of the sperm-producing part of the testicles (the seminiferous elithelium) to make adequate numbers of mature sperm. This failure may occur at any stage in sperm production for a number of reasons. The testicle may completely lack the cells that divide to become sperm (Sertoli Cell-Only Syndrome). There may be an inability of the sperm to complete their development (maturation arrest). Sperm may be made in such low numbers that few, if any, successfully travel through the ducts and into the ejaculated fluid (hypospermatogeneses). This situation may be caused by genetic abnormalities, hormonal factors, or varicoceles.

Even in the case where the testes are only producing low numbers of sperm, the sperm may be harvested and used in conjunction with advanced reproductive techniques to attempt a pregnancy.

Cryptorchidism
Cryptochiridism may be a cause of testicular failure. When a baby boy is born without the testes having fully descended into the scrotum, the condition is known as cryptorchidism.

Since the testes are very sensitive to temperature, if they do not descend into the scrotum prior to adolescence, they will stop producing sperm altogether. In fact, they have a higher rate of malignancy. The current recommendation is that at approximately one year of age, if the testes have not descended by themselves, they be brought down surgically.

Cryptorchidism is often associated with male factor infertility. Eight-one percent of men who have a single testis that is cryptorchid have normal fertility. However, approximately, 50% of men who have bilateral cryptorchidism have normal fertility. This may be due both to something inherent in the testes, to the surgery, or to damage done by not having the testes brought down in time.

Drugs
There are a number of fairly common drugs that may have a negative effect on sperm production and/or function. They include:

• Ketoconazole (an anti-fungal)
• Sulfasalazine (for inflammatory bowel disease)
• Spironolactone (an anti-hypertensive)
• Calcium Channel Blockers (anti-hypertensives)
• Allopurinol, Colchicine (for gout)
• Antibiotics: Nitrofuran, Erythromycin, Gentamicin
• Methotrexate (cancer, psoriasis, arthritis)
• Cimetidine (for ulcer or reflux)

The following drugs can cause ejaculatory dysfunction:

• Antipsychotics: Chlorpromazine, Haloperidol, Thioridazine
• Antidepressants: Amitripltyline, Imipramine, Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft)
• Anti-hypertensives: Guanethidine, Prazosin, Phenoxibenzamine, Phentolamine, Reserpine, Thazides

Hormonal Abnormalities
The testicles need pituitary hormones to be stimulated to make sperm. If these are absent or severely decreased, the testes will not maximally produce sperm. Importantly, men who take androgens (steroids) for body building, either by mouth or injection, shut down the production of hormones for sperm production.

A hormonal profile must be performed on all men with male factor infertility. This will help rule out serious medical conditions, give more information on the sperm-producing ability of the testes, and may reveal situations where hormonal treatment is indicated.

Infections
Men may have infections of their reproductive tract. These may include infections of the prostate (prostatitis), of the epididymis (epididymitis), or of the testes (orchitis).

Post-pubertal viral infections of the testes may cause significant damage (atrophy) of the testes and may cause absolute and irreversible infertility. Bacterial infections or sexually transmitted diseases may cause blockages at the sperm ducts. The patient may have normal production of sperm, but the ducts carrying it are obstructed.

Active bacterial or viral infections may have a negative effect on sperm production or sperm function. White blood cells, which are the body's response to infection, may also have a negative effect on sperm membranes, making them less hearty.

If excessive white blood cells or bacteria (more than one million/cc) are seen in a semen specimen, cultures should be done. This usually includes cultures for commonly asymptomatic, sexually-transmitted diseases including mycoplasma, ureaplasma, and Chlamydia. Also, a general genital culture is usually taken. If the infection and the white blood cells are persistent, antibiotics may be considered.

It is important to note that, in most men, the ejaculate is not sterile. In controlled studies, the average man will culture positive for approximately two organisms. It is therefore very important to be judicious in the treatment of non-sexually-transmitted organisms found on cultures.

Genetic Abnormalities
When these conditions are treated, a man will often see a significant improvement in his semen analysis.

Lifestyle Factors
Cigarette smoking has been shown to significantly affect semen quality.

Regular smoking causes a 23% decrease in sperm density (concentration) and a 13% decrease in motility (when averages are taken from nine separate studies). To a lesser extent, smoking causes toxicity to the seminal plasma (the fluid ejaculated with the sperm). Sperm from non-smokers were adversely affected (had significantly decreased viability) when placed in the seminal plasma (hormonal) of smokers.

Smoking affects the hypothalamic-pituitary-gonatropin axis, most commonly affecting levels of estradiol and estrone (estrogens, which are hormones found in higher concentrations in women). The Leydig Cells, which are in the testes and produce testosterone, may have secretory dysfunction. Most worrisome is that there is evidence that suggests that paternal smoking may also be associated with congenital abnormalities and childhood cancer, though the relative risk in most studies is less than two.

