Male Infertility

What is Male Infertility?

Infertility is generally described as a couple’s inability to get pregnant after trying for at least one year without using any form of birth control. This problem affects around 15% of couples in the US and about 180 million couples around the world. Specifically, male infertility is when a man cannot get a woman pregnant despite having regular unprotected sex for at least a year. Males are the main cause of infertility in about 20% of cases, and contribute to another 30% to 40% of cases.

It’s often the case that both the male and female may have issues causing infertility, so it’s important to investigate and manage both partners together. When you look at the bigger picture, the male’s role can contribute to about half of all infertility cases.

There are many causes for male infertility, some of which can be fixed, while others can’t. Some other factors affecting both partners may include age, medicine use, past surgeries, exposure to harmful chemicals in the environment, genetic issues, and health diseases. The primary reason for checking a male for infertility is to find out what’s causing it, treat any conditions that can be reversed, see if the male can take part in assisted reproductive strategies (technology used to achieve pregnancy), and provide support for unchangeable and untreatable conditions.

A small percentage, about 6% of men tested for infertility, might have a more serious hidden medical problem, such as cancer. This adds another reason to do a thorough check-up of the male partners in couples who are struggling to get pregnant, so any major health issues can be detected and treated correctly.

What Causes Male Infertility?

There are several reasons why a man might have trouble fathering a child, which can be grouped into general categories. These include hormone disorders (generally due to low testosterone), which account for 2% to 5% of cases, problems with sperm transportation (like having a vasectomy) at 5%, primary testicle problems (which include abnormal sperm without any clear cause) at 65% to 80%, and unexplained infertility (where a man has normal sperm and semen but still can’t conceive) at 10% to 20%.

Please bear in mind that these percentages are rough estimates, as exact numbers aren’t available due to underreporting and regional differences. Patients referred to a specialist clinic are more likely to have their condition recorded, while patients who are privately treated might never have their data collected.

Let’s look at specific causes:

– Acquired abnormalities in the urinary and genital area like bilateral obstruction or blocking of the vas deferens, removal of both testicles, inflammation of the epididymis, varicoceles, and retrograde ejaculation.
– Congenital abnormalities in the urinary and genital area include dysfunctional or blocked epididymis, congenital abnormalities of the vas deferens, undescended testes, and ejaculatory duct disorders like cysts.

– Hormonal causes: congenital lack of Gonadotropin-releasing hormone (GnRH, a hormone controlling sexual development), Prader-Willi syndrome, Laurence-Moon-Beidl syndrome, iron overload syndrome, familial cerebellar ataxia, head trauma, radiation to the brain, and excessive thyroid hormone.
– Harmful substances in the environment like pesticides, smoking, heavy drinking, and other chemicals.

– Genetic causes: mutations in the CFTR gene associated with cystic fibrosis, Kallmann syndrome, Klinefelter syndrome, Young syndrome, and certain chromosomal anomalies and gene deficiencies.
– Idiopathic causes: unexplained male infertility where semen parameters are all normal, but the male remains infertile.
– Immune disorders: inflammation of the pituitary gland caused by immune cells, hemosiderosis, hemochromatosis, sarcoidosis, tuberculosis, and fungal infections.

– Cancer: certain brain masses, tumors in the pituitary gland, craniopharyngiomas, and their associated treatments, as well as testicular and adrenal tumors that produce excessive male hormones.
– Medications or drugs: cannabinoid and opioid use, psychotropic drugs that can inhibit GnRH, misuse of testosterone or steroids, glucocorticoids, and certain medications used for cancer treatments or enlarged prostate. A full list can be found at https://reprotox.org.
– Sexual dysfunction: premature ejaculation, inability to ejaculate, infrequent sex, and erectile dysfunction.
– Genitourinary tract infections: Gonorrhea, chlamydia, syphilis, recurrent genitourinary infections, inflammation of the prostate, and recurrent inflammation of the prostate and seminal vesicles.

