Mediclinic Al Sufouh

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Male infertility

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Infertility is a disease that may affect males, females, or both making the couple unable to conceive even after a year of frequent unprotected intercourse. Statistically, compared to the past decades, infertility is becoming more and more common, affecting approximately 15 percent of all couples in the United States and at least 180 million people worldwide. Male fertility has multiple causes, reversible and irreversible conditions, and might be idiopathic (without reasons apparently) or secondary (caused by some underlying disease). The primary purpose of evaluating male infertility is to determine its odds and influencing factors, provide treatment for reversible infertility, assess its suitability for assisted reproductive technology, and provide counseling for irreversible and untreatable conditions. In rare cases, more severe diseases may cause infertility. It is another reason for thoroughly evaluating both men and women of infertile couples so that all significant underlying conditions are identified and treated.

Table of Contents

What is Male infertility?

We define male infertility as the inability of a female to get pregnant because of male factors. Male infertility factor means that the male may have some disease or condition, making the semen unable to induce pregnancy in the female partner. We can distinguish different situations:

  • Male sterility: in 12% of infertile men, we cannot detect any sperm cells in the semen analysis; this situation is almost always not reversible, and assisted reproductive technologies are not applicable;
  • Male infertility with reversible semen abnormalities occurs in 18% of infertile male cases; the treatment of male conditions leading to infertility makes natural induction of pregnancy possible;
  • Male infertility with not reversible semen abnormalities occurs in 70% of infertile male cases; the conditions leading to infertility are not curable, and the only possible treatment is artificial fertilization.

Why male infertility occurs: causes of male infertility

Testicles produce the sperms through a maturation process that starts from a staminal cell (immature basal cell) and ends up with a mature cell called sperm. The sperm cell can move and carry its DNA through the female genital tract until entering the oocyte and starting the pregnancy.

For this sperm journey to be effective and end up with a pregnancy:

  • The basal cells reservoir must be represented; in some cases, the male is sterile because there are not even germline cells (12% of male infertility factor);
  • The DNA of the basal cells must be intact without damage; so the immature cells can start the maturation process;
  • The maturation process, called spermatogenesis, must be smooth and not affected by hormone misbalance or by a variety of substances or agents which can prevent the regular maturation of sperm;
  • Sperms must have a regular shape and effective forward movement;
  • Sperms must survive at least 24-48 hours in the female genital tract.

Any factor that can interfere with the presence and maturation of the sperms, the reaching, and penetration into the egg cell, will cause male infertility. However, not only semen abnormality may cause infertility. Other male infertility factors include the inability to ejaculate into the vagina because of erectile dysfunction or ejaculatory disorders. To simplify the causes of male infertility, we can distinguish the following:

Pre-testicular causes: that prevent the anatomically intact testicle from producing normal sperms or the efficient sperm release in the vagina; would include:

Testicular disorders: testicular damage can eliminate the basal stem cells or cause sperm maturation failure:

  • Infections like tuberculosis and viral mumps orchitis;
  • testicular tumors;
  • orchiectomy, the surgical removal of the testis;
  • complex genetic syndromes like Klinefelter; in these cases, male infertility may run in families;
  • Cryptorchidism and atrophic testicles;
  • Varicocele is associated with male infertility, most likely due to impaired testicular thermoregulation due to disruption of the thermoregulatory mechanisms of the testicular venous plexus;
  • Epididymis dysfunction can be caused by in-utero exposure of the fetus to estrogen, various drugs, and chemical toxins;
  • Cysts of the epididymis or spermatocele, spermatogonia with or without surgery;
  • epididymitis;
  • idiopathic: the testicle is damaged without apparent causes.

Post-testicular causes: when even normal sperms cannot proceed through the male and female genital tract to reach the egg cell; would include

Infertility is Idiopathic when it is unexplained, and the causes are unknown. The testes are normal and produce normal sperm, but the male remains infertile (in 10-20% of male infertility cases). Idiopathic unexplained infertility may run in the family as well.

The pre-testicular, testicular, and post-testicular causes can also combine to explain other possible secondary causes of male infertility:

  • advanced paternal age;
  • the decline of semen quality;
  • lifestyle factors (sedentary lifestyle, obesity, cell phone use, stress, alcohol use, smoking, unhealthy diet).

Male Infertility diagnosis

Urologists and andrologists can evaluate and treat male patients with infertility. The goals of assessing the male partner of a couple with infertility are to:

  1. determine if the male factor is causing the infertility problem;
  2. identify a small proportion of cases (approximately 20%) that can return to normal with treatment;
  3. determine if assisted reproductive technology (ART) will benefit the couple.

The medical history

During the initial medical interview, important information is gathered to help determine the potential reasons for infertility.