Recreational Drugs

Marijuana
Marijuana often causes a decreased average sperm count, motility, and normal morphology. It affects the hormonal axis (HPG), causing decreased plasma testosterone. It may also have a direct negative effect on the Leydig Cells.

Cocaine
Even infrequent cocaine use causes decreased sperm count, motility, and normal morphology. These effects can be found in men who have used cocaine in the two years preceding their initial semen analysis. Cocaine also decreases the ability of sperm to penetrate the cervical mucous, making it difficult for them to enter the uterus.

Anabolic Steroids (male hormones)
The use of anabolic androgenic steroids has reached almost epidemic proportions. Nearly seven percent of 12th-grade males use or have used them to build muscle mass and improve athletic performance. These male hormones suppress the testes' ability to make testosterone. This decreases the intratesticular testosterone level. This may cause severely diminished spermatogenesis or complete absence of sperm (azoospermia). When taken, these steroids cause a persistent depression of the hypothalamus and pituitary, which may be irreversible even when the steroids are stopped.

Alcohol
Moderate alcohol use does not affect male fertility. Excessive alcohol use affects the hormonal axis and is a direct gonadotoxin. It may cause associated liver dysfunction and nutritional deficiencies, which are also detrimental for sperm production.

Lubricants
Most vaginal lubricants, including K-Y Jelly, Surgilube, and Lubifax, are toxic to sperm. Couples should avoid their use during the fertile time of a woman's cycle.

Exercise
Moderate amounts of exercise can only be helpful. However, long-distance runners (men who run more than 100 miles per week) and distance cyclers (men who ride more than 50 miles per week) have decreased spermatogenesis. These activities should be moderated when a sub-fertile man is attempting conception.

Back to top Testing The general purpose of a man's evaluation (semen analysis and, if appropriate, a consultation) is to identify any problems and address them in order to maximize the quality of the man's semen. This may reduce the need for more complicated interventions for the female partner. It is also important to rule out significant medical problems that may contribute to a poor semen analysis. Therefore, the most important first step in any man's evaluation is the semen analysis.

Semen Analysis
Semen is the fluid that a man ejaculates. This fluid is produced at several different sites. The sperm within the semen are the cells that actually fertilize the egg and are therefore the most important to assess. However, the sperm account for only 1% to 2% of the semen volume. Problems with the surrounding fluid may also interfere with the movement and function of the sperm. Therefore, both the sperm and the fluid must be tested.

There is no absolute numerical cutoff between the semen analysis of men whose partners will get pregnant and those who won't. The partners of some men with a very poor semen analysis may conceive easily. The partners of some men with an excellent semen analysis may experience difficulty. However, men with good semen analysis results will, as a group, conceive at significantly higher rates than those with poor semen analysis results. The semen analysis will help determine whether there is a male factor involved in the couple's sub-fertility. If so, an evaluation is usually indicated. Some findings of the semen analysis suggest certain specific potential problems. For example, an increased white blood cell count may indicate infection or inflammation. However, other abnormalities in many of the main parameters are non-specific. For example, there are a number of different causes for a decreased sperm count or diminished sperm movement. Some of these causes have other serious medical implications. A thorough evaluation helps determine the cause of an abnormal semen analysis and rules out medical problems.

Standard Semen Analysis Tests
Almost all laboratories will conduct tests and report on the following information, using values established by the World Health Organization:

• Concentration (sometimes referred to as the count): This is a measurement of how many million sperm there are in each milliliter of fluid. There are various techniques for obtaining this number. Some prove to be more accurate than others. Average sperm concentration is more than 60 million per milliliter (>60 million/cc). Counts of less than 20 million per milliliter (<20 million/cc) are considered sub-fertile.
• Motility (sometimes referred to as mobility): This describes the percentage of sperm that are moving. Fifty percent or more of the sperm should be moving.
• Morphology: This describes the shape of the sperm. The sperm are examined under a microscope and must meet specific sets of criteria for several sperm characteristics in order to be considered normal. Most commercial laboratories will report WHO morphology (use World Health Organization criterion). Thirty percent of the sperm should be normal by these criteria.
• Volume: This is a measurement of the volume of the ejaculate. Normal is two milliliters (two ccs) or greater. The volume may be low if a man is anxious when producing a specimen, if the entire specimen is not caught in the collection container, or if there are hormonal abnormalities or ductal blockages.
• Total Motile Count: This is the number of moving sperm in the entire ejaculate. It is calculated by multiplying the volume (cc) by the concentration (million sperm/cc) by the motility (percent moving). There should be more than 40 million motile sperm in the ejaculate.
• Standard Semen Fluid Tests: Color, viscosity (how thick the semen is), and the time until the specimen liquefies should also be measured. Abnormalities in the seminal fluid may adversely affect the sperm. For example, if the semen is very thick, it may be difficult for the sperm to move through it and into the woman's reproductive tract.

