Male Infertility

Difficulty in conceiving a child is called infertility. Infertility is different than sterility. Sterility refers to the conditions that totally prevent pregnancy from occurring. The medical definition of infertility is the inability for normal people to get pregnant after one year of stopping birth control. This article is here to discuss conditions in men that contribute to problems with conception.

Infertility is a complex medical problem and can occur due to both male and female factors. Men alone account for about 30% of infertility. In an additional 20% of infertile couples, there is a combination of both male and female factors contributing to problems with conception of a child.

Infertility is a problem for 15-20% of all couples in the USA. This equates to between 4 and 5 million men in the USA. With modern technology, many causes of infertility are now treatable.

In addition, over the last 4-5 decades, there has been a slow, worldwide decrease in the number of sperm with normal morphology emitted per ejaculation. The cause of this is unknown but is theorized to be due to the number of chemical pollutants in the environment. Examples of these chemicals are DDT, dioxin, polychlorinated biphenyls (PCBs), and hexachlorobenzene. While some of these chemicals are toxic, many of these chemicals act as estrogen-like compounds.

Men taking estrogen have a decrease in sperm and testosterone production. Foods such as soy products are high in isoflavones. Isoflavones are in the category of phytoestrogens. Phytoestrogens are estrogens in plants that may affect hormone levels in humans.

An alternate theory is that the epidemic of obesity plays a significant role in declining fertility. Obesity has been directly tied to diabetes. Diabetes has several effects on men. Obesity is associated with both erectile dysfunction (ED) and an increase in circulating estrogen. Both of these conditions contribute to infertility.

Infertility Evaluation Costs

Infertility treatment costs are frequently not covered by health insurance. That does not mean that the basic evaluation is not covered under your health insurance policy. Infertility treatments such as In Vitro Fertilization (IVF) and Intra Cytoplasmic Sperm Injection (ICSI) can run into the tens of thousands of dollars. These two treatments are what are usually not covered by regular health insurance policies.

If your semen quality can be optimized to a sperm count of 20 million, you may want to look for a gynecologist that does artificial insemination. This usually costs about $1,000 per cycle, and most couples will achieve pregnancy in 4 cycles. This is much cheaper than even one cycle of In Vitro Fertilization (IVF). It seems that most of our local fertility clinics do not find artificial insemination cost effective enough for them to perform, and they have stopped offering artificial insemination. Instead, they immediately opt for the more expensive and higher tech therapies of IVF and ICSI.

On the other hand, a basic evaluation may only be a couple of thousand dollars. Frequently, your insurance will cover the cost of the basic medical tests. If you shop around, the evaluation can be done one step at the time. Stopping the testing, when the evaluation identifies a treatable cause of male infertility, allows for treatment of that cause of infertility. After appropriately 3 months of treatment, re-checking a semen analysis will then evaluate your response to that therapy.

Be patient. Men can only be cycled on a 3 month basis. It can be a several, month long process to identify and improve male infertility. Most treatments show an improvement rate of about 30% at three months of therapy. So, as you see, your urologist may need to try 3-4 different treatments over 12 months before finding something to which you may respond.

While many men are embarrassed about discussing their problems with their urologist, it is important to give a complete history of any symptoms you may have. This will help your urologist determine which tests are covered by your insurance policy and which are your responsibility. That way, there are no hidden costs for you later. If you have erectile dysfunction (ED), decreased libido (Low T), fatigue, decreased energy levels, decreased stamina at sports, weight gain, or memory problems, your labs may be covered by your basic health insurance. This would possibly include all the basic blood work such as testosterone, FSH, LH, prolactin, thyroid function, and all basic chemistries.

If you have a varicocele on physical examination that is associated with testicular pain or small testicular size, insurance should cover the cost of a scrotal ultrasound. At an imaging center, not a hospital, this ultrasound may cost anywhere from 1/10th to 1/5th of the hospital cost for the same ultrasound. For example, at an imaging center, the cash price locally is about $250 (3/1/2013). At an imaging center, you may pay an office co-pay rather than the hospital deductible, which can be anywhere from $500-$5,000 depending on your policy. An imaging center’s lower price is a cash-only, one-time sum; they do not have payment plans. You may need to shop for the best price yourself; many offices don’t seem to know the out of pocket patient costs of the tests they order.

