Infertility in Men MD Consult - Patient Education Handout 93k

Infertility in Men

How Does The Male Reproductive System Work?

Male Reproductive System

Male fertility depends on the proper function of a complex system of organs and hormones:

The process begins in the area of the brain called the hypothalamus-pituitary axis , a system of glands, hormones, and chemical messengers called neurotransmitters, which are critical for reproduction.
The first step in fertility is the production of gonadotropin-releasing hormone (GnRH) in the hypothalamus, which prompts the pituitary gland to manufacture follicle-stimulating hormone (FSH) and luteinizing hormone (LH) .
FSH maintains sperm production and LH stimulates the production of the male hormone testosterone.
Both sperm and testosterone production occurs in the two testicles, or testes, which are contained in the scrotal sac (the scrotum). (This sac develops on the outside of the body because normal body temperature is high enough to reduce or even prevent sperm production.)

Sperm are manufactured in several hundred microscopic tubes, known as seminiferous tubules, which make-up most of the testicles.

Surrounding these tubules are clumps of tissue containing so-called Leydig cells . Here, testosterone is manufactured.

Sperm

Sperm Development. The life cycle of the sperm consists of a remarkable journey that depends on hormonal signals combined with a mechanical process. It takes about 74 days:

Sperm begin their life in germ cells . During the first phase of their development, they are partially embedded in a nurturing amoebae-like cell known as a Sertoli cell in the lower parts of the seminiferous tubules.
As they mature and move along, they are stored in the upper part of the tubules. Young sperm cells are known as spermatids.
When the sperm has completed the development of its head and tail, they are released from the cell into a microscopic tube called the epididymis. This remarkable C-shaped tube is 1/300 of an inch in diameter, about 20 feet long, and loops within a space one and a half inches long. The sperm's journey through the epididymis takes about three weeks.
The fluid in which the sperm is transported contains sugar in the form of fructose, which provides energy as the sperm matures. In the early stages of its passage, the sperm cannot swim in a straightforward direction and can only vibrate its tail weakly. By the time the sperm reaches the end of the epididymis, however, it is mature and looks like a microscopic squirming tadpole.
At maturity, each healthy sperm consists of a head that contains the man's genetic material, his DNA, and a tail that lashes back and forth at great speed to propel the head forward at about four times its own length every second. The ability of a sperm to move forward rapidly and straight is probably the most significant determinant of male fertility.

Ejaculation. When a man experiences sexual excitement, nerves stimulate the muscles in the epididymis to contract, which forces the sperm out through the penis:

The sperm first pass from the epididymis into one of two rigid and wire-like muscular channels, called the vas deferentia. (A single channel is called a vas deferens .)
Muscle contractions in the vas deferens from sexual activity propels the sperm along past the seminal vesicles, which are clusters of tissue that contribute fluid, called seminal fluid, to the sperm. The vas deferens also collects fluid from the nearby prostate gland . This mixture of various fluids and sperm is the semen.
Each vas deferens then joins together to form the ejaculatory duct. This duct, which now contains the sperm-containing semen passes down through the urethra. (The urethra is the same channel in the penis through which a man urinates, but during orgasm, the prostate closes off the bladder so urine cannot enter the urethra.)
The semen is forced through the urethra during ejaculation, the final stage of orgasm when the sperm is literally thrown out of the penis.

Semen. In addition to providing the fluid that transports the sperm, semen also has other benefits:

It provides a very short-lived alkaline environment to protect sperm from the harsh acidity of the female vagina. (If the sperm do not reach the woman's cervix within several hours, the semen itself becomes toxic to sperm and they die.)
It contains a gelatin-like substance that prevents it from draining from the vagina too quickly.
It contains sugar in the form of fructose to provide instant energy for sperm locomotion.

The Path to the Egg. Usually about 100 to 300 million sperm are delivered into the ejaculate at any given time, but, even under normal conditions, only about 15% are healthy enough to fertilize an egg. After ejaculation only about 400 sperm survive to complete the journey.

A mere 40 or so sperm survive the toxicity of the semen and the hostile environment of the vagina to reach the vicinity of the egg.
Sperm that manage to reach the mucous lining in the woman's cervix (the lower part of her uterus) must survive about four more days to reach the woman's fallopian tubes. (Here, the egg is positioned for fertilization for only 12-hours each month.)
Normally, the cervical mucus forms an impenetrable barrier to sperm. However, when a women ovulates (releases her egg , the oocyte ), the mucous lining thins to allow sperm penetration.
After the few remaining sperm finally penetrate the cervical mucus, they become capacitated.
Capacitation is an explosion of energy that triggers the action of the acrosome, a membrane filled with enzymes, which covers the head of the sperm and resembles a warhead.
As the acrosome dissolves, the enzymes in it allow the sperm to drill a hole through the tough outer coating of the egg (the corona cells and zona pellucida ).
And, in the end, only one gets through to fertilize the egg.

What Is Male Infertility?

Infertility is defined as the failure of a couple to become pregnant after one year of regular, unprotected intercourse. In both men and women the fertility process is complex, and, in many cases, infertility is caused by a combination of problems in both partners that conspire to prevent conception. About 10% to 15% of couples experience some form of infertility, and, in approximately 40% of these cases, male infertility is the major factor. Another 40% of infertility problems are caused by abnormalities of the woman's reproductive system, and the remaining 20% involve couples who both suffer reproductive difficulties.

Infertility affects one in 25 American men. More than 90% of male infertility cases are due to low sperm counts, poor sperm quality, or both. Whether sperm counts are declining overall in industrialized countries is a controversial issue. [ See Box Declining Male Fertility?]

Declining Male Fertility?

Although there have been reports of declining male fertility in the US and in Europe, several recent studies have not found a drop in sperm counts over the past 50 years. A large 2000 study based in Los Angeles, for example, found virtually no change in sperm count from a study conducted in the 1950s. Similarly, a Danish study showed no change in sperm quality in men born between 1950 and 1970.

Some experts suggest that the decline observed in other studies may not have taken into consideration normal sperm fluctuations that can occur from year to year and from season to season. Sperm counts also appear to differ by region.

Temperature and climate, then, may play some role in the differences seen from country to country and from year to year. In one study, Finland had the highest measured sperm count in the world, while Britain's was low. (It should be noted that a more recent study has reported a significant decline in sperm count in Finnish men between 1981 and 1991.) In another study, the sperm count in New York City was much higher than that in Los Angeles.

Note: Many studies are limited, and most rely on data from sperm banks, which also may not reflect the male population as a whole.

How Do Sperm Abnormalities Contribute To Male Infertility?

More than 90% of male infertility cases are due to low sperm counts, poor sperm quality, or both. In 30% to 40% of cases of sperm abnormalities, the cause is unknown. It may be the end result of one or a combination of factors that include chronic illness, malnutrition, genetic defects, structural abnormalities, and environmental factors. Partial obstruction anywhere in the long passages through which sperm pass can reduce their sperm counts. In one study, obstruction was believed to be a contributing factor in over 60% low sperm count cases. Obstruction itself can be caused by many factors. [ See What Are the Causes of Sperm Obstruction in Male Infertility?, Below. ]

General Problems with Sperm Production and Quality

Defining Sperm Abnormalities. Sperm abnormalities are categorized by whether they effect sperm count, sperm quality, or both:

Low sperm count (oligospermia) . Sperm count is less than 10 million sperm/mL of semen. (A normal sperm count is considered to be 20 million/mL.)
No sperm (azoospermia ). Complete failure of the testes to produce any sperm is relatively rare, affecting less than 5% of infertile men.
Low-quality sperm (dysspermia) . Quality is determined by the sperm's motility (it's ability to move) or its morphology (it's shape and structure.) The quality of the sperm is often more significant than the count.
No ejaculated semen (aspermia) .

One study reported the fertilization rates in men with one or more defects (sperm count, motility, or morphology) as follows:

71% for men with a single defect.
50% for a double defect.
39% for triple defects.

Low Sperm Count. Sperm count is now considered to be below normal (oligospermia) if it is less than 10 million/mL. In the past, a sperm count of less than 40 million/mL in the ejaculate was believed to cause infertility. Now, however, if the woman is fertile and young, a count as low as 10 million can often accomplish conception over time, even without treatment. In fertilization clinics, men with low sperm counts report fertilization rates of about 30%, while those with average sperm counts have rates between 60% and 80%.

It should be noted that sperm count varies widely over time and temporary low counts are common. Therefore, a single test that reports a low count may not be a representative result.

Sperm Motility. Sperm motility is the sperm's ability to move. If motility is slow, not straight forward, or both, the sperm have difficulty invading the cervical mucous or penetrating the hard outer shell of the egg. If 60% or more of sperm have normal motility, then the sperm is at least average in quality. If less than 40% of sperm are able to move in a straight line, the condition is considered abnormal. Sperm that move sluggishly may also have other defects that render them incapable of fertilizing the egg.

Sperm Morphology. Morphology refers to the shape and structure of an object. Morphology may be even more important than count or motility in determining potential fertility. Abnormally shaped sperm cannot fertilize an egg. About 60% of the sperm should be normal in size and shape for adequate fertility.

The perfect structure is an oval head and long tail. Abnormally shaped sperm may include a number of variations:

A very large round head. (In one study, if 14% or more of sperm had round enlarged heads, the chances for pregnancy fell to about 20%. Such an abnormality indicates early unraveling of genetic material. In the same study, pregnancy was impaired if 7% or more of sperm had abnormalities in the acrosomes causing them to release enzymes prematurely.)
An extremely small pinpoint head.
A tapered head.
A crooked head.
Two heads.
A tail with kinks and curls.

What Are The Causes Of Male Infertility?

In general, most cases of infertility are due to low sperm count. In general, there are two reasons for low sperm count, abnormalities in production and obstruction of the tubes that carry sperm.

Age

The effect of aging on male fertility is not clear. One study suggested that sperm number and quality do not decline until beyond age 64. One British study has found, however, that as men age, it takes longer for couples to conceive. In the study, the probability of conception taking more than a year doubled from 8% in men under age 25 to 15% in men over 35.

Temporary and Lifestyle Causes of Low Sperm Count

Nearly any major physical or mental stress can temporarily reduce sperm count. Some common conditions that lower sperm count, temporarily in nearly all cases, include the following:

Emotional Stress. Stress may interfere with the hormone GnRH and reduce sperm counts.

Sexual Issues. In less than 1% of males with infertility problems, a problem with sexual intercourse or technique will affect fertility. Impotence, premature ejaculation, dyspareunia (painful intercourse), or psychologic or relationship problems can contribute to infertility, although these conditions are usually very treatable. Lubricants used with condoms, including spermicides, oils, Vaseline, can affect fertility. Astroglide or Replens or mineral oil may not be as harmful to sperm.

Testicular Exposure to Overheating. Overheating (such as from high fever, saunas, and hot tubs) may temporarily lower sperm count. Work exposure to overheating may even impair fertility. One French study suggested that driving for only two hours a day can increase temperature in the scrotum and reduce sperm count. This study was small, and more research is needed. A number of studies have found no negative effects on fertility from wearing tight trousers, briefs, or athletic supports, even every day.

Substance Abuse. Cocaine or heavy marijuana use appears to temporarily reduce the number and quality of sperm by as much as 50%. Sperm actually have receptors for certain compounds in marijuana that resemble natural substances and which may impair the sperm's ability to swim and may also inhibit their ability to penetrate the egg. (Alcohol itself does not appear to affect fertility unless it is so abused that it causes liver changes.)

Smoking. Smoking impairs sperm motility, reduces sperm lifespan, and may cause genetic changes that affect the offspring. Additionally, a 1999 study found that men who smoke have lower sex drives and less frequent sex.

Malnutrition and Nutrient Deficiencies. Deficiencies in certain nutrients, such as vitamin C, selenium, zinc, and folate, may be particular risk factors for infertility in such cases.

Obesity. Some studies, but not all, have found an association between obesity in men and infertility.

Genetic Factors

Specific Genetic Mutations. Genetic defects may contribute to many cases of male infertility. Such mutations may be inherited or caused by environmental assaults.

Much research is now focusing on defective genes on the Y chromosome. (Only men have the Y chromosome; women have two Xs.) Of interest, for example, is a group of deletions in certain regions of the Y chromosome known as AZF, which may prove to be a major genetic cause of severe male infertility.
Some research has reported mutations in testicular genetic material involved with repair of DNA.

Inherited Disorders. Inherited disorders can genetically impair fertility. Examples include the following:

Cystic fibrosis patients often have missing or obstructed vas deferens (the tubes that carry sperm).
Klinefelters syndrome carry two X and one Y chromosomes (the norm is one X and one Y), which causes destruction of the lining of the seminiferous tubules in the testicles during puberty, although most other male physical attributes are unimpaired.
Kartagener's syndrome, a rare disorder that is associated with a reversed position of the major organs, also includes immotile cilia (hair-like cells in lungs and sinuses, which also form the tails of the sperm). Germ cells may also be affected by this condition.

Of some concern is the possibility that the sons will inherit some of these mutations, and that this risk may be higher in men who undergo in vitro fertilization techniques.

Environmental Assaults

Over exposure to environmental assaults (toxins, chemicals, infections) can reduce sperm count either by direct effects on testicular function or on the hormone systems, although the extent of the effect and specific environmental assaults involved are often controversial.

Oxygen-Free Radicals (Oxidants). The primary suspects in the link between environmental assaults and infertility are oxygen-free radicals, also called oxidants. These are unstable particles that are released as the by-product of many natural chemical processes in the body. Infections and environmental assaults can produce high levels of these particles. And, high levels can do harm--even affect the genetic material in cells. Evidence now strongly indicates that they can also damage sperm. Oxidants then may be responsible for infertility associated with chemicals, certain infections, and other environmental assaults.

Exposure to Chemicals. In most cases, avoiding toxic environments can restore sperm count.

Pesticides with estrogen-like effects have the strongest evidence for sperm reduction. Overexposure to estrogen reduces the number of Sertoli cells (the cells necessary for the initial development of sperm). Such pesticides include DDT, aldrin, dieldrin, PCPs, dioxins, and furans. One 1999 study of couples in a fertility clinic reported that when men had a history of moderate or high on-the-job exposure to pesticides their fertility rates were lower than men without such exposures. Although tests of single chemicals containing estrogen have reported little dangers, other studies indicate that exposure to more than one of these chemicals may be very harmful. In addition to the effect on fertility, some researchers believe such overexposure may also contribute to testicular cancers.
Other chemicals are under investigation. In one 2000 study, workers in a rubber factory who were chronically exposed to hydrocarbons (ethylbenzene, benzene, toluene, and xylene) had lower than average sperm count and sperm quality. Another 1999 study suggested that men whose work exposes them to aromatic solvents used in paints, varnishes, glues, and metal degreasers and other products, may be at risk of reduced fertility. Still, not all major work has confirmed the effects of these chemicals and evidence showing any significant effect is weak

Exposure to Heavy Metals. Chronic exposure to heavy metals such as lead, cadmium, or arsenic may affect sperm quality. Trace amounts of these metals in semen seem to inhibit the function of enzymes contained in the acrosome, the membrane that covers the head of the sperm. Radiation Treatment. Radiation treatments and x-rays affect any rapidly dividing cell, so cells that produce sperm are quite sensitive to radiation damage. Cells exposed to significant levels of radiation may take up to two years to resume normal sperm production, and, in severe circumstances, may never recover.

Problems with Semen

A reduced amount of ejaculated semen (less than 0.5 millimeters per sample) may be caused by or a structural abnormality in the tubes transporting the sperm.

Varicocele

A varicocele is a varicose vein of the testicle. (A vein is considered to be varicose when it is abnormally enlarged and twisted.) Varicoceles are found in 15% to 20% of all men and in 25% to 40% of infertile men. It is not clear how they affect fertility, or even it does at all. Some theories for their effect include the following:

Varicocele may partially obstruct the passages through which sperm pass.
The varicocele may produce higher levels of nitric oxide (a substance that causes blood vessels to dilate). Nitric oxide, in turn, has certain damaging effect that might injure sperm.
Varicoceles may block oxygen to the sperm
Varicocele damages testicles over time

It should be noted that some evidence supports the idea that varicoceles play only a very insignificant role in infertility. One small study suggested that infertility and varicocele may actually have a genetic cause that affects both independently. One eight-year study of men with and without varicoceles found no differences in sperm quality or in the ability to conceive.

Testosterone Deficiencies and Hypogonadism

Low levels of testosterone from any cause may result in defective sperm production. Hypogonadism is the general name for severe deficiency in gonadotropin-releasing hormone (GnRH), the primary hormone that signals the process leading to the release of testosterone and other important reproductive.)

Hypogonadism is most often present at the time of birth and is usually the result of genetic diseases affecting the pituitary gland. Such conditions are very rare contributors, but include the following:

Selective deficiency of FSH and LH
Kallman's syndrome
Panhypopituitarism (in which the pituitary gland fails to make almost all hormone

Hypogonadism can develop later in life from other causes:

Tumors of the pituitary gland.
Other brain tumors
Radiation treatments

Autoantibodies

Autoimmunity is a condition in which the antibodies of the immune system attack specific cells in the body, mistaking them for foreign microinvaders. In the case of male infertility, such so-called autoantibodies target the sperm. Antibodies bind to specific parts of the sperm (eg, the head or tail) and cause problems depending on the site of attachment:

Sperm may stick together (agglutinate).
They may fail to interact with cervical mucous.
They may be unable to penetrate the egg.

Some experts believe that in most cases the presence of these antibodies will not prevent conception unless a large percentage of sperm are affected.

Vasectomy and Autoantibodies. Vasectomy, the primary sterility procedure in men, is the most common cause of sperm autoantibodies. Experts believe their typical development is as follows:

Vasectomy works by severing the vas deferens (the sperm-carrying tube).
After vasectomy, sperm continue to be produced but, instead of being confined to the reproductive passages, they leak out into the body.
Here, the immune system may perceive them as foreign invaders and develops antibodies to attack them.
Such antibodies often persist, even if a man restores fertility by a successful reversal procedure (vasovasostomy). Even if the surgery successfully restores sperm flow, however, infertility may persist because of autoantibodies. [ See Vasectomy.]

Other Causes of Autoantibodies. Antibodies to sperm can also appear in men without previous vasectomies and have been reported to be present in 10% of all subfertile men. The causes of antibodies in these cases are usually not known.

Retrograde Ejaculation

Retrograde ejaculation occurs when the muscles of the urethra do not pump properly during orgasm and sperm are forced backward into the bladder instead of forward out of the urethra. This is the consequence of a number of conditions:

Bladder neck or prostate surgery. (These are the most common causes of retrograde ejaculation.)
Diabetes.
Multiple sclerosis.
Spinal cord injury.
A temporary side effect of certain drugs such as tranquilizers or hypertension medication.

Physical or Structural Abnormalities

Any structural abnormalities that affect the testes, tubes, or other reproductive structures can have a severe effect on fertility. Some specific causes of such abnormalities include the following:

Cryptorchidism is a failure of the testes to descend from the abdomen into the scrotum during fetal life. It is associated with mild to severe impaired sperm production. In one study, even one undescended testicle may impair fertility. In cryptorchidism, the testes are exposed to the higher degree of internal body heat, but this may not totally explain the damage in germ-cell production when it occurs.
Some men are born with blockage in the epididymis or ejaculatory ducts, or other problems that later affect fertility. One center reported that 2% of men seeking treatment had no vas deferens.
In the very rare condition, anorchia, a man is born without any testes.
Syringomyelia, a disease of the spinal cord, results in no ejaculate at all (aspermia).
Hypospadias, a birth defect in which the urinary opening is on the underside of the penis, increases the risk for low sperm count later on and if not surgically corrected can prevent sperm from reaching the cervix.

Cancer and its Treatments

Birth rates among cancer survivors are only 40% to 85% of the expected rates. Certain cancers, particularly testicular cancer, impair sperm production, often severely. The major cancer treatments impair both egg and sperm cells. The closer radiation treatments are to reproductive organs, the higher the risk for infertility. Fortunately, while men may fail to produce sperm for as long as five years after radiation therapy, sperm production may eventually recover. Chemotherapy with alkylating agents or other drugs that can harm reproductive function tends to affect fertility more severely in men than in women. New regimens are helping to improve fertility rates.

Infections

There is some controversy over the effect of infections on infertility. Simply detecting the presence of an infection in infertile men does not necessarily mean that it has any relationship to the infertility itself. Some experts believe that the immune response to some infections may release inflammatory factors and oxidants, chemically unstable particles that can damage sperm. The exact effect of this process on sperm is unclear, however. Infections may affect liquifaction of semen and sperm motility, although these are likely to be temporary effects. Among the infections most implicated in infertility are the following:

Sexually Transmitted Diseases. Repeated Chlamydia trachomatis or gonorrhea infections are most often associated with male infertility. Such infections can cause scarring and block sperm passage.
Mycoplasma. Mycoplasma is an infectious organism that appears to fasten itself to sperm cells and render them less motile.
Mumps. Mumps after puberty causes damage to the testicles in 25% of men afflicted with the disease. (Interferon, an anti-viral drug, may help prevent infertility in adult males with active mumps, but the drug is highly toxic and caution is essential.)
Glandular infections in the urinary tract or genitals. Glandular infections that may affect fertility include prostatitis (in the prostate gland), orchitis (in the testicle), inflammation of the seminal vesicles (the glands that produce semen), or urethritis (in the urethra). Such infections, such as prostatitis, appear to alter sperm motility. Even after successful antibiotic treatment, infections in the testes may leave scar tissue that blocks the epididymis.