  • reproductive history: if the patient has already induced pregnancies in the past with another female partner may be helpful to rule out reversible and not reversible causes of infertility;
  • family history: in some cases, male infertility runs in families; it may give insights into the possible genetic cause of infertility;
  • major trauma to the pelvis, testicles, or head may result in damage to the testicles and the organs controlling the testicular function;
  • sexual performance and libido: they may impact the ability to have regular sexual intercourses;
  • occupation, exposure to toxic chemicals such as pesticides: can affect testicular function and spermatogenesis;
  • systemic illnesses: can have a combined impact on spermatogenesis through direct or indirect testicular damage; chronic renal failure has been associated with low testicular function; sickle cell disease can cause intratesticular ischemia.,
  • alcohol use and smoking: have proven impact on spermatogenesis;
  • recreational drugs, medications, and steroid abuse may heavily impact sperm maturation;
  • previous chemotherapy/radiation therapy: it may destroy the germline stem cells or produce genetically abnormal sperm cells;
  • testicular descent: an undescended testicle, whether unilateral or bilateral, can affect male fertility even when surgically repaired;
  • history of scrotal and groin surgery that may have injured the testis or other concerned organs;
  • sexually transmitted infections (STI): are proven causes of male infertility; tuberculosis, mumps, scrotal infection such as epididymitis; infections (especially gonorrhea) can cause scarring to tiny tubules carrying sperm out of the testicle and lead to obstructive absence of sperm in the semen, while mycoplasma infections tend to reduce sperm motility
  • anosmia (associated with Kallmann syndrome);
  • breast enlargement, galactorrhea, and precocious (9 years or earlier) or delayed puberty (later than 12 years): may let us suspect some hormone misbalance;
  • precocious puberty (9 years or earlier), etc.
  • Use of sexual lubricants: sexual lubricants are toxic to sperm (e.g., water-based, water-soluble, saliva, etc.) and should be avoided. Nontoxic lubes include egg whites, peanut oil, and vegetable oil. Petroleum jelly is not particularly toxic to sperm but is still not recommended due to its stickiness.

The physical examination

During a physical examination, a urologist or andrologist examines the body shape and checks for signs of hormone abnormalities, such as gynecomastia, skin and hair distribution, muscle mass, and fat distribution. If a patient has a low sperm count and a muscular appearance, we may suspect testosterone abuse. The testosterone/estrogen balance may be abnormal in obese patients.

Other examinations:

  • Penis to rule out abnormalities like hypospadias, micropenis, and Peyronie plaques;
  • The testis volume and the largest dimension to exclude testicular causes of infertility;
  • The absence of the vas deferens, since we report the bilateral absence of the vas in 1% to 2% of infertile men;
  • Any clinical abnormalities of the testicles, epididymal lesions, spermatoceles, and large varicoceles;
  • The presence of a hydrocele;
  • An identifiable varicocele

Male infertility test

The semen analysis is the main laboratory evaluation to screen infertile men. Because of the extreme variability of the semen parameters, we must submit two samples collected at least one week apart. At least three days of abstinence should precede the first sample. Semen analyses greatly help identify and classify the severity of male infertility factors.

Semen analysis examines sperm parameters like the number, concentration, morphology, and motility. Other parameters are pH, volume, viscosity and, liquefaction, agglutination.

Test home kits for infertility are available in selected pharmacies, but their reliability is questionable since they do not check all the semen parameters. Therefore, we cannot recommend it.

Baseline infertility diagnostic workup

After medical history collection and physical examination, the first lever diagnostics to evaluate infertile man are:

  • Semen analysis
  • Hormonal screening (testosterone and SHBG), FSH, LH, and prolactin

If these results are normal, there is no need for diagnostic escalation. Further sophisticated diagnostic tests may be recommended if the female partner is also normal and the couple is still infertile. These sets of tests are offered in specialized infertility centers. These are:

  • Capacitation, Acrosomal Reaction, and Sperm Penetration Assays
  • DNA integrity test
  • Post-coital test
  • Sperm Vitality Staining
  • Post-ejaculatory urinalysis

In males with abnormal results detected during the baseline investigation (semen abnormalities), the diagnostics must escalate to further level tests:

  • Genetic Screening
  • Hormonal tests
  • Hypoosmotic Swelling Test
  • Inhibin B level
  • Scrotal Ultrasound
  • Testicular biopsy
  • Transrectal ultrasound
  • Vasography

Treatment of Male Infertility

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.


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.

Did you know?

  • The sperm counts of men undergoing semen analysis have gradually declined over the past few decades. The average sperm count was 113 million/ml in 1940 but dropped to 66 million/ml in the 1990s. This trend continued globally as the average sperm count fell by 51.6% between 1973 and 2018. The rate of decline accelerated after 2000, from 1.16% per year after 1972 to 2.64% per year after 2000.
  • Although the exact reasons are unknown, increased long-term exposure to environmental toxins might be the possible cause of this progressive worldwide semen quality deterioration.
  • Infertile men appear to have a higher cancer risk than the general population. This risk is higher in men with azoospermia. For example, azoospermia has been reported in 5% to 8% of patients with testicular cancer.
  • COVID-19 appears to cause some recovered men to be less fertile or infertile, especially after severe infection. The virus seems to affect the testis through direct cellular infection, cytokine storm, and side effects of various antiviral and immunotherapies used in treatment. We need further research to elucidate better the mechanisms of harm associated with COVID-19 infection and possible specific therapies.
  • Healthy lifestyle changes and practices are generally helpful in improving fertility. Patients are recommended to stop smoking, eliminate cannabis use, reduce weight, and stop drinking excess alcohol, as these healthy lifestyle changes may help.
  • US Centers for Disease Control (CDC) stated that no evidence exists that vaccines may cause infertility in either men or women, including the COVID-19 vaccines.

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