Causes of Male Infertility

Male infertility is a broad and complex area. There are a wide number of reasons for male infertility. Some are caused by physical problems that prevent the sperm from being ejaculated normally in semen. Others affect the quality and production of the sperm itself.

Infections

Men may have infections of their reproductive tract. These may include infections of the prostate (prostatitis), of the epididymis (epididymitis), or of the testes (orchitis).

Post-pubertal viral infections of the testes may cause significant damage (atrophy) of the testes and may cause absolute and irreversible infertility. Bacterial infections or sexually transmitted diseases may cause blockages at the sperm ducts. The patient may have normal production of sperm, but the ducts carrying sperm are obstructed.

Active bacterial or viral infections may have a negative effect on sperm production or sperm function. White blood cells, which are the body's response to infection, may also have a negative effect on sperm membranes, making them less hearty.

If excessive white blood cells or bacteria (more than one million/cc) are seen in a semen specimen, cultures should be done. This usually includes cultures for commonly asymptomatic, sexually-transmitted diseases including mycoplasma, ureaplasma, and Chlamydia. Also, a general genital culture is usually taken. If the infection and the white blood cells are persistent, antibiotics may be considered

It is important to note that, in most men, the ejaculate is not sterile. In controlled studies, the average man will culture positive for approximately two organisms. It is therefore very important to be judicious in the treatment of non-sexually-transmitted organisms found on cultures.

Active bacterial or viral infections may have a negative effect on sperm production or sperm function. Please contact us to know more about possible factors affecting male infertility.

Cryptorchidism

Cryptorchidism(undescended testis) is often associated with male factor infertility. Eighty-one percent of men who have a single testis that is cryptorchid have normal fertility. However, approximately, 50% of men who have bilateral cryptorchidism have normal fertility. This may be due both to something inherent in the testes, to the surgery, or to damage done by not having the testes brought down in time.

What is Cryptorchidism?

Cryptorchidism/Undescended Testicle is a condition in which the testicles do not descend from the abdomen, where they are located during development, to the scrotum shortly before birth. Also called undescended testicle.

As a baby boy grows inside his mother, he develops testicles. Early in his development, his testicles are in his belly. Normally before he is born, his testicles move down into his scrotum, the sac that hangs below the penis. When one testicle does not move into the scrotum as it should, the baby has an undescended testicle. In rare cases, both testicles are undescended.

About 5 out of 100 baby boys are born with an undescended testicle.It is most common in babies who were born before their due date or who were very small at birth. Why a baby's testicle does not move into the scrotum is not well understood. It probably has a number of causes. This condition runs in some families (can be inherited).

In more than half of cases, the testicle descends on its own by the time the baby is 3 months old. If your baby's testicle has not descended by the time he is 6 months of age, your doctor may suggest treatment.

What are the symptoms?

Having an undescended testicle does not cause pain or other symptoms. The scrotum may look a little smoother or less developed on one side, or the side without a testicle may look smaller and flatter.

How is an undescended testicle diagnosed?

At newborn and well-baby visits, your doctor will check your baby's scrotum.

If the testicle can be felt but it is not in the scrotum, the doctor will probably want to check your baby again at 3 to 6 months of age. By this time, the testicle may have moved into place on its own.

Sometimes the doctor can't feel the testicle at all. It could still be in the baby's belly, it could be too small to feel, or it could be absent. After taking a wait-and-see approach, a doctor may recommend a type of surgery called laparoscopy to see if he or she can find the testicle. Laparoscopy requires only a small cut below the belly button, which heals quickly. During laparoscopy, the surgeon puts a tiny lighted instrument into the baby's belly. The doctor may be able to move the testicle into the scrotum during this procedure so that the baby will most likely not need another surgery.

If both testicles are undescended and cannot be felt in the groin, the doctor will do a blood hormone test to find out if the testicles are absent. It is rare to have two absent testicles.

Doctors sometimes use an imaging test, such as ultrasound, to help find an undescended testicle. These tests are more useful for older boys and men than for babies.

Some other conditions are closely related to undescended testicles. Your doctor will take care to make the correct diagnosis so your child can get the right treatment.

How is it treated?

Usually, doctors recommend a wait-and-see approach for newborns. If the testicle has not descended on its own within the baby's first year, your doctor may recommend surgery to move it into the scrotum, probably when the baby is 9 to 15 months old. In most cases, surgery takes about an hour. The baby will be given medicine so he sleeps through it. After surgery, the baby will be watched for a while after he wakes up, and then he can go home. Most babies recover quickly.

When babies have a testicle that can't be felt (nonpalpable), doctors may perform a different surgery that needs only a small cut (laparoscopy).

In some cases, the doctor may want to give your baby hormones before surgery to see if they cause the testicle to move down into the scrotum. Studies of hormone therapy have not found it to be very effective, and it can cause side effects. It may be a good option if the testicle is already very close to the scrotum.