Can these fertility issues be corrected or assisted? Well, about 18% of male infertility cases are treatable. These include blockages, hormone deficiencies, sexual function disorders, allergic reactions to sperm, varicoceles, and reversible effects of toxins.

Up to 70% of cases, however, can’t be corrected but some measure of fertility might be retained – though assisted reproductive technology (ART) like in-vitro fertilization can often help. These cases include: low sperm count, abnormal sperm movement, abnormal sperm shape, and normal sperm with functional defects.

Finally, so-called untreatable male sterility is seen in 12% of cases. These include primary failure of the tubules in the testes where sperm are produced, a condition where only Sertoli cells exist in the testes but no germ cells which develop into sperm, and removal of both testes.

Risk Factors and Frequency for Male Infertility

Infertility is a problem for many couples worldwide, with differing rates in developing and developed countries. It’s harder to tackle this issue in developing countries due to limited healthcare resources, high treatment costs, and cultural barriers. About 13% to 15% of couples globally face infertility issues, and in the U.S., about half of healthy young couples who aren’t able to conceive in the first year will most likely do so in the next year without any specific treatment. Infertility can be due to the man alone in 20% to 30% of cases.

Figuring out the exact rate of male infertility is difficult because it’s not a reportable disease and often treated privately. Therefore, statistics about male infertility treatments don’t often appear in medical insurance data. Additionally, male infertility treatments are mainly carried out in outpatient settings and thus aren’t typically included in large clinical databases.

• In general, male factor infertility can range from 2.5% to 12%.
• North America sees a male infertility rate of between 4.5% to 6%, while in Australia it’s around 9% and 8% to 12% in Eastern Europe.
• Research indicates that male factors cause about 25.6% of infertility cases. It’s estimated at 20% in France and much higher in Nigeria at 42.4%.

Generally, it’s believed that one-sixth of all couples worldwide suffer from infertility, with male factor infertility playing a significant role in about half of these cases and being the sole cause in 20% to 30% of cases.

Worryingly, over the past few decades, there’s been a global reduction in sperm counts. The average sperm count in the 1940s was 113 million/mL, but dropped to 66 million/mL in the 1990s. This decline continued and even accelerated after the year 2000. Several factors could contribute to this, including environmental toxins and variations in laboratory techniques.

Men with fertility issues often have other health problems as well. There’s a higher risk of testicular cancer in infertile men who also have abnormal semen parameters, with the highest risk in men with no sperm present (azoospermia). Men with azoospermia have a higher overall risk of cancer and a higher mortality rate as well compared to men with normal sperm counts.

COVID-19 appears to cause reduced fertility, and even infertility, in some recovered males, particularly if the infection was severe. It seems that the virus damages the testes directly or through various side effects caused by treatments. More research is needed to gain a better understanding of infertility related to COVID-19.

Signs and Symptoms of Male Infertility

When looking into the reasons causing a couples infertility, it is equally important to check the man’s fertility health as well. There are several objectives of testing the male such as;

• Identifying if the man is contributing to the fertility problem
• Finding out if his fertility issues could be improved with treatment (applies to about 20% of cases)
• Checking whether Assisted Reproductive Technology (ART) would be helpful for the couple
• Identifying any serious health issues or conditions that could be affecting his fertility
• Finding out if factors like age, lifestyle choices, or genetic issues could affect the success of ART if used

The fertility checkup starts with a detailed interview to collect data about the man’s health history, lifestyle choices, past injuries, and other factors that could affect his fertility. This could include things like drink or drug usage, having sexually transmitted diseases, or previous radiation treatment. After the interview, the man’s bodily symptoms are checked for anything abnormal, such as wounds, hormone imbalances, or testicular issues. The man’s sperm is also checked for any irregularities.

People who used to use testosterone supplements, or those who were found to have any abnormalities during the checkup, are referred directly to a fertility specialist. This is because solving male fertility problems is a complex process and must be managed well.

