Male Infertility: Causes and Treatment

A high percentage of infertile men can be effectively treated, and more are good candidates to use their sperm for in vitro fertilization than ever before, thanks to progress made in recent years in discovering the causes of male infertility, in surgical techniques, and in methods used to locate and extract "hidden" but viable sperm.

That's comfort for the many couples who have trouble getting pregnant but wish to have children. Infertility problems are nearly as likely in men as they are in women, and doing a "work-up" to determine the problem is less invasive (and less costly) with men than with women, so it makes sense to involve men at the front end of infertility treatment.

Jay Sandlow, MD, Medical College of Wisconsin Associate Professor and Vice Chairman of Urology, recently discussed for HealthLink the causes of male infertility and treatment advances. Dr. Sandlow is a fellowship-trained specialist in male infertility and practices in the Reproductive Medicine program of Froedtert & The Medical College of Wisconsin.

"The most common cause of male infertility is called a varicocele, a group of dilated veins typically around the left testis although they can be around both testes," said Dr. Sandlow. "Varicoceles are very common in the general male population. About 15% of all men have varicoceles, although the majority of men with them are fertile so they don't always cause infertility.

"But among men who have infertility, about 40% to 45% of them will have a significant varicocele that can be at least in part related to infertility. There can be less common causes, such as blockages, infections, hormonal issues, exposures to things that are toxic to sperm. So when we do the evaluation we're typically looking for those things that are correctable and reversible."

Using Small Numbers of Sperm
Varicoceles are typically treated with an outpatient surgery involving a small incision, Dr. Sandlow said. Usually the procedure takes about an hour or so with most men back to work within three to five days. Most blockages that impair sperm delivery can also be surgically repaired, he said, and abnormal hormonal production that is a factor in some infertility cases can also be treated medically.

"One big advance, not directly in my field but related to our work, is the ability to use very small numbers of sperm with a process called ICSI (intracytoplasmic sperm injection)," said Dr. Sandlow. "It has allowed us to treat men who in the past were considered sterile. Now we can take one sperm and inject it into each egg during in vitro fertilization. Therefore you only need as many sperm as the woman makes eggs.

"That has totally revolutionized what we do, because what we've found now is that there are some men who make extremely small numbers of sperm who in the past were told, 'sorry, there's nothing we can do.' Now we're able to find and use their sperm. That's probably the biggest (advance in dealing with infertility) and although it's not something that treats the underlying cause, it has made a huge difference in terms of what we can offer.

"Now we know that even in men with no sperm in their ejaculate, a good percentage of them will have small numbers of sperm in their testicle that we can go in and retrieve, and then use that with in vitro fertilization. That's something that we're doing here fairly regularly that isn't being done anywhere else in this area.

"The other advance would be that the microsurgical techniques that we use are better than they were ten or fifteen years ago. The success rates for things like vasectomy reversals or the bypass of blockages tends to be higher."

High Percentage of Patients Are Treatable
Couples having trouble getting pregnant can take hope in the fact that, if the problem is with the man, chances are it's a treatable condition.

"I published a paper on that a while ago," said Dr. Sandlow. "What we found was that about two-thirds of men had something that was treatable, whether it was a varicocele, a hormone issue, a blockage that we could fix, something where we could actually make a difference. And we were able to find the cause of the infertility, although it wasn't always treatable, in about three-quarters of the patients.

"So there's still a percentage of patients, about 20% to 25%, where we just say 'you know what, we don't know why.' I think what we're finding is that more and more of those are probably going to be genetic in nature. When we look at what we knew about the genetics of male infertility ten or fifteen years ago compared to where we are now, we know a lot more now.

"My suspicion is that fifteen years from now, when we know that much more about the genetics, there's going to be another significant group of those whose infertility is what we call unexplained or idiopathic that we'll be able to say that it's because of this gene, or lack of this gene, that you're having problems."

Team Approach Helps Both Partners
Dr. Sandlow stressed the team approach used by the Reproductive Medicine program in helping both partners through the emotion-laden quest for fertility. It's common for cases to be handled by Dr. Sandlow in concert with reproductive endocrinologists, genetic counselors and pre-implantation genetic diagnosticians. "And, of course, our nurses are extremely important in terms of counseling patients," he said.

"I think the biggest thing, for instance when a couple is going through in vitro fertilization and particularly if there's a significant male factor or there's a sperm retrieval needed, is that the right hand knows what the left hand is doing" said Dr. Sandlow.

"We work together, we're in the same clinic, and we'll often see couples together. I'll see the man, they'll see the woman, and then the four of us will sit down and say 'OK, in your case, in this scenario, these are the options that you have and based on what you want to do this is what we would recommend. We've had, I think, some very good success with that approach."

The process starts with a thorough work-up on the patient. "We do a detailed history first, looking at potential factors that may contribute to infertility or put you at risk, such as childhood history, surgeries, medications, social history involving alcohol, tobacco, marijuana, that kind of thing," said Dr. Sandlow. "Then there's a fairly general exam, because it's not all just about the male genitalia, although it's obviously focused on that. A lot of times we find other things that can represent significant health problems; I've found lymphoma with enlarged lymph nodes, I've found testicular cancers, as well as hormonal disorders that manifest as infertility.

"And then, we do specific blood testing for that person. Although there are some routine labs that I get, I don't get them on everyone and some men get different labs than others depending on what I think the cause is and what I think they're at risk for. That's the general workup."

Semen Analysis Critical, If Imperfect
"And, obviously, at least two semen analyses are used," said Dr. Sandlow. "Semen analyses are interesting because it's what we use to screen for male infertility, and it's a very imperfect test. There's a lot of variability just on a day-to-day basis in any patient, plus there's a lot of variability in labs. We have a lab where all they do are semen analyses, so I'm confident that it's as accurate as it can be.

"So we need to have at least one semen analysis from our lab. But even when they're from here, they do vary, and so it's very difficult. You can't tell someone, based on their semen analysis, if they're fertile or infertile. There's no cutoff above which you're fertile and below which you're infertile, except for zero. At zero it's pretty unlikely that a patient is going to be able to get someone pregnant, and even then occasionally people do. Zero's not always zero. If you check enough semen analyses, some men who are zero will actually have some sperm.

"Studies have been done checking sperm counts a couple times a week over the course of a year, and what they've shown is that the numbers bounce all over the place. Someone with proven fertility can have numbers as low as less than a million or as high as a couple hundred million. If you get a bunch of them you'll get sort of a baseline, and that's what we're looking for. If you get two or three analyses that are in the same ballpark, then we can say this is probably your baseline."

Working with both partners helps the program ensure success, Dr. Sandlow said. "Even those we don't see as a couple together, we're still working together because she's already been seen and then he gets referred to me, or I've seen him and then I refer her to the reproductive endocrinology people," he said. "Probably about half of our patients are what I would consider 'joint patients' where we're managing both partners. There really aren't any other clinics in town that are quite as focused on the couple together. And it's because of this unique practice that our couples do so well."

Dan Ullrich
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.