Other Medical Conditions that Cause Infertility

Other medical conditions that can affect male fertility include any severe injury or major surgery, diabetes, HIV, thyroid disease, Cushing's syndrome, heart attack, liver failure, chronic anemia, or kidney failure.

Medications

The effects of medications on sperm quality and count have not been rigorously studied, and many medicines are commonly prescribed without knowing whether they impair fertility. Anabolic steroids (which are those abused by weight lifters and other athletes) deserve special notice because they are known to severely impair sperm production. Among the other drugs that effect male fertility are cimetidine (Tagamet), sulfasalazine (Azulfidine), salazopyrine, colchicine, methadone, methotrexate (Folex), phenytoin (Dilantin) corticosteroids, spironolactone (Aldactone), and thioridazine (Mellaril), and calcium channel blockers.

What Tests Are Used To Diagnose Male Infertility?

In any fertility work-up, both male and female partners are tested. [For female infertility, See Infertility in Women.]

Fertility History

The patients will provide the physician with a detailed history of any medical or sexual factors that might affect fertility.

Physical Exam

A fertility specialist, usually a urologist, will perform a physical examination:

A physical examination of the scrotum, including the testes, is essential for any male fertility work-up. It is useful for detecting large varicoceles, undescended testes, absence of vas deferens, cysts, or other physical abnormalities. Checking the size is also helpful. Smaller-sized and softer testicles along with tests that show low sperm count are strongly associated with essential problems in sperm production. Normal testicles accompanied by a low-sperm count, however, suggest possible obstruction. The physician may also take the temperature of the scrotum with a test called scrotal thermography.
The physician will also check the prostate gland for abnormalities.
The penis is checked for warts, discharge from the urinary tract, and hypospadias (incorrect location of the urethra opening).

Urine Sample

A urine sample to detect sperm in the urine may rule out or indicate retrograde ejaculation. It also may be used to test for infections.

Semen Analysis

The basic test to evaluate a man's fertility is a semen analysis. The sperm collection test for men who can produce semen involves the following procedures:

A man should abstain from ejaculation for several days before the test because each ejaculation can reduce the number of sperm by as much as a third. (The maximum number of sperm is usually obtained by abstaining for about four days.)
A man collects a sample of his semen in a collection jar during masturbation either at home or at the physician's office. Specially designed condoms may be available that will enable collection of a sample during sexual intercourse. (Regular condoms are not useful, since they often contain substances that kill sperm.)
Proper collection procedure is important, since the highest concentration of sperm is contained in the initial portion of the ejaculate.
The sample should be kept at body temperature and delivered promptly, because if the sperm are not analyzed within two hours or kept reasonably warm, a large proportion may die or lose motility.
A semen analysis should be repeated at least three times over several months.

Both the man and the woman should be present when the physician discusses the result of this analysis so that both partners will understand the implications. The analysis should report any abnormalities in sperm count, motility, and morphology as well as any problem in the semen.

Sperm Count. A low sperm count should not be viewed as a definitive diagnosis of infertility but rather as one indicator of a fertility problem. Counts of less than 20 million per milliliter are currently considered strong indicators of infertility, although pregnancy is sometimes possible even with lower counts if the woman is fertile.

Sperm Motility. At least half of total sperm count and no less than 10 million/mL of the sperm should be motile for normal fertility. Motility (the speed and quality of movement) is graded on a 1 to 4 ranking system.

Grade 1 sperm wriggle sluggishly and make little forward progress. (Sperm that, in fact, clump together may indicate that antibodies to the sperm are present.)
Grade 2 sperm move forward, but they are either very slow or do not move in a straight line.
Grade 3 sperm move in a straight line at a reasonable speed and can home on an egg accurately.
Grade 4 sperm are as accurate as Grade 3 sperm, but move at terrific speed.

Testing for sperm motility may be particularly valuable for predicting the success of artificial insemination and which men might be candidates for the ICSI fertilization technique, in which the sperm is inserted directly into the egg and motility plays almost no role.

Sperm Morphology. Morphology is the structure of the sperm. About 60% of the sperm should be normal in size and shape for adequate fertility. Determining the morphology of the sperm is particularly important for the success of the fertility treatments in vitro fertilization (ART) and intracytoplasmic sperm injection (ICSI).

Seminal Fluid. The seminal fluid (semen) itself is analyzed for abnormalities.

The fluid should be gray colored.

The amount of semen is important. Most men ejaculate 2.5 to 5 cc (1/2 to 1 teaspoon) of semen:

Amounts greater than 1 cc but lower than 2.5 cc may indicate prostate problems or frequent intercourse.
A semen sample that is less than 1 cc could indicate a blockage of the ejaculatory ducts or other tubular abnormalities.
No ejaculate at all may signal retrograde ejaculation.
High amounts of ejaculate may, in some cases, also contribute to infertility.

Sperm will be tested for how liquid it is:

Normal semen is liquefied within 20 minutes by certain enzymes.
Overly sticky fluid suggests problems in the prostate gland (which add fluid to sperm).
Overly watery fluid suggests lack of sperm.

The amount of sugar (fructose) in sperm will be measured.

Since fructose is added to the semen in the epididymis, an absence of fructose indicates that an obstruction has occurred either in the vas deferens or the epididymis.
Conversely, if there is fructose in the semen but no sperm, then the channel from the epididymis is open but there is a defect in sperm production.

Other factors may also be measured in semen.

White blood cell counts are taken to detect infection.
Low levels of inhibin B, which appears to be produced only in the testes, may indicate blockage or abnormalities in the seminiferous tubules.
Low levels of another compound, alpha-glucosidase, indicate blockage in the epididymis.

Hormone Tests

Blood tests are usually taken to determine levels of the hormones testosterone and FSH. Other hormones may also be measured, including LH, estrogen, and prolactin. Low testosterone, FSH, and LH indicate hypogonadotropic hypogonadism. Very high FSH levels may indicated abnormalities in initial sperm production. Normal results, however, do not ensure fertility. For example, germ cells may produce adequate amounts of sperm in response to normal hormone levels, but there may be a defect in sperm maturation or a blockage in the sperm transport system that does not depend on hormones but does reduce the final sperm count. Usually, only if the testicles are very defective will FSH hormone levels rise abnormally.

Fertilization Tests

The Hamster Test. The hamster test, or micro-penetration assay test, uses the sperm sample to fertilize hamster eggs that have had their covering removed to allow penetration. If less than 5% to 20% of the eggs are fertilized, infertility is diagnosed. It may be useful for determining the best assisted reproductive treatment options for men with infertility.

The Human Zona Penetration Test. A newer procedure, the human zona penetration test, uses sperm to fertilize dead human eggs, which are usually obtained from an ovary that was removed for medical purposes. (Like the hamster test, the procedure cannot result in a living embryo.) Researchers hope it will provide the same information as the hamster test and also indicate whether the sperm can penetrate the outer coating of an egg.

Postcoital Test

The postcoital, also known as cervical mucus penetration, test is designed to evaluate the effect of a woman's cervical mucus on a man's sperm. Typically, a woman is asked to come into the physician's office within two to 24 hours after intercourse at mid-cycle (when ovulation should occur). A small sample of her cervical mucus is examined under a microscope. If the physician observes no surviving sperm or no sperm at all, the cervical mucus should then be cultured for the presence of infection. The test cannot evaluate sperm movement from the cervix into the fallopian tubes or the sperm's ability to fertilize an egg.

Sperm Antibodies

If a man has had a vasectomy reversed and still cannot conceive or if semen analysis shows sperm clumping together, blood tests for anti-sperm antibodies will be conducted. The primary negative effect of these antibodies is to bind the sperm to the woman's cervical mucus, preventing the sperm from swimming further up.

Testicle Biopsy

Occasionally, a testicle biopsy may be performed. The standard biopsy procedure requires incisions (called an open approach) under anesthesia. It can be painful afterward. A biopsy is most useful for detecting obstruction in the transport system when sperm production looks normal but the count is low. Biopsies of both testes are more accurate than one. The use of needle aspiration, which is less invasive that standard biopsies, is proving to be as effective in evaluating infertility as the open approach and may also be used to retrieve sperm for assisted reproduction techniques in some cases.

Ultrasound

Ultrasound imaging may be used to accurately determine the size of the testes or to detect cysts, tumors, abnormal blood flow, or varicoceles that are too small for physical detection (although such small veins may have little effect on fertility). It also detects testicular cancer, which some experts believe make it worthwhile as a routine procedure for any male infertility work-up.

What Are The General Guidelines For Treating Male Infertility?

Many men diagnosed as sterile in past years would be considered treatable now, even some men with spinal cord injuries. Unless a man produces no sperm at all, recent developments in treatment have made fertility possible for many men willing to undergo treatment and bear the expense. Before undergoing more advanced procedures, some simple lifestyle changes should be attempted.

Planning Sexual Activity

Timing Sexual Activity for Best Results. Both male and female hormone levels fluctuate according to the time of day and they also vary from day to day and month to month. Here some timing tips that might be helpful:

Male hormone levels along with sexual interest are highest in the morning.
In men, sexual activity (as well as conception) is highest in October.
A woman's sexual peak is usually around the second week of her menstrual cycle. (A menstrual cycle is counted starting from the first day of a woman's period.)
This sexual peak coincides with ovulation. Studies indicate conception is most likely when intercourse occurs during the two days before or on the day of ovulation. (A woman can use a special thermometer to measure her body, or basal, temperature, which also surges at ovulation.)
The question of how often a couple should have intercourse is in debate. Some experts say that having sex more than two days a week adds no benefits. And, in fact, frequent sexual activity lowers sperm count per ejaculation. Some studies have indicated, however, that having intercourse every day or even several times a day, before and during ovulation improves pregnancy rates. Although sperm count per ejaculation is low, a constantly replenished semen supply is more likely to result in a fertilized egg.

Lifestyle Changes

A man who wants to increase his sperm count should also improve his lifestyle:

Avoid cigarettes and any drugs that may affect sperm count or reduce sexual function.
Eat healthy foods low in fat and rich in whole grains, fruits, and vegetables. Be sure the diet has sufficient minerals (zinc and selenium).
One study suggested that fish oil supplements might have some benefits on sperm. Such supplements contain fatty acids that are found in certain oily fish (eg, salmon, tuna, mackerel, sardines). Choosing fish in any case is always a healthy choice.
Overweight men should try to reduce.
Get sufficient rest, and exercise moderately but regularly. (Those who exercise excessively might cut back, but not stop altogether.)
Stress may contribute to reduced sperm quality. It is not known if stress reduction techniques can improve fertility but they may help couples endure the difficult processes involved in fertility.
Although studies now indicate that tight underwear and pants pose no threat to fertility, there is no harm in wearing looser clothing.
To prevent overheating of the testes men should avoid hot baths, showers, and steam rooms.
Because oxidant particles may play a harmful role in infertility, some research has focused on antioxidant supplements. They include vitamins C and E, glutathione, selenium, and coenzyme Q10. Vitamin C may help the body absorb trace elements of zinc, copper, magnesium, potassium, and calcium, which improve the vitality and longevity of the sperm. In one study, vitamin E improved fertility in men who had normal sperm count but evidence of excess free-oxygen radicals. (One 1999 study reported, however, that taking high doses of vitamin C, E, or a combination of the two had no effect on fertility in men with defective sperm.)

Choosing a Fertility Clinic

Choosing a good fertility clinic is important. The government does not always regulate centers offering assisted reproductive techniques, and abuses have been reported, including lack of informed consent, unauthorized use of embryos, and failure to routinely screen donors for disease.

The clinic should always provide the following information:

The live-birth rate (not just pregnancy success rate) for other couples with similar infertility problems. (Multiple births, such as twins or triplets, are counted as one live birth.)
Such statistics should include high-risk women, such as those who are older or fail to produce eggs. (Some disreputable clinics give success percentages that exclude high-risk women from their total, thereby making the percentage of success much higher.)

Advanced fertility procedures and medications are extremely expensive and often not covered by insurance. Warning: Couples should be cautious about offers of rebates in the event of failure; the clinics offering them are often significantly more expensive than those that don't. [For more information, see Infertility in Women.]

Planning for Stress and Depression

The fertility process is a roller coaster of emotions, present throughout both failure and success. There are almost no sure ways to predict which couples will eventually conceive. Some couples with multiple problems will overcome great odds, while other, seemingly fertile couples fail to conceive. Many of the new treatments are remarkable, but a live birth is never guaranteed. The emotional burden on the couple is considerable and some planning is helpful:

Decide in advance how many and what kind of procedures will be emotionally and financially acceptable and attempt to determine a final limit. Fertility treatments are expensive and often not covered by insurance, and a successful pregnancy often depends on repeated attempts. (Some couples become addicted to treatment, and continue with fertility procedures until they are emotionally and financially drained.)
Determine alternatives (adoption, donor sperm or egg, or having no children) as early as possible in the fertility process. This can reduce anxiety during treatments and feelings of hopelessness in case conception does not occur.

Locate support groups or counseling services for help before and after treatment to help endure the process and ease the grief should treatment fail.

It should be noted that in one 1999 study male infertility caused higher levels of stress and social concerns in both partners than female infertility.

What Are Artificial Insemination And Assisted Reproductive Technologies?

Artificial Insemination

Artificial insemination (AI) places sperm directly in the cervix (called intracervical insemination) or uterus (called intrauterine insemination or IUI). It is useful under the following circumstances:

When the cervical mucus is unreceptive.
When donor sperm are required.
When the male partner's semen contains very low numbers of sperm.
When unexplained infertility exists in both partners.