During the physical checkup, potential signs of hormone imbalances are checked. Hormone imbalances could be indicated by various bodily qualities such as a body type, signs of possible gynecomastia, an unusual pattern of body hair, or abnormal secondary sexual characteristics. Low sperm count along with a muscular appearance could signify the misuse of substances that increase body mass, such as testosterone. Being overweight is also associated with a decrease in testosterone as it is converted into estrogen in the body’s peripheries.

The examination further includes checking the penis for conditions like hypospadias, phimosis, and Peyronie plaques, while the testicles are inspected for their size, for example, in a normal full-grown man, they should at least be a size of around 15 ml or greater than 4 cm in length. The absence of vas deferens or presence of diseases such as Hydrocele, gonad failure in childhood or puberty, or testicular failures are acknowledged. These conditions can lead to a reduced sexual desire, infertility, impotence, and lack of secondary sexual features.

After inspecting for symptoms of vein enlargement in the scrotum, it is found that it could significantly affect fertility and can be treated. These are generally found on the left side due to the bodily structure of the man but if found on the right side, there may be unusual reasons for it, such as a kidney tumor. Nevertheless, an enlarged vein on the right side is not always a confirmation of such a severe condition. Imaging is hit upon if the enlarged vein on the right side of the scrotum is not able to be minimized, appears suddenly, or is noticeably large.

Absence of vas deferens, which makes up almost 1-2% of all male infertility cases, is linked to mutations in the CFTR gene. In this case, both partners should get a gene check. Upon detection of a positive result, genetic counseling becomes crucial before any procedures like ART, IVF, or ICSI are performed.

If a man has a hump of fatty tissue below the neck area and between the shoulder blades along with a rounded face, thin skin with multiple bruises, and stretch marks, it might suggest Cushing’s disease. Similarly, if a man has widespread hyperpigmentation, it might indicate an overload of iron in the body.

A patient with nil sperm count and with bilateral atrophic testes may only expect good results from the treatment through IVF and ICSI.

Testing for Male Infertility

The main way doctors check for male infertility is through a semen analysis. Ideally, two different samples should be taken, roughly one week to a month apart. The man should refrain from sexual activity for roughly three days before each sample is taken. This is because semen can vary a lot, and these measures help doctors get a more accurate picture.

Semen tests can be very helpful in figuring out the cause and severity of male infertility. The woman’s fertility, as well as whether the man has been unable to father a child ever (primary infertility) or just after previously being able to (secondary infertility), also matter a lot.

The World Health Organization has specific instructions for collecting semen. Home sperm tests are available these days, but they’re not strongly recommended as they don’t always provide accurate and full information.

When the man provides his semen sample, he needs to follow instructions well. Semen can be collected through masturbation or using a special condom that doesn’t contain harmful chemicals. Ideally, the semen is collected at the doctor’s office, but it can be done at home too. In that case, the sample needs to be kept at room temperature and taken to the laboratory quickly. The sample must be examined within an hour of collection.

The semen then gets evaluated in the lab by different parameters. These include the volume of semen, its acidity (pH), the number of white blood cells present, if there are any immature sperm cells, and how quickly it turns from a gel-like substance into a liquid (liquefaction). The sperm itself is assessed for its number, concentration in the semen, vitality (percentage of live sperm), ability to move effectively, presence of debris, and the shape and structure (morphology).

Doctors follow specific guidelines when evaluating the semen analysis results, which help them identify potential issues that could be causing male infertility.

Besides semen analysis, other tests may be carried out. These include checks for antisperm antibodies, genetic screening for chromosomal defects more common in infertile men, DNA integrity tests to check if the sperm DNA is fragmented, and hormonal tests to determine if hormonal disorders are contributing to infertility.

In summary, semen analysis is a key test in investigating male infertility, providing valuable insights into the

Treatment Options for Male Infertility

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What else can Male Infertility be?