A semen analysis is rarely covered by health insurance. Not many hospitals continue to do this test. The basic cash price is currently about $150-$200. (3-1-2013)

Once you have been billed for a service through your insurance, if it is not a covered service, then you are responsible for the full price of the lab tests.    Therefore, at the time of your initial visit, ask your doctor about his wholesale lab account, if he has one, and what it would cost you to pay him cash up front for the tests versus your insurance cost.  Your doctor’s cost is about 25-30% of your cost if the labs are billed to his commercial account. If rejected by your insurance, this cannot be rebilled to the doctor’s account at a later time.   For example, a total and free testosterone is currently about $45 through the wholesale account, but billed through the lab to you, you would be responsible for roughly $145.  Most doctors will need for you to pay this up front; they do not have laboratory payment plans.  This arrangement still saves you a lot of money.

Beginning an infertility evaluation may seem like an overwhelming task, but taken a step at the time, the evaluation can be accomplished at an affordable rate for most couples.

Possible Reversable Causes of Infertility

Your urologist will take a full history to help look for the most easily treated causes of infertility. Infertile couples can make some lifestyle changes and decrease their degree of infertility.

Men trying to conceive may want to consider these changes in advance of trying to conceive. It will likely take up to 3 months after cessation of the use of drugs, tobacco, and alcohol before semen quality improves.

Smoking cessation helps improve semen quality. Tobacco usage causes problems with sperm motility. The decrease is in the range of a 10-15% decrease in motility. Motility is the medical term for the sperm’s ability to swim in a straight line, also described as forward progression. Tobacco has also been linked to sperm death. There is a 20-25% decrease in sperm concentrations in men that smoke. Smoking also causes DNA damage within the sperm’s chromosomes, resulting in larger numbers of damaged sperm. DNA damage is theoretically due to the cadmium found in cigarette smoke replacing zinc in DNA polymerase.

Caffeine intake has been noted in some studies to decrease sperm motility as much as 20-30%. Therefore, a reduction in caffeine may be beneficial.

Marijuana smoke has been shown to have a similar effect as that of tobacco on sperm movement or motility. Abnormal sperm and increased numbers of dead sperm are noted on semen analyses of chronic smokers of marijuana. Marijuana use, unlike tobacco use, also has the reported effect of lowering testosterone levels. Low testosterone results in lower sperm counts. When the abnormal sperm do result in fertilization, there is an increased risk of miscarriage.

Alcohol can have multiple effects on sperm as well. Alcohol affects testosterone levels. Alcohol effects on the liver result in an increase in men’s estrogen levels. Increased estrogen levels counterbalance testosterone levels. Regular intake of more than 3-4 beers per night or 2 drinks per night containing 1 ounce of alcohol per drink is enough to affect semen quality. Binge drinking even one weekend a month likely has the same effect as daily drinking.

Recreational use of Cocaine, Heroin, PCP and amphetamines has been linked to infertility. Cocaine increases the number of abnormal sperm, decreases sperm counts, and causes a decrease in sperm motility. Cocaine has been found to decrease the sperm’s ability to penetrate cervical mucus. Cocaine enters the testicular tissue and attaches to the sperm. Cocaine then enters the egg reportedly increasing the risk of birth defects. Cocaine and heroin users may have abnormal semen analyses as long as 2 years after their last use of the drug. All of these drugs have an association with ejaculatory dysfunction, erectile dysfunction, and decreased sex drive or libido.

Chronic use of narcotics (opioid medications) for pain may lower testosterone levels. This includes both legal and illegal narcotics. Percocet (Oxycodone), Vicodin (Hydrocodone), and Demerol (Meperidine) are examples of these types of medications.

Men quite commonly use anabolic steroids. Some studies suggest that 5-6% of 18-year olds have tried or regularly use steroids as a body building aid. These drugs can permanently damage the testes and their ability to make sperm or testosterone even after the steroids are stopped. Sperm counts may return to normal 4-12 months after stopping anabolic steroids.

Avoiding heat to the scrotum helps restore sperm numbers and motility. Heating the scrotum to 101°-102°F has a significant effect on sperm quality. Sperm quality may be improved by avoiding hot showers, hot tub baths, and constrictive clothing. Wearing tight jeans and other constrictive clothing does not allow the testicles to drop away from the body when they are hot. Increased heat damages sperm and sperm producing cells in the testicle. The scrotal skin elongates when men are hot. This helps regulate the temperature of the testes. Even prolonged periods of time above 98.6°F may damage the testicles. Saunas have the same affect on sperm viability and motility as hot baths and showers. Laptop computers have been shown generate enough heat to affect sperm quality. Tanning bed sessions may also affect semen parameters.

Timing of intercourse is helpful in conceiving a child. There are only 3-5 days in a woman’s cycle when the egg is available for fertilization. Having intercourