Many causes of male infertility are due to spermatogenesis failure; some are medically treatable.

While the urologist and andrologist are the doctors to see for male infertility, the comprehensive evaluation and treatment require coordination between a family physician, an endocrinologist, and an andrologist experienced in diagnosing and managing male infertility.

Team working is the best way to deal with infertility couples. The physician leader (possibly the urologist or andrologist the couple sees first) should refer patients to a geneticist and the endocrinologist, the gynecologist, as required. When the couple requires intrauterine insemination, in vitro fertilization, and ICSI, the urologist or andrologist refers the patient to qualified fertility centers.

Psychological distress in the couple should prompt adequate psychological support, especially if we diagnose genetic abnormalities.

No Treatment

If left untreated, some infertile couples can still start a pregnancy. 23% of untreated infertile couples may conceive after two years, up to 33% after four years. Even in men with severe oligozoospermia (<2 million sperm/mL), 7.6% of these untreated male infertility patients can produce a pregnancy within two years.

Lifestyle Changes

Couples should be advised on healthy lifestyles, particularly male infertile patients:

• stopping smoking;
• limiting or eliminating alcohol intake;
• adopting a more nutritious diet;
• weight loss measures if obese;
• increased exercise;
• avoiding potentially toxic artificial lubricants during sexual activity;
• reducing stress;
• eliminating illegal and recreational drug use (such as marijuana);
• minimizing prescription drugs;
• preventing exposure to pesticides and heavy metals (such as lead, mercury, boron, and cadmium);
• eliminating any unnecessary chemical exposures;
• Fish oil supplements in the diet have been suggested as helpful in male fertility.
• Underweight is also a possible risk factor for male infertility.

We recommend using boxers instead of briefs to avoid alterations in the testis temperature of a testis too close to the body. While avoiding hot baths, saunas, and tight-fitting underwear has not been conclusively demonstrated to improve male fertility, discussing these suggestions with patients is not unreasonable. 

Medications to improve the production of sperm (spermatogenesis)

• Clomiphene is an anti-estrogen and, in small doses, can stimulate sperm production, making it potentially useful in idiopathic cases of male infertility;
• Tamoxifen may enhance the benefit of anti-estrogens;
• Gonadotropin therapy in selected patients.
• We can use low-dose nasal testosterone gel that has minimal effect on semen quality and may help pales with low libido associated with infertility;
• Aromatase inhibitors like Letrozole can improve semen parameters.
• L-Carnitine and antioxidants: they may reduce the effects of oxidative stress on semen and sperm and would seem an appropriate male infertility therapy.

Overall, few data support definitively recommending any of these therapies. Still, offering one or more of them to a couple for consideration may be reasonable. Every practitioner must decide whether to provide these tempting but unproven remedies. However, the physician must consider not denying a simple, harmless, inexpensive potential therapy to a desperate infertile couple, even if its clinical efficacy is unclear.

Treatment of underlying sexual disorders

Twice a week is the expected frequency of sexual intercourse in a couple during the most fertile period. We can treat with oral medications the erectile dysfunction. Premature ejaculation is highly treatable with behavioral, psychological (sex therapy), and pharmacological interventions.

Ejaculatory Duct Cyst Puncture or Resection

Midline prostatic and ejaculatory duct cysts are present in 10% of all infertile men. Such cysts should be suspected when the ejaculate volume is low, when semen analysis detects azoospermia or severe oligozoospermia, when the hormonal screening is normal, the patient has typical secondary sexual characteristics and dilated seminal vesicles on transrectal ultrasound examinations. It’s been suggested that the cysts must be >0.017 mL in size to be clinically significant. We consider transurethral resection the most definitive therapy for this condition. Improvement in semen analysis is generally seen in about 50% of treated infertile men; about half of these will eventually produce a pregnancy.

Varicocelectomy

We recommend varicocele repair in infertile men with abnormal semen parameters and large, clinical grade 3 varicoceles. Essentially, these are the varicoceles that are clinically apparent on physical examination. Varicocele repair is also reasonable if the varicocele causes symptoms with or without infertility. According to most experts, men with infertility and small varicoceles that are not palpable on physical examination are not likely to benefit from varicocelectomy. Overall, varicocelectomy is expected to improve semen parameters in 60% to 70% of patients. We do not recommend Varicocele surgery in men with extremely low sperm counts with bilateral small testes. These features suggest extensive testicular germ cell damage making it unlikely that these men will improve fertility.

Sometimes, subclinical, smaller, lower-grade varicoceles may impact semen characteristics based on testicular size and intratesticular hemodynamics rather than varicocele size, palpability, or vein diameter. Among men with subclinical varicoceles, those with infertility were more likely to have bilateral disease and lower average testicular volumes.

Transurethral Resection of the Ejaculatory Ducts

Patients with obstruction of the ejaculatory duct may benefit from transurethral resection.

Vasovasostomy and Vasoepididymostomy

These are advanced microsurgical procedures performed on men with obstructive azoospermia due to bilateral epididymal or vas deferens obstruction. This is observed obviously in patients who had bilateral vasectomy surgery. Still, in others, obstructive azoospermia is suggested by finding no sperm in the semen together with the average testicular size and hormone levels. The use of surgical microscopes has dramatically increased the success rates of these procedures. However, even after successful surgery, some men will remain infertile.

Intrauterine Insemination (IUI)

We collect sperm, and we artificially instill them into the fertile uterus. The success rate is about 12% per attempt, which decreases as more attempts are made. Pregnancy rates increase to about 40% – 50% after nine attempts. In most unexplained or mild male factor infertility cases, three to four attempts are often recommended before resorting to IVF.

In Vitro Fertilization (IVF) and Intracytoplasmic Sperm Injection (ICSI)

In case of intrauterine insemination failure, in women over 40, or where general conditions preclude using more straightforward techniques such as bilateral tubal disorders, we can refer patients to IVF. With IVF, we fertilize the female egg outside of her body. About 100,000 sperm are added to each egg in a particular medium. Pregnancy rate results are reported at 10% to 45%.

The ultimate assisted reproductive technique currently available, ICSI, is like the IVF described above but involves using a micro-injection of a single sperm directly into an egg surgically extracted from the female partner. After fertilization, we implant the eggs into the uterus. The overall fertilization rate of ICSI is about 60%.

Complications of male infertility

Complications are typically due to psychological distress, stress, and issues with the marital relationship. Evaluating and treating infertility can be expensive and frustrating when unsuccessful. Moreover, insurance companies do not cover this condition. There is also the possible chance for complications related to surgical procedures.