There are various conditions and disorders that can lead to male infertility. These include a wide range of issues, from hormonal disorders to lifestyle factors. Here’s a list of some potential causes of male infertility:

• Adult growth hormone deficiency
• 5-Alpha reductase deficiency
• Androgen receptor gene changes
• Twin conditions of testicle twisting
• Sterilization surgery for men
• Brain damage due to tumors or injury
• Celiac disease (related to hormone resistance)
• Chemotherapy
• Chromosome abnormalities
• Adrenal gland disorder present at birth
• Cryptorchidism (undescended testicles)
• Cushing disease
• Cystic fibrosis
• Down syndrome
• Medication side effects
• Blockage of the tubes that carry sperm
• Too much estrogen
• Disorders related to follicle-stimulating hormone
• Hemochromatosis (too much iron in the body)
• HIV infections
• Certain types of cancer, such as Hodgkin lymphoma
• Hypogonadism (low function of the testicles)
• Issues related to the pituitary gland
• Kallmann syndrome (a genetic condition)
• Kartagener syndrome (a rare disease affecting the lungs and sinuses)

The list extended to include other conditions and lifestyle issues:

• Lead exposure
• Liver failure
• Marijuana use
• Obesity
• Opioid abuse
• Exposure to chemicals and pesticides
• Previous surgery involving the prostate or pelvis
• Exposure to radiation
• Recurrent urinary tract infections
• Renal failure
• Sarcoidosis (clumps of inflammatory cells in the body)
• Testicular tumors
• Sickle cell anemia
• Smoking
• Spinal cord injury
• Sexually transmitted diseases
• Testicular cancers
• Testicular trauma
• Use of testosterone supplements
• Thyroid disorders
• Tuberculosis
• Infections or injury to the urethra
• Varicoceles (swelling of the veins that drain the testicle)
• Young syndrome (a rare disorder affecting the lungs and reproductive system)

What to expect with Male Infertility

The chances of a man overcoming infertility depend on the underlying cause of the issue. Therefore, it’s necessary to perform suitable medical tests, which should be decided based on the individual’s situation. It’s crucial to have an open discussion with the patient about these tests, as they may have financial and emotional impacts. After this, the best approach for treatment can be selected, which may include counseling, surgery, or assisted reproductive technologies.

It’s important to note that the quality of a man’s sperm can decrease as he gets older. This could lead to an increase in defective sperm and chromosomal abnormalities, as well as higher chances of birth defects in future children. These risks exist separately from other potential factors that could affect fertility.

Possible Complications When Diagnosed with Male Infertility

Complications from infertility stem from a variety of sources. These include emotional distress, stress, and marital problems. Financial strain is also a significant issue since families often struggle with the high costs of infertility evaluations and treatments in the U.S. It’s important to note that these medical procedures don’t always guarantee success. Moreover, most insurance companies don’t typically cover these expenses. Surgical procedures necessary for infertility treatment can also lead to further complications.

Common Complications:

• Emotional distress
• Stress
• Marital issues
• Financial difficulties due to high treatment costs
• Uncertainty and frustration due to no guaranteed success
• Lack of insurance coverage
• Potential complications from necessary surgical procedures

Preventing Male Infertility

Preventing and treating male infertility often involves education about lifestyle choices and potential environmental factors. Doctors can help men understand what actions they can take to protect their fertility, such as maintaining a healthy lifestyle. Suggestions might include stopping smoking and cannabis use, maintaining a healthy weight, or cutting back on alcohol. Some people worry that vaccines can cause infertility, but according to the Centers for Disease Control (CDC), there’s no evidence that any vaccines, including the COVID-19 Vaccines, could harm your fertility.

It’s also important for men to know how important it is to get their fertility checked sooner rather than later if they suspect an issue. This early intervention can help them avoid potential future problems. Patient education also tackles myths about male infertility, reducing the stigma and encouraging more men to seek help. The more men understand about their fertility, the better they’re able to take the right steps to protect it. This proactive approach is key in fertility and reproductive health.