Likelihood of Occurrence
A male factor is involved in 60% infertility cases. Forty percent are primarily male and 20% are combined male and female. Thus, when a couple is having trouble conceiving, it makes sense to evaluate the man as well as the woman. It is recommended that a comprehensive and accurate semen analysis be scheduled at the outset to evaluate the male partner before scheduling expensive and invasive tests for the female.
Varicoceles are dilated veins in the scrotum, causing a negative effect on sperm production. Varicoceles are extremely common. Approximately 40% of men with infertility will have varicoceles. Interestingly, 80% of men with secondary infertility (they are not able to initiate an additional pregnancy) will have varicoceles. Varicoceles may be easily corrected through outpatient surgery performed by a male infertility specialist. This is done with a local and sedation, through a small incision where the pubic hair is (so no muscle is involved), and with the use of an operating microscope. Multiple studies have shown that this technique causes more improvement, and leads to significantly fewer complications and much less post operative pain.
Seminal Fluid Abnormalities
If the seminal fluid is very thick, it may be difficult for the sperm to move into the woman’s reproductive tract. Often, in cases of seminal fluid abnormalities, the sperm can be placed directly inside the uterus with intrauterine insemination (IUI).
Ductal System Problems
Ducts that carry sperm may be missing or blocked. In some situations, the ducts may be repaired or unblocked. If this is not possible, the sperm may be harvested and then injected directly into a woman’s eggs.
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. 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.
Impotence: Difficulties with Erections and Ejaculations
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.
This generally refers to the inability of the sperm-producing part of the testicles to make adequate numbers of mature sperm. The testicle may completely lack the cells that divide to become sperm, sperm may be made in low numbers or there may be an inability of the sperm to complete their development. 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 with advanced reproductive techniques.
When a baby boy is born without the testes having fully descended into the scrotum, the condition is known as cryptorchidism. 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 may be a cause of testicular failure. Fifty per cent of men who have both testes undescended at birth, will have no sperm in the ejaculate even if they were surgically brought down.
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: Nitrofurantoin, 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
The testicles are stimulated to make sperm by pituitary hormones. If these are absent or severely decreased, the testes will not maximally produce sperm. Importantly, men who take androgens (steroids) for body building 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 Prostate Protocol testes and may reveal situations where hormonal treatment is indicated.
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 of the sperm ducts.
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 are seen in a semen specimen, a general genital culture should be done as well as cultures for commonly asymptomatic, sexually-transmitted diseases including mycoplasma, ureaplasma, and chlamydia.
Men whose total number of moving sperm in the ejaculate (calculated by multiplying the volume of the ejaculate, by the concentration of sperm, by the percent that are moving) of less than 5 million must have genetic testing done. Sometimes, this production of low numbers of sperm is the result of genetic abnormalities that could have significant implications for children.