Male Infertility
Medically reviewed by Norbert Gleicher, MD, FACOG, FACS - Written by CHR Staff - Updated on Nov 15, 2014
What Is Male Infertility?
Male infertility refers to the inability of a male to contribute to conception with a fertile female. With modern treatment tools, in a large majority of cases, men with male infertility can become fathers.
Among couples with infertility, approximately 55% have a female problem, about 45% have a male factor infertility and a full quarter (25%) have issues on both sides. Therefore, the ability to evaluate and treat female and male infertility adequately in parallel is crucial for modern infertility care. At CHR, about 20% of the couples have male factor infertility (or a combination of male and female factors).
Whatever the severity of male infertility, CHR has the knowledge and experience to help at least 90% of affected men to become the genetic fathers of their children. We work closely with prominent urologists in cases requiring special male infertility expertise. Furthermore, with our special expertise in complex cases of female infertility, including premature ovarian aging and diminished ovarian reserve, CHR is a one-stop infertility center for female as well as male infertility.
"CHR has the knowledge and experience to help at least 90% of affected men to become the genetic fathers of their children."
Get the facts about male infertility
Norbert Gleicher, MD, FACOG, FACS
Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.
Causes
There are a number of causes for male infertility, but they all affect quantity and/or quality of sperm. These causes include:
- The sperm's exit route is blocked (from birth, by scarring from infection, past vasectomy, etc.)
- Retrograde ejaculate (semen is ejaculated backwards, into the bladder)
- Sperm production in the testes is low or absent (there can be many causes for this finding)
Low sperm count
Low sperm count, also called oligospermia, is the most common cause of male infertility. Complete lack of sperm, called azoospermia, is much less common, affecting less than 1% of the population. Low sperm count is diagnosed when the number of sperm falls below 20 million in a milliliter of semen. (Normal range is between 20 million and 120 million per milliliter of semen.) When sperm count is too low, sperm has a much lower chance of reaching and fertilizing the egg, leading to infertility.
As the list above shows, many possible causes of low sperm count exist. Some are structural: even when sperm is produced normally in the testes, an obstruction in the ejaculation tract may block the sperm. Other causes include hormonal insufficiency, testicular injuries and chromosomal/genetic abnormalities (such as Klinefelter syndrome). In addition, vasectomy can be considered a cause of male infertility, if the male partner changes his mind about having children after having had a vasectomy.
One of the most common factors leading to decreased sperm count is varicocele. This is when the veins in the scrotum (the skin "sack" that contains the testicles) are dilated on one or both sides. This heats the inside of the scrotum excessively and may affect sperm production. Other factors can also include a blockage in a man's reproductive system, retrograde ejaculate and certain medications.
Azoospermia
Azoospermia is a condition in which the man has no sperm in the ejaculate. Families often assume that a diagnosis of azoospermia rules out the possibility of having a child. However, with the treatments available today, that is not necessary the case. There are now methods that can harvest even small amounts of sperm that are produced in the testes as a result of interventions, and CHR’s affiliate urologists can perform these micro-surgeries to help azoospermic men become fathers.
Get the facts about male infertility
Norbert Gleicher, MD, FACOG, FACS
Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.
Diagnosis
When pregnancy does not occur after more than a year of unprotected intercourse in women under age 38 and within six months at older ages, a couple should see a fertility specialist. As a part of an initial infertility diagnostic workup, the fertility specialist often orders a semen analysis. Semen analysis tests quantity and quality of sperm. A complete semen analysis involves the assessment of many different parameters, but only three are really important:
Parameters | Normal Findings |
| At least 50% of sperm should "swim" in more or less straight line. Sperm that "moves" well is more likely to reach the egg. |
| At least 15% of the sperm should have a normal shape and structure, with an oval-shaped head. Abnormally shaped sperm is less likely to be able to fertilize an egg. |
| Sperm count should be above 20 million in a milliliter of sperm. Complete semen sample should have at least 40 million sperm. |
When any one or more factors are "abnormal," male infertility may be diagnosed. Here is the real truth, however: Nobody really cares very much about what sperm counts, morphology and motility results really are. What we are really after is to find out how well sperm "functions." And sperm has only one biological function, which is to penetrate the wall of the egg (called zona pellucida), and to fertilize the egg. These factors are only approximations of that one crucial function of the sperm.
Unfortunately, we have no reliable test to determine how well sperm does in this function (as it would not be very ethical to test sperm against someone's eggs). We, therefore, do the next best thing: we test sperm function indirectly via a semen analysis. If sperm count, motility and morphology are all normal, then, with over 99 percent likelihood, the sperm's function will be normal as well, and if one or more parameters are abnormal, one can assume a fertilization problem exists. The severity of the fertilization problem is usually considered proportionate to the severity of observed abnormalities in the semen analysis.
Get the facts about male infertility
Norbert Gleicher, MD, FACOG, FACS
Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.
Treatment
Treatment approaches for male infertility varies greatly, depending on the severity of the sperm problem. In mild cases, artificial insemination (or intrauterine insemination, IUI) may be enough. In an IUI cycle to address male infertility, semen sample is prepared and concentrated in the laboratory before it is injected directly into the uterus. Higher concentration and direct injection alone can sometimes overcome male infertility.
In more severe cases, in vitro fertilization (IVF) may be the best option. IVF for male infertility allows performance of intracytoplasmic sperm injection (ICSI), which virtually guarantees fertilization, even with very poor sperm (for further details on ICSI, see below).
In most severe cases of male infertility in which sperm is completely absent (azoospermia), we are successful in retrieving very small amounts of sperm directly from the man's testicles, in approximately 85% of cases. At CHR, this procedure is performed by highly specialized urology colleagues with special expertise in these procedures. The small amounts of sperm, obtained either by testicular sperm extraction (TESE) or testicular biopsy, can then be used in ICSI to fertilize the woman's eggs in an IVF cycle.
ICSI for Male Infertility
ICSI is a microsurgical procedure, in which an embryologist selects the best sperm from a prepared sample and injects it directly into an egg. This micromanipulation of eggs and sperm ensures the mechanical fertilization of one egg by one
sperm. ICSI has revolutionized the treatment of male infertility, making it possible for a vast majority of males, even with very severe male factor infertility, to become genetic fathers of their children.
In the picture on the left, the egg is held in place with a micropipette while an embryologist inserts a tiny needle containing a sperm into the egg. The sperm is released into the egg for fertilization. ICSI is a way to “visualize” the fertilization process and make sure that fertilization actually occurs. Since with ICSI we can now achieve fertilization for practically almost any male as long as he has even only a handful of sperm, there is really no longer any reason to try mostly ineffective treatment options for male infertility.
Surgery: Not Recommended to Treat Male Infertility
Some of our urology colleagues at times recommend (micro-)surgery to treat male infertility deriving from structural problems. The two most common indications for surgical treatments are the presence of the so-called varicoceles and obstruction of semen outflow due to an earlier vasectomy.
Varicoceles are dilated veins in the scrotum, which may raise the temperature inside the scrotum, which negatively affects sperm production. In varicocelectomy, a surgical approach to varicoceles, these dilated veins are ligated in order to lower the temperature within the scrotum and restore normal sperm production.
In a vasectomy reversal, a surgical approach to reverse past vasectomy, the surgeon tries to reconnect the interrupted duct (vas deferens) that carries sperm from the testes. The aim of vasectomy reversal is to restore the passageway for sperm out of the testes so the sperm can make their way into the ejaculate.
Our urology colleagues sometimes disagree with us, the fertility specialists, about when these surgeries may be the best option. Vasectomy reversals, in our opinion, are effective in only lf 50% of cases at best. While some urology colleagues claim higher success rates, we actually have doubts about even this 50% number. We are even more skeptical about varicocelectomies. At our fertility center, we very rarely see a varicocelectomy turning an infertile male into a fertile male, who can father a child “the natural way.” A vast majority of men, even after a varicocelectomy, still need IVF+ICSI to father a child.
And that is the principal reason why we, on occasion, disagree with our urology colleagues on when to perform surgery for male infertility. For our urology colleagues, the question is whether surgeries improve the sperm parameters of the male. If they do achieve a better sperm analysis by surgery, they consider this a success. However, for us, the fertility specialists, improvement in semen analysis parameters is not enough. For us, a successful male infertility surgery is one that converts a couple from needing IVF+ICSI to being able to conceive spontaneously, on their own. Unfortunately, the number of surgeries that do this in cases of male infertility is rather small.
Comprehensive Treatment
Given the proportion of infertile couples with issues on both male and female, the ability to treat female and male infertility in parallel is essential for modern infertility care.
Whatever the severity of male infertility, CHR has the knowledge and experience to help at least 90% of affected males to become the genetic fathers of their children. Furthermore, with our special expertise in complex cases of female infertility, including premature ovarian aging and diminished ovarian reserve, CHR is a one-stop infertility center for female as well as male infertility.
Get the facts about male infertility
Norbert Gleicher, MD, FACOG, FACS
Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.