Why is it important to treat an undescended testicle?

Treatment is important because having an undescended testicle increases the risk of:

Infertility. Being in the scrotum keeps the testicles cool, which helps them make sperm. If the testicle remains inside the body, it stays too warm and its ability to make sperm drops. This can cause infertility later in life. Damage to the testicle's sperm-making ability can begin as early as 12 months of age. That is why many doctors advise treating an undescended testicle by the time a baby is 1 year old and no later than age 2.

Cancer of the testicles. Although rare, testicular cancer is the most common form of cancer in men between the ages of 20 and 40. Men who have undescended testicles have a much higher rate of testicular cancer than other men. This cancer can usually be cured, especially if it is found early. Treatment of an undescended testicle makes it easier for you or your doctor to find testicular cancer if it develops. If you are a young man who has an undescended testicle, talk to your doctor about what you should do. For more information about testicular exams, see the topic Testicular Examination and Testicular Self-Examination.

Infertility and undescended testicle

Men who have or have had an undescended testicle are more likely to have problems with the reproductive system that may cause them to be unable to father a child (infertility).

Most doctors believe that early diagnosis and treatment for an undescended testicle improves chances for fertility in adulthood. Generally, doctors recommend surgical treatment to place the testicle in the scrotum by age 1 and no later than age 2. The location of the undescended testicle and the boy's age when he is treated influence the outcome. Boys who have one undescended testicle that is just above the scrotum or low in the inguinal canal are more likely to be fertile than boys who have two undescended testicles that are high in the inguinal canal or in the abdomen.

Varicocele

Varicoceles are enlarged varicose veins that develop in the scrotum and prevent blood from flowing properly. Varicoceles are found in 15% of all men, but in up to 40% of men being evaluated for infertility. Although they may be a factor in male infertility, a few studies question whether surgery to correct varicoceles has any beneficial effect. The vast majority of studies indicate benefits from Varicocele repair. An improvement in semen quality can be expected in roughly 67% of patients who have varicocele ligation, Including sperm count, motility and morphology. The pregnancy rate following varicocele repair is approximately 50%, with pregnancy occurring an average of 6-12 months after surgery.

Varicocele remains the most correctable factor when poor semen quality is discovered, but since it is a very common lesion, the operation should only be considered if other infertility risk factors are absent. Varicoceles can be corrected by venous embolization, laparoscopy or through a small inguinal or subinguinal incision.

Varicocele and male infertility explained by Dr. Jeffrey Buch

Testicular Failure

This generally refers to the inability of the sperm-producing part of the testicles (the seminiferous elithelium) to make adequate numbers of mature sperm. This failure may occur at any stage in sperm production for a number of reasons. The testicle may completely lack the cells that divide to become sperm (Sertoli Cell-Only Syndrome). There may be an inability of the sperm to complete their development (maturation arrest). Sperm may be made in such low numbers that few, if any, successfully travel through the ducts and into the ejaculated fluid (hypospermatogeneses). This situation may be caused by genetic abnormalities, hormonal factors, or varicoceles.

Even in the case where the testes are only producing low numbers of sperm, the sperm may be harvested and used in conjunction with advanced reproductive techniques to achieve a pregnancy.

Testicular failure can cause inadequate numbers of mature sperm. Please consult with our reverse vasectomy doctor for the proper treatment course.

Retrograde Ejaculation

The most common complaint about ejaculation is too rapid or what is called "pre-mature ejaculation." This topic is discussed in the orgasm section. Less commonly, men can have what is called retrograde or backward ejaculation. In this case, climax is reached, but no fluid comes forward out the end of the penis. Rather, a nerve malfunction has resulted in the fluid going backward into the urinary bladder, and the ejaculation fluid (semen) safely passes out the next time the man urinates. This is not a significant problem unless the man is trying to get his wife pregnant. In many cases simple medications can be used to stimulate the nerves to propel the semen forward so as to allow pregnancy through intercourse to occur. However, when this medicine fails, sperm can be successfully harvested by collecting the first urine sample voided immediately after climax. These sperm can be "washed" and concentrated in the laboratory to be used for insemination of the man's female partner.

Sperm can be successfully harvested and processed in a laboratory to be used for insemination of your female partner.

Hormonal Abnormalities

The testicles need pituitary gland hormones to be stimulated to make sperm. If these hormones are absent or severely decreased, the testes will not maximally produce sperm. Importantly, men who take androgenic steroids such as Testosterone for body building, either by mouth or injection, shut down the production of pituitary hormones needed for sperm production.

A hormonal profile must be performed on all men with male factor infertility. This will help rule out serious medical conditions, give more information on the sperm-producing ability of the testes, and may reveal situations where hormonal treatment is indicated.