A review of 45 studies reported that in unexplained infertility cases, the per-cycle pregnancy rates were 4% for intrauterine insemination (IUI) alone and 8% and 17% per cycle for IUI combined with superovulation. Since AI is less expensive and poses less risk for multiple births than the more advanced techniques using assisted reproductive technologies (ART), many experts recommend trying several AI cycles first. [See below.] A recent study has suggested that although ART is more effective per cycle, couples are more likely to repeat AI more often, so the pregnancy rates over time are very similar.

The AI procedure is as follows:

A woman usually (but not always) takes fertility drugs in advance.
The man must produce sperm at the time the woman is ovulating.
The sperm are subjected to certain so-called “washing” procedures. [See Box Preparing Sperm for IUI and ART, below.]
The sperm are then inserted into the uterine cavity through a long, thin catheter.

Assisted Reproductive Technologies: General Guidelines and Success Rates

Assisted reproductive technologies (ART) are procedures that either use donated eggs or employ techniques that retrieve eggs from the ovary and reimplant them. Fertilization may occur either in the laboratory or in the uterus. A total of 71,826 ART cycles were carried out in 1997. The live birth per egg-retrieval was 27%. The procedures and their 1997 success rates based on per egg retrieval are as follows:

In vitro fertilization (IVF). (IVF is the most common procedure). Success rates 27.7%.
Gamete intrafallopian transfer (GIFT). Success rates are 29.8%.
Zygote intrafallopian transfer (ZIFT). Success rates are 28%.
Additionally, in 1997 14% of ART cycles used frozen fertilized eggs (embryos), live birth rates were 16.8%.

It is important to factor in some additional information when assessing these success rates:

GIFT and ZIFT are more invasive than IVF and may not be useful for many women with tubal obstruction.
The statistics are based on live birth per successful egg retrieval. (About 14% of cycles are canceled before egg retrieval.)
Statistics are also based on women between the ages of 30 and 39, not in older women, whose chances are smaller (about 10% after age 40).
70% of all ART cycles do not produce pregnancy, and even women who do become pregnant often require more than one fertility cycle.
One 2000 study suggested that African American women have significantly lower success rates than Caucasian women.
A woman who uses her own eggs has a better chance for success than with donor eggs. Older women are more likely to use donor eggs, but success rates depend on the age of the donor, not the age of the recipient. In fact, when donor eggs are from women under 35, live birth rates are 30% and over.
Chances for success are also greater among women who do not have uterine abnormalities and have had previous successful pregnancies.

In Vitro Fertilization

About 71% of ART procedures use in vitro fertilization (IVF) with the woman's own eggs. An in vitro procedure is one that is performed in the laboratory. The best candidates for IVF are women with damaged fallopian tubes, and some experts believe it is a better option than attempting surgical repair. IVF is also used when infertility is unexplained or when the male partner has the infertility problem. An typical IVF procedure is as follows:

The physician first induces superovulation using fertility drugs so that several eggs can be harvested from the ovary before they have been released from the follicles. Some women prefer to try a natural cycle, which produces only one egg but has a lower success rate. Higher doses of fertility drugs for subsequent cycles do not appear to add any advantage in women who have a poor response the first time.
To harvest eggs, the physician generally uses a probe inserted into the vagina and guided by ultrasound. A needle is then used to drain the liquid from the follicles, and several eggs are retrieved.
The eggs and sperm are combined in a petri dish. Between 48 to 72 hours later the eggs are usually fertilized.
The resulting embryos (the first stage toward the development of the fetus) are reimplanted into the woman's uterus. (Thinning the membrane of the fertilized egg before implanting (assisted hatching) may increase egg implantation rates in certain women, such as those over age 40.)
It takes about two weeks to determine if the process is successful.

IVF success rates for the first three cycles of treatment are about equal. They then decline modestly for the fourth cycle and drop significantly after the fifth cycle.

Gamete/Zygote Intrafallopian Transfer

Gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT) are adaptations of IVF. GIFT and ZIFT are used in unexplained infertility and in mild male infertility. The success rates are similar to those of IVF, but a woman must have at least one functioning fallopian tube.

GIFT: The procedure is as follows:

The eggs are harvested as in IVF.
They are mixed with the sperm but not fertilized.
They are immediately injected back into the woman. Laparoscopy is used with this procedure to guide the placement of the embryos or egg through a long, thin catheter into the fallopian tubes.
The sperm and egg are placed exactly where they would be in natural fertilization.

ZIFT: The procedure is as follows.

The eggs are harvested as in IVF.
They are then mixed with the sperm, and in this case are fertilized in the laboratory.
They are then implanted in the fallopian tubes as in GIFT. (The advantage of this procedure over GIFT is that the physician and couple are assured that fertilization has taken place and the eggs can be examined for defects before implantation.)

Blastocyst Transfer

A new IVF technique known as blastocyst transfer is very promising. Instead of implanting two- or three-day old embryos in the uterus, the procedure implants blastocysts, embryos that are about five days old and so more complex. In one study, 40% of women achieved pregnancy (although use of this procedure is in early stages.) In addition, fewer blastocysts are implanted than embryos, resulting in fewer multiple births.

Intracytoplasmic Sperm Injection

Intracytoplasmic sperm injection (ICSI) is one of a highly sophisticated group of techniques referred to as micromanipulation. ICSI injects one single sperm into an egg using microscopic instruments. It is used for couples who have failed IVF or when the man has severe infertility problems. It is proving to be effective even in some severe female fertility cases, and pregnancy rates are now equivalent to other ART techniques. The procedure itself is deceptively simple.

A tiny glass tube (called a holding pipet) stabilizes the egg.
A second glass tube (called the injection pipet) is employed to penetrate the egg's membrane and deposit a single sperm into the egg.
The egg is released into a drop of culture medium.
If fertilized, the egg is allowed to develop for one or two days and then is either frozen or implanted.

The greatest concern with this procedure, if it is successful, is the risk of passing on any male genetic defects that caused infertility in the first place to the offspring. Research is ongoing. [See What Are the Complications of Assisted Reproductive Technologies?, below.]

Other Experimental ART Procedures. New techniques involving micromanipulation of sperm are being developed for the one-third of infertile men who have severely low sperm counts, a high percentage of abnormal sperm, tubular obstruction, or no vas deferens.

An experimental technique called FASIAR (follicle aspiration, sperm injection, and assisted follicular rupture) may prove to be a significantly less expensive treatment and also reduce the risk of multiple births. After ovulation induction, the physician punctures the follicle and retrieves the eggs and fluid in a syringe that also contains sperm. The mixture is then reinjected near the ruptured follicle. The procedure can be done in the physician's office.
Procedures called round spermatic nuclear injection (ROSNI) and elongated spermatid injection (ELSI) use immature sperm aspirated from the testes and inject it into the egg using ICSI. The sperm can either be fresh or frozen. This procedure is being investigated for very severe male infertility, but there appear to be some significant risks for birth defects from these procedures.
Some centers are developing IVF techniques that allow a longer time for the embryo to develop in the laboratory (five days instead of two to three). This enables the embryo to reach the blastocyst stage, which is the natural embryonic stage for implantation in the uterus.

Sperm Retrieval and Preparation for IUI and ART

Before fertilization using IUI or ART can take place, the sperm must be collected and prepared for optimal chances for success. Sperm can be fresh or frozen in advance. Studies are reporting that frozen sperm provide excellent results and can be used confidently for fertilization procedures. A number of methods have been devised for this.

Retrieval Procedures. When a man has no available sperm in the ejaculate (usually from blockage, vasectomy, or lack of vas deferens), the sperm must be retrieved from the testes or the epididymis. Various microsurgical techniques are no available for retrieval.

Percutaneous Epididymal Sperm Aspiration (PESA). PESA uses a needle to obtain mature sperm from areas in the upper parts of the epididymis (the coiled tube where sperm are stored before ejaculation). PESA is useful in men with tubular obstruction and even in those with no vas deferens.
Microepididymal Sperm Aspiration (MESA). MESA uses microsurgical techniques to collect sperm that are close to blocked portions of the epididymis.
Testicular Sperm Extraction (TESE). TESA removes a small amount of tissue from the testes under local anesthesia. (One study suggested that the best results for ICSI were obtained using sperm from the testes.)

Sperm Washing. A sperm's energy output is twenty times greater once it is removed from the seminal fluid, so researchers have devised methods for washing sperm that have a dramatic effect on the ability of sperm to move towards the egg. The simplest method involves the following:

The sperm is mixed with nutrient fluid or culture media in a test tube.
They are then centrifuged (spun very rapidly) for about five minutes.
The heavy sperm settle on the bottom, forming a dense button of millions of pure sperm. The fluid left on top is siphoned off.
This procedure may be repeated again.

This simple method of sperm washing, however, does not eliminate heavy debris, such as dead sperm, white blood cells, or bacteria.

Swim-Up Technique. The swim-up technique is not only a useful diagnostic procedure for testing the ability of sperm to escape from the semen into the cervical mucus but it also achieves the goal of removing sperm from semen.

A specially prepared semen sample is placed in a tube.
A culture media (a substance in which organisms can multiply) is placed on top of the sample.
The medium is a hospitable environment for sperm, and those that are healthy will swim up to it.
After an hour or more, the culture is examined, and the number of sperm that have reached the medium is compared to the number still remaining in the semen.

The result gives a fair estimation of the number of sperm potentially capable of fertilization. It is superior to sperm washing because the live sperm will swim up to the culture media leaving behind most of the debris, although some may float up into the medium. The strongest sperm, which are those at the top of the medium, can be collected for in vitro fertilization or artificial insemination. A good swim test yields about 1/2 million very active sperm.

What Are The Complications Of Assisted Reproductive Technologies?

Multiple Births

Since ART procedures have become more widespread since the 1980s, multiple births have significantly increased. About 38% of all ART births are multiple ones, with 5.8% being triplets or more.

Complications from Multiple Births. The risk for birth defects in babies born with ART procedures is, according to one study, over 5%. Studies indicated, however, that higher risk is due to multiple births or the age of the mother, not the procedure itself. The effects of multiple births on children are considerable:

Higher rates of caesarean sections.
Low birth weight.
Higher mortality rates (13 times that of single births).
Higher risks for later lung and heart problems.
Higher risk for mental retardation or learning disabilities.

Limiting Birth Numbers. Given these hazards, the mother must make some hard decision if the treatment produces multiple embryos. Once a mother knows she has multiple embryos, her choices are limited:

Carry all them to term, which increases health risks for both her and the developing fetuses.
Complete abortion.
Embryo reduction, in which the physician removes one or more embryos (possibly endangering the remaining embryos).

At this time, the best approach is to limit the number of implanted embryos in the first place. Experts are attempting to develop methods to reduce the risk for multiple births:

Most centers now implant two to three embryos at a time, and the remainder can be frozen for future use. (To date, frozen eggs do not appear to pose a risk for developmental problems in children conceived using them, but follow-up studies are needed.) This limits the chance for success, but implanting more than three implants only increases success rates very slightly but the risk for multiple births increases significantly.
Reducing the dosage of fertility drugs also reduces the risk for multiple births, but, not significantly and it too reduces the chance for successful outcome.
Blastocyst transfer may help reduce the chances for multiple births. [ See above. ]

Risks to the Woman

Risks from ART Procedures. In one study of women who conceived only one child, the only risks that IVF posed for a mother were a higher rate of urinary tract infections before delivery and a much higher rate of cesarean sections (41.9% for IVF vs. 15.5% for natural conceptions). It should be noted that infertile women in general have a poorer than average chance for full-term pregnancies regardless of whether they conceive spontaneously or with fertility treatments. In women using donor sperm from sperm banks, rare cases of AIDS, hepatitis, and other sexually transmitted diseases from infected sperm have been reported. Semen should be acquired only from a sperm bank licensed by either the state health department or the American Association of Tissue Banks.

Risks from Fertility Drugs. There has been concern about an increased risk for ovarian and breast cancers in women taking fertility drugs, particularly clomiphene and human menopausal gonadotropins. One puzzling study reported that women who had only one or two cycles of clomiphene had a higher risk for breast cancer, but there was no increased risk in women who had greater exposures to the agent, suggesting the drug may actually be protective. Another reported a temporary increase in risk for breast cancer. In general, however, a growing body of evidence is finding no higher risk from the drugs themselves, but is suggesting, instead, that these cancers are actually most likely due to the same factors contributing to the infertility.

Risk for Birth Defects and Developmental Issues in Children

Although, in general, analyses of studies indicate that there is no higher risk for birth defects with ART procedures, long-term studies are needed on the newer procedures.

To date, frozen eggs do not appear to pose a risk for developmental problems in children conceived using them, but follow-up studies are needed.
Of concern are studies indicating that men with low or non-existent sperm counts due to genetic factors and who conceive using ICSI are at risk of transmitting these same genetic defects to their offspring. In one study, three men who conceived using ICSI passed their genetic defects in the Y chromosome on to each of their sons. There is also a slightly higher risk for a structural, but surgically correctable, defect called hypospadias, in which the urinary outlet is located on the underside of the penis rather than at the tip.

What Are Other Male Fertility Treatments For Special Conditions?

Hormones and Other Drugs

Hormonal Treatments. Hormone therapy has been effective for women with infertility problems but has been disappointing in men except in a few specific cases:

Gonadotropin-releasing hormone (GnRH) is beneficial for men with gonadotropin deficiency and hypogonadism.
GnRH may be useful for restoring sperm production after chemotherapy treatments.
Sperm production occasionally responds to low doses of estrogen and testosterone or testosterone alone, menotropins (Pergonal, Repronal), clomiphene citrate (Clomid), human chorionic gonadotropin (hCG), or human follicle stimulating hormone (r-hFSH).
Prolonged treatment with follicle-stimulating hormone (FSH) prior to ICSI may improve implantation rates.

Bromocriptine. Bromocriptine (Parlodel) is used in men whose infertility is related to excess prolactin manufactured by the pituitary.

Antibiotics. Infections are treated with antibiotics.

Antihistamines. One interesting study reported that the agent ebastine improved sperm quality and pregnancy rates. Ebastine is an antihistamine used overseas for hay fever and other seasonal allergies. The drug blocks mast cells, inflammatory immune factors that also may play a role in lower sperm quality. Similar antihistamines in the US are fexofenadine (Allegra), loratidine (Claritin), and cetirizine (Zyrtec), although there is no evidence these drugs have any effect on fertility.