Additional Semen Analysis Tests

• Forward Progression: This describes how well the sperm that are moving are making progress. Only when the motility (percent moving) is combined with the forward progression is an accurate picture of sperm movement obtained. Unfortunately, this is often not tested by commercial laboratories. A man's motility may be normal and the fact that the sperm are moving sluggishly or almost not at all will be overlooked if the forward progression is not recorded separately.
• Kruger Morphology: This is a more detailed evaluation of the morphology. Slides are specially stained and the sperm examined microscopically under high-power magnification. The sperm must meet a stringent set of criteria that evaluate the shape and size of the head, midpiece, and tail in order to be considered normal. A Kruger test helps determine which of the available advanced reproductive techniques may be most appropriate and successful.
• Anti-Sperm Antibodies: Some men may produce antibodies to their own sperm. These antibodies may decrease fertility rates in a number of ways. They may impede the movement of sperm through a woman's cervical mucous, inhibit the binding of a sperm to the egg, and/or inhibit its penetration into the egg. Men who are most at risk for developing antibodies are those with previous testicular and epididymal infection, trauma, surgery, or large varicoceles. The presence of these antibodies is often not predictable from other semen parameters or from the man's history.
• White Blood Cells: The semen may contain a high number of white blood cells, which may be an indication of either infection or inflammation.White blood cells are considered significant if more than one million are found in each milliliter of the ejaculate.

White blood cells cannot be differentiated from other round cells normally found in the semen (debris and immature sperm) without special staining. If more than one-million round cells are found in the ejaculate, a portion of the ejaculate should be specially stained to look for an increased number of white blood cells.

If the white blood cell count is elevated, semen cultures should be performed on a subsequent specimen. Unfortunately, the semen culture cannot be performed on the original specimen as it must be the first step performed on the specimen in order to keep it sterile.

Other Tests
In certain situations, specialized tests are needed. These depend on the findings at the time of the analysis and can often be performed on that specimen.

• Spun Specimen: Even if no sperm are seen on the test slide, the sperm count may still not be zero (there may be very low numbers of sperm in the ejaculate). This has very important implications as it may determine if the couple can conceive using advanced reproductive techniques. This must be assessed by spinning down the specimen so all of the sperm are concentrated in a pellet on the bottom of the tube and then examining the pellet beneath the microscope.
• Viability: Sperm may be alive, but not moving. A specialized staining technique is used to determine what percentage of the sperm are alive and is indicated when the motility (percent moving) is less that thirty percent.
• Fructose: In men with no sperm or very low numbers of sperm in the ejaculate, it is important to determine whether the sperm are not being produced at all, or whether they are being produced but are blocked from “getting into” the semen. A fructose test can help differentiate between these two problems.
• Post-Ejaculatory Urinalysis (PEU): Some men ejaculate all or part of the sperm backward into the bladder. This can be detected by having a man ejaculate and immediately afterward urinate into a separate cup. The post-ejaculatory urine is then centrifuged to see if any sperm are present.

Laboratory Needs

• Expertise: Semen testing is a sophisticated and technical field. An improperly or incompletely performed semen analysis may miss significant problems. Unrecognized problems may unnecessarily delay a man's treatment. Unlike many other lab tests, a semen analysis relies completely on the expertise of those performing it. Make sure the lab has sophisticated protocols and well-trained, specialized technicians.
• Timing: In order to get accurate results, the specimen must be processed within one hour of collection. If not, the measurement of the movement of the sperm may be extremely inaccurate. With any lab you use, make sure that the analysis is performed on site and not shipped elsewhere for evaluation.
• Thoroughness: As a semen analysis is being performed, certain findings may indicate the need for additional tests. Ideally, you should use a laboratory that has the capability to do complete initial testing as well as the flexibility to do the appropriate follow-up testing on the same specimen.

Comfort and Convenience: In order to maximize your results, it is important that you are as relaxed as possible. Ideally, the specimen should be collected at the laboratory itself in a comfortable room that is meant specifically for that purpose.

Back to top Treatment More that 50% of men will have a treatable cause of male factor infertility. These factors include varicoceles (dilated veins in the scrotum), infections, hormonal abnormalities, abnormalities in the seminal fluid, ductal blockages, and difficulties with erections and ejaculation. When these conditions are treated, either through medication (hormones or antibiotics) or surgery (varicocelectomy, vasal reconstruction, repair of a blocked ejaculatory duct), a man will often see a significant improvement in his semen analysis.

Those men with poor semen analyses whose conditions are not treatable may still have the option of using advanced reproductive techniques to achieve a pregnancy. Even those men with no sperm in the ejaculate may be able to have some living sperm procured from them through other methods and achieve a pregnancy using advanced reproductive techniques. Those few men who produce absolutely no sperm at all will have this information so that they can explore other options.

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