How does the doctor evaluate an infertile male?

At the doctor’s office, the couple should be evaluated as a single unit. The husband is asked about his age, duration of marriage and any history of previous children fathered. Husband is also asked about his past medical/ surgical history, occupational history and about any difficulty in intercourse. Social habits like smoking, tobacco use and alcohol are of importance. This is followed by a complete examination of the husband.

 

Diagnostic tests for male infertility.

The doctor may request routine blood and urine tests. Specific tests include semen analysis and ultrasound.

Semen analysis: what is it?

This is the commonest specific test for male infertility and is hence discussed in detail here.

A semen analysis is used to check the quality and quantity of sperms in semen. The sample is ideally collected at the doctor’s clinic or laboratory. If sample is collected at home, it should reach the laboratory in less than 30 minutes. The doctor then studies this sample under a microscope and runs several other tests on it.

 

What a semen analysis can detect?

Few of the conditions detected in semen analysis are as follows:

Azoospermia- No sperms are detected.

Oligospermia- Fewer than normal sperms are detected.

Problems with sperm motility- If sperms are not moving normally, they are less capable of fertilizing the wife’s eggs.

Problems with sperm morphology: Abnormalities in sperm shape and size can cause infertility.

Presence of pus cells: This suggests the presence of infection.

The above conditions can help the clinician narrow down the probable cause of infertility and help plan the treatment.

Causes of male infertility

There are various causes for male infertility. Discussing every cause in depth is beyond the scope of this article. Here, we will discuss only a broad outline of the causes.

Birth defects:

One of the commonest birth defects causing infertility is called undescended testes. In this condition, the testes do not complete the journey from the abdomen to the scrotal sac and the testes may be found at various levels of descent. The hormonal levels of these individuals remain unaffected but sperm production function is markedly depressed.

Thermal (heat related) causes:

The scrotal temperature is raised in conditions like vericocele, big hydrocele or filariasis. Other causes include using tight undergarments or working in hot environments. In most of these conditions, the sperm producing function is temporarily decreased and may recover by proper therapy.

Infections:

Several infections target the male reproductive system. Some infections may cause permanent damage, while others cause temporary damage.

Hormonal causes:

Hormonal problems may affect thyroid and pituitary glands. This may secondarily affect testicular function leading to low counts.

Genetic:

Some genetic abnormalities may cause low or absent sperm count. This condition is permanent and cannot be cured.

Immunological causes:

In this condition, the body produces antibodies (substances that protect the body against infections) against its own sperms and these antibodies attack and disable the sperms causing low sperm count and low motility.

Obstruction of efferent ducts:

Efferent ducts are small microscopic pipes that transport the sperms from testes (place of production) to penis (place of ejaculation). These ducts may be obstructed due to birth defects, due to infections, or due to surgery near the male reproductive system.

Other factors:

Often diabetes and hypertension (high blood pressure) complicate male infertility. Several antihypertensive and antipsychotic medications have a negative impact on sperm production. Other factors like radiation exposure, physical damage and pollution can affect sperm parameters. Habits like alcohol and tobacco in any form depress the sperm production.

Penile disorders:

Conditions like erectile dysfunction and premature, retrograde or absence of ejaculation can cause infertility. There may be an abnormality in the shape and structure of the penis.

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Treatments used to achieve pregnancy:

Intra uterine insemination

Intrauterine insemination (IUI) is a procedure that involves placing sperm inside a woman’s uterus to facilitate fertilization. This is usually the first line of therapy in male infertility. The goal of IUI is to increase the number of sperm that reach the fallopian tubes and subsequently increase the chance of fertilization. Sperm sample is washed and prepared in the clinical laboratory allowing the separation and concentration of motile spermatozoa in relatively small volumes. Therefore, physicians/gynecologists deliver high numbers of spermatozoa into the woman’s uterine cavity by using an IUI catheter. This procedure in combination with ovulation induction has further increased the chance of achieving a pregnancy.

Varicocele:

This is a common condition detected in almost 30 to 40% of males having infertility. Varicoceles are enlarged varicose veins that develop in the scrotum that prevent smooth and normal blood flow. This abnormal blood flow causes the scrotal temperature to increase (heat up). Sperm production is depressed by this heated temperature. Varicoceles are more common in the left side than the right. Most men with vericocele do not have any symptoms or may complain rarely of scrotal pain. Ultrasound with Colour Doppler is the best method for diagnosis of this condition and also helps in grading the severity.

Varicoceles associated with infertility need to be treated immediately by surgery. The main aim of this surgery is to tie the abnormal blood vessels so that the abnormal blood flow is stopped. This surgery is relatively pain free and is usually done under day care (same day discharge). As per statistics, varicocele repair has a variable success rate. The success depends on proper case selection and surgical method used.

Male infertility


Most people still think of infertility as a “woman’s problem”. Almost 30% of infertile couples have problems only with the male partner. Infertility in a man may be the sole reason that a couple cannot conceive, or it may simply add to the difficulties caused by infertility in the woman (mixed infertility).


It is also important that men get tested for fertility as well as women. In infertility evaluation, a couple constitutes a biological unit and therefore, investigations of both partners individually and collectively is essential to plan a rational approach to treatment. This also ensures couple counseling and improves success rates.


In my routine medical practice, I commonly see women coming for consultation without their husbands or husbands not willing to be tested. Early and thorough testing of the husband can spare their partners a great deal of unnecessary discomfort, expense and time.

Role of ultrasound in male infertility:

Ultrasound is useful to examine the anatomy of the testes and other scrotal contents. One of the commonest conditions detected after ultrasound is varicocele. The Doppler ultrasound helps to understand the severity of vericocele and helps in planning further treatment.

 

Treatment of male infertility:

The specific treatment depends on the cause detected during the investigation process.

  • The general treatment consists of supplementing the diet with specific vitamins and antioxidants which are known to improve sperm function.
  • Sexually transmitted diseases and other male reproductive system infections require specific medical therapy.
  • Diabetes and hypertension requires to be controlled and if possible with sperm-friendly medications.
  • Obstructions, birth defects or physical damage needs to be corrected by surgery. Some of these surgeries are complex.
  • Erectile dysfunction, retrograde or premature ejaculation usually has underlying causes. Correction of the underlying cause needs to be done.
  • Genetic diseases: These conditions have a poor prognosis and fewer treatment modalities that can help.
  • Hormonal problems: These need to be corrected and are usually reversible.

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In vitro fertilization (IVF):

This is commonly called test tube baby treatment. This is one of the major treatments of infertility and is done when other treatments have failed. This treatment is also used as a first line treatment in extremely low sperm count or poor morphology. IVF is a process by which an egg is fertilized by sperm outside the body. This fertilized egg is further matured to form an embryo (an early development stage of baby). This embryo is transferred into the woman’s uterus.

Donor insemination:

This treatment involves IUI with sperms provided by a sperm bank. This is done with informed consent of the couple and is completely legal. This treatment is usually done in cases where no sperms are found in the semen. This treatment is also done in case of extremely low sperm counts if the couple cannot afford IVF. This is a cost effective alternative that has completed many families.