Varicocele Repair

Varicocelectomy. Repair of a varicocele (varicocelectomy) in men with infertility problems is a common surgical practice. The procedure involves tying off the swollen and twisted veins. Recovery takes six days and most men cannot resume full activity for about three weeks. Recent techniques use tiny incisions (less than an inch) and have quicker recovery, although the procedure itself takes longer.

Varicocele Embolization. A nonsurgical technique called varicocele embolization may eventually prove to be an effective and less painful treatment for varicoceles. It involves inserting a narrow tube through a small incision in the neck or leg. Tiny steel plugs are passed through the catheter that block off the affected veins. It takes 15 to 45 minutes under local anesthetic.

Effects of Varicocele on Male Fertility. Studies are conflicted over whether repair of varicoceles actually improves fertility in many men. One small 1998 study reported that counseling was as effective as varicocele repair in achieving pregnancies. (The study did not describe how severe the varicoceles were, however.) Some experts believe that surgery may be useful in some younger men to prevent progression. The procedure does not appear to be at all beneficial for improving fertility in men whose varicoceles are very small (grade 1). In another study varicocele repair restored some sperm in men with abnormal sperm production, but assisted reproductive technologies were still needed to achieve pregnancy after repair.

Miscellaneous Surgical Procedures

Obstructions in the area of the ejaculatory ducts have been successfully treated by excising or scraping the area where the prostate gland surrounds the urethra. Undescended testicles of young boys may be repositioned surgically to prevent later infertility. It is important to perform the operation before age two to prevent the destruction of most of the sperm-producing cells, which occurs if the testicles remain in the abdomen.

Treatment for Retrograde Ejaculation and Failure of Emission

Men with retrograde ejaculation and failure of emission caused by surgery, severe disease, or spinal cord injury are treated with various methods.

Drugs known as alpha-adrenergic agonists, including phenylpropralamide, ephedrine, and pseudoephedrine, stimulate muscle contraction and help ejaculation.
If they are not effective, electrovibration (or electrical stimulation) is often beneficial, even in men with spinal cord injuries.
The tricylclic antidepressant imipramine (Tofranil) is often beneficial for some men with retrograde ejaculation after surgical procedures.
Retrograde ejaculation can also be managed by first having the man take sodium bicarbonate four times a day to reduce the acidity of the urine. After ejaculation, the man urinates or has a catheter (a tube) inserted to withdraw urine, which is then submitted for washing techniques to separate out the sperm.

With any of these methods, the sperm can be collected for intrauterine insemination or assisted reproductive techniques. Spontaneous conception is possible, but not common, even with these treatments.

Techniques for Men with Spinal Cord Injury

Procedures that assist ejaculation are helping men with spinal cord injury conceive children. Ejaculation was achieved in all men in one study group with the use of vibratory or electronic stimulation. The sperm was then inserted into the women using self-insemination, IUI, IVI, or ICSI. Nearly a third of the couples achieved pregnancy, a success rate that approaches natural conception.

Vasectomy Reversal (Vasovasostomy)

Vasovasostomy. For men who wish to conceive after vasectomy, reversal surgery (vasovasostomy) may restore fertility. In vasovasostomy the severed ends of the vas deferens (which were cut during vasectomy) are reconnected to reestablish the flow of sperm. The reversal procedure is difficult; it involves sewing together the two ends of both tubes, each with pinhead sized openings.

Pregnancy Rates after Vasovasostomy. Pregnancy rates of over 50% have been reported after a vasovasostomy. One study reported that when successful conception occurs, it does at an average of one year after the surgery.

A successful reversal is more likely if the following conditions are present:

The section removed during vasectomy was not long.
The original procedure was performed on straight sections of the vas deferens.
The pieces joined during the vasovasostomy are of equal size.
The closer in time the vasovasostomy is to the original vasectomy the better. (In one large study, the pregnancy rates were 76% for those who had vasectomy less than three years before reversal surgery decreasing to 30% for those with vasectomy more than 15 years prior. The lower rates as time goes by are probably due to increasing chance for obstruction of the epididymis and the development of antisperm antibodies.)

Reversal versus ART. Vasovasostomy is still a better choice than ART, even with the newer techniques such as ICSI . In one study the pregnancy rate for vasovasostomy was 52% while success after an ICSI technique was under 25%. In addition, a vasovasostomy does not pose a risk for multiple births. A 2000 study concluded that vasovasostomy was even a more cost-effective way to achieve fertility in men with partners above 37 years of age. Even for men who have failed vasovasostomy, a repeat procedure appears to be less expensive than embarking on fertility treatments at that time. (ART may be the best approach at this time for men with evidence of antisperm autoantibodies due to vasectomy.) [For more information see Vasectomy.]

Treating Antisperm Autoantibodies

ART is the best approach at this time for men with evidence of antisperm autoantibodies due to vasectomy or other causes. High doses of corticosteroids may be useful in conjunction with intrauterine insemination. Their effectiveness, however, is not proven and they have potentially serious side effects with prolonged use. Interesting research is testing a factor called fertilization antigen (FA-1), which may be able to remove autoantibodies from the sperm surface. Some experts believe, however, that immune factors are not significant in causing infertility, and that many men can still conceive despite antibodies to their sperm.

Where Else Can Help Be Obtained For Male Infertility?

RESOLVE, Inc., 1310 Broadway, Somerville, MA 02144. Call (617-623-0744) or on the Internet (http://www.resolve.org)
This is the best support association for infertility. It provides names of fertility specialists and local associations. Its newsletters are excellent, and back issues are available. In addition to providing the latest in-depth information on important clinical and adoption issues, many articles deal with the difficult emotional problems confronting infertile couples. They have recently added a web site that is an invaluable resource for people with access to the Internet.

American Society for Reproductive Medicine (Formerly the American Fertility Society), 1209 Montgomery Highway, Birmingham, AL 35216-2809. Call (205-978-5000) or on the Internet (http://www.asrm.com/)
This organization provides useful information, including their Clinic Specific Annual Report . This valuable report gives the success rates of treatment for fertility centers around the country. They also publish the professional journal Fertility and Sterility and other publications for consumers.

Fertility Research Foundation, 877 Park Avenue, New York, NY 10021. Call (212-744-5500)
Foundation offers information on treatment, latest research on male and female infertility.

American Foundation for Urologic Disease, 1128 North Charles Street, Baltimore, MD 21201. Call (800-242-2383) or (410 468-1800) or on the Internet (http://www.afud.org/)

American Urological Association (AUA) or on the Internet (http://www.auanet.org/) and its journal (http://www.jurology.com/)

American Association of Clinical Endocrinologists, 701 Fiske Street, Suite 100, Jacksonville FL 32204. Call (904-353 7878) or on the Internet (http://aace.com)
The association provides names of local endocrinologists.
Find a Fertility Specialist at http://www.asrm.org/search/providersearch.html

Find a Urologist at http://www.auanet.org/patient_info/find_urologist/index.cfm
Very good sites on infertiliy

http://www.urologychannel.com/

http://www.maleinfertility.org/

http://www.conceivingconcepts.com/

http://www.americaninfertility.org/