Overview

Approximately 15% of couples are unable to conceive after one year of unprotected intercourse. Research has demonstrated that male factors are involved in couples' infertility in up to 50% of cases. It is essential that BOTH partners are evaluated for infertility when fertility concerns are present.

The first step in diagnosing and treating infertility is an initial evaluation which includes a health history and physical exam, semen testing, and a hormonal evaluation. It is important that men are not just evaluated with a semen analysis, as many aspects of infertility may not be obvious with semen testing alone.

History

A properly collected health history is critical to making the correct diagnosis. For instance, it is important to note the following: whether men have fathered children in the past, if they have had any infections involving their testicles, if they have been exposed to chemicals or radiation, had any surgeries that could potentially compromise their fertility, or have had issues with erections or ejaculation.

Unfortunately, many men facing fertility issues will have difficulty with erectile dysfunction, low libido (sexual desire), and ejaculation. These problems are usually under diagnosed and under treated as many young men are uncomfortable addressing these issues with a doctor. These troubles are particularly upsetting for the male, but can also create significant relationship issues that further complicate infertility struggles.

Physical Exam

A physical exam by a properly trained urologist is also a critical part of the male fertility evaluation. Oftentimes a varicocele (dilated veins around the testicle) is found in men with abnormal semen parameters. A varicocele is a well-known cause of male infertility and the most common cause of secondary infertility.  Thankfully, these issues are generally correctable with outpatient surgery that is typically covered by insurance.

On rare occasions, men with cancer will present with infertility. Cancers such as testicular cancer or lymphoma are well known causes of abnormal semen parameters and making this diagnosis is of paramount importance for these patients.

Other genetic conditions, such as congenital bilateral absence of the vas deferens (CBAVD) may be diagnosed by the examining physician. This is a genetic condition where men are carriers of a cystic fibrosis gene. These men are generally missing both of their vas deferens (tubes that carry sperm from the testicle) and have no sperm in their ejaculate. Genetic testing for BOTH partners is strongly recommended prior to trying for a pregnancy, as the potential offspring may be at risk for developing cystic fibrosis.

Semen Testing

We generally prefer that men have 2 properly collected semen tests to assess their fertility. It is important to get 2 semen analyses since it is common for men to have isolated abnormalities on a single semen test and semen parameters can also have significant variation from sample to sample.  These isolated abnormalities may also be put to rest on repeat semen testing if normal.

When a man decides to undergo semen analysis, a semen specimen is produced and collected through self-stimulation. A formal semen analysis will examine the volume of semen produced, the amount of sperm present, the motility (how well they swim), and the shape. We ask that men have no ejaculations for 2-5 days prior to producing this specimen to ensure it is of the highest quality.  If men have no sperm in the ejaculate, there is no need to panic as approximately 50% of these men will have sperm present during a microsurgical testicular sperm extraction (micro-TESE).

Hormone Evaluation

Lastly, a hormonal evaluation is necessary in many men presenting with infertility. Approximately 20% of men will be diagnosed with hypogonadism (low testosterone) during a fertility evaluation. Some men who have abnormalities in their hormones will see improvements in their semen parameters and/or sexual dysfunction once their hormones have been optimized.

Conclusion

Fortunately, many causes of male infertility are reversible with proper diagnosis and treatment. Even in the event where an irreversible male factor is identified, not all hope is lost. Thanks to recent advances in assisted reproductive technology (ART) such as intrauterine insemination (IUI) and in vitro fertilization (IVF), many couples who were previously considered infertile are able to conceive children who are biologically their own.

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