Testicles need pituitary hormones to be stimulated to make sperm. Absent or severely decreased pituitary hormone is among the factors which can cause male infertility.

Immunological Infertility

This term is typically applied to sperm antibodies. Antibodies are proteins produced by our immune system that circulate through the bloodstream and into body organs to fight off infection and cancer cells. However, sometimes these antibodies are mistakenly created against normal cells or tissues, and they are then called an auto-immune response. One such case that can complicate human fertility is the occurrence of sperm antibodies. Certain conditions such as varicocele, undescended testes, testicular torsion, testis trauma or persistent low motility after successful vasectomy reversal have all been associated with the development of sperm antibodies. However, in most cases there is no obvious cause other than an irregularity of the immune system.

Sperm antibodies when present at higher levels can negatively impact fertility by decreasing sperm motility or impairing the sperm from penetrating the egg. Sperm antibodies have been primarily detected in semen, on the sperm surface, in blood samples and in the female partner's cervical mucus. Sperm antibodies are primarily anticipated in cases of isolated sperm motility issues in screening semen analyses and when immobilized sperm are seen in an abnormal cervical mucus sample taken after intercourse at the time of ovulation (post coital test). The most common tests for sperm antibodies are done directly on the sperm, Direct Immunobead Test (DIBT), or indirectly from the blood or seminal fluid of the man or from the blood or cervical mucus of the female partner, Indirect Immunobead Test (IIBT).

Treatment of sperm antibodies can be accomplished by treatment of the male or female partner with oral pill(mild to moderate immunosuppressive agents) such as Prednisone. Effectiveness of treatment is noted by improvement in sperm motility in follow up semen analyses or by improvement in follow up post coital tests, and ultimately by achieving pregnancy. Alternately, laboratory processing of the semen sample to remove sperm antibodies (Sperm Wash) has been combined with intra-uterine insemination of the female partner (IUI) to bypass sperm antibody related motility problems. When egg penetration impairment due to sperm antibodies is suspected and treatment of the man with prednisone has not been effective, this problem can be bypassed by a special type of in vitro fertilization combined with direct injection of single sperm into the egg under highly specialized laboratory conditions (IVF-ICSI).

Lifestyle Factors

Cigarette Smoking

Cigarette smoking has been shown to significantly affect semen quality. Regular smoking causes a 23% decrease in sperm density (concentration) and a 13% decrease in motility (when averages are taken from nine separate studies). To a lesser extent, smoking causes toxicity to the seminal plasma (the fluid ejaculated with the sperm). Sperm from non-smokers were adversely affected (had significantly decreased viability) when placed in the seminal plasma (hormonal) of smokers.

Smoking affects the hypothalamic-pituitary-gonatropin axis, most commonly affecting levels of estradiol and estrone (estrogens, which are hormones found in higher concentrations in women). The Leydig Cells, which are in the testes and produce testosterone, may have secretory dysfunction. However, this is really a mild factor on its own, and will not push a severely infertile male into a normal range simply by quitting smoking.

Exercise

Moderate amounts of exercise can only be helpful. However, long-distance runners (men who run more than 100 miles per week) have been noted to manifest a 10% decrease in sperm counts. Once again this is only a mild effect.

Recreational Drugs

Marijuana

Heavy use of Marijuana may decrease sperm count. This appears to be a mild effect and is presumed to be mediated by mild Estrogenic(female hormone) effects.

Cocaine

Cocaine use has been reported to cause decrease sperm count. Typically this is seen heavy rather than casual use.

Anabolic Steroids (male hormones)

The use of anabolic androgenic steroids(testosterone and related steroids) has reached almost epidemic proportions. Nearly seven percent of 12th-grade males use or have used them to build muscle mass and improve athletic performance. These male hormones suppress the testes' ability to make testosterone. This decreases the intratesticular testosterone level. This may cause severely diminished spermatogenesis or complete absence of sperm (azoospermia). When taken, these steroids cause a persistent depression of the hypothalamus and pituitary, which may be irreversible even when the steroids are stopped.

Increasingly, men in their 30's and 40's treated for low testosterone(LOW T) are presenting to our clinic with nearly zero or azoospermic semen analysis. Fortunately we are experts at managing medications to restore fertility in the vast majority of cases.

Alcohol

Moderate alcohol use does not affect male fertility. Excessive alcohol use affects the hormonal axis and is a direct gonadotoxin. It may cause associated liver dysfunction and nutritional deficiencies, which are also detrimental for sperm production.

Lubricants

Most vaginal lubricants, including K-Y Jelly, Surgilube, and Lubifax, are toxic to sperm. Couples should avoid their use during the fertile time of a woman's cycle.

There are some commercially available lubricants that do not impact motility. Please discuss this with your local pharmacist.

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