A Male Side to Infertility

When you look at couple having trouble conceiving, about 30% have a female issue, 30% have a male issue, 30% have both male and female issues, and 10% are unexplained.  So that means that there is a sperm problem in 60% of couples who are struggling with infertility.  That is why we always look at sperm, even when we know there is a female problem such as irregular or no periods.  There is no use in fixing the ovulation problem with fertility medication, if there is a sperm issue that hasn't been addressed.

The first step in diagosis is a semen analysis.  The male is asked to ejaculate into a sterile container and the semen is then evaluated.  Most fertility centers will have a special room dedicated to this function.  There is usually a lock on the door for peace of mind and appropriate magazines or videos, if needed.  Many centers, like ours, will also allow the patient to produce a specimen at home and bring it in for analysis.  Usually there is a time limit of one hour from when the sperm is produced to when we want it in the office.  These are usually visits that are scheduled in advance, so that the medical technician who evaluates the sperm has time to look at the sample right away.  So you do not have to worry that we are going to surprise you with a cup and a demand for sperm!  To get the best sperm, it is also important that the last ejaculation before the semen analysis be 3-5 days beforehand.  The quality of the lab that the analysis is done in can have an impact on how accurate the results are.  Sperm swim quite fast, and so counting them can be difficult.  If possible, try to have the semen analysis done in a fertility center.  They count sperm all day long and so are usually quite good at it.  As I said before, fertility centers will also have a dedicated room.  Many labs do not, and that can be a problem.  If you do not live near a fertility center, you can ask your doctor for a recommendation. 

A semen analysis should look at a few things.  The volume of the semen sample should be measured, as well the sperm count per milliliter and a total sperm count for the specimen.  Opinions vary on exactly what a normal sperm count is, but most would agree that it is over 20 million sperm per milliliter.  The number of sperm that are moving should also be calculated.  At least 30% should be moving.  The movement is graded and varies from just shaking in place, swimming in circles, moving forward but not in a straight line, and moving forward in a straight line.  Obviously, moving forward is desirable.  The shapes of the sperm are also examined.  There are several different ways that this can be done.  The most common method these days is called the strict Kruger method.  This is a very picky way to look at sperm, but it has been shown to correlate with the ability of sperm to fertilize eggs in the lab.  4%  or more of normally-shaped sperm is a good number for this method.  The technician will all look at the thickness of the semen, its pH, the presence of white blood cells, and whether the sperm are sticking together.  A report is generated for your doctor with all of this information.

If a problem is seen on the semen analysis, further testing may be required.  Low sperm counts can occur when there is a hormonal problem, so blood tests are usually done to look at the patient's hormone levels.  It is also possible that a blockage has occurred.  A physical exam can be done, and sometimes ultrasounds of the testicles are done as well.  Vericose veins can form around the testicles, and these will lower sperm counts.  Ultrasound will show vericose veins.  In extreme cases, a blood test to look at the patient's chromosomes may be needed.  Abnormalities in the Y-chromosome can lead to very low or no sperm production.  Lifestyle alterations such as quitting smoking, staying out of hot tubs and saunas, putting laptops on a table rather than in the lap, discontinuing marijuana use, and taking multivitamin supplements may be suggested.

If sperm counts are found to be slightly low, then intra-uterine inseminations (IUI) can be helpful.  This is a procedure where the sperm are washed and placed in a very small volume of fluid.  A small tube, or catheter, is then threaded through the cervical canal and into the uterus.  The sperm is deposited at the top of the uterus, and the catheter is removed.  It usually takes a minute or two to do, and it feels like a PAP smear.  If your cervical canal is very twisty or turns sharply, it can take a little longer and be a little more uncomfortable.  Most fertility centers are open 365 days a year, so that inseminations can be done even if you are ovulating on a weekend or holiday.  This gets millions more sperm to the eggs.  With intercourse, 99.9% of the sperm never make it into the uterus.  If the sperm counts are on the low side, then this becomes a real issue.  Getting the sperm into the uterus and beyond the mucus in the cervix where a lot of sperm get stuck can be a great help.  Often the IUI is combined with fertility medication for the female.  This may not, on the surface, make sense; but it does help.  Each egg is different.  Some are easier and some harder to fertilize.  Producing more than one egg will give the sperm more chances to be successful.

More serious sperm issues often require IVF (in vitro fertilization).  The female partner is given fertility medication so that several eggs are produced.  They are removed from the ovaries and fertilized in the laboratory.  This can be done by placing the sperm and eggs in direct contact with eachother, or by a technique callled ICSI (intra-cytoplasmic sperm injection).  With ICSI (pronounced ick-see), a single sperm is injected into each egg ensuring that the sperm are able to penetrate the egg.  This can give a couple a great chance of being able to conceive, when there was little chance beforehand.  When there are blockages, a urologist can remove sperm from behind the blockage to use with IVF/ICSI too.

Another option is to use donated sperm.  There are many excellent sperm banks in the United States, and they will ship sperm all over the country.  Sperm donors are screened ahead of time to make sure that they are in good health, have good sperm, have no history of genetic diseases in the family, and have no infectious diseases that are likely to be passed through the sperm.  Donor sperm is frozen and quarantined for 6 months, and then the donor is rescreened for infectious diseases.  This ensures that he was not in the early stages of an infection, and the testing was falsely negative, when the sperm specimen was obtained.  The FDA monitors sperm banks in this country to ensure they are doing this correctly.  The sperm bank will give you a lot of information on the sperm donor, and some will now even give you pictures.  The donor sperm is usually used in combination with the IUI described above.

I should add a final note on vasectomies.  If a vasectomy has previously been performed and now pregnancy is desired, then there are several options.  If it has not been too long since the vasectomy was performed, less than 10 years is best, then a urologist may be able to reverse the vasectomy.  This is a surgical procedure where the 2 ends of the vas deferens are sutured back together with very fine sutures.  Success rates vary, but are generally good.  Another option is to do IVF/ICSI with an aspiration of sperm from behing the vasectomy site (as described above).  This is a simpler procedure from the male standpoint, but more involved from the female standpoint.  The final option would be to use donor sperm or donated embryos to conceive.  Donated embryos would mean that it is neither the female nor the male's genetic child, and so this is usually done when there is also an egg issue as well.  Adoption, of course, is also always an option in any of the above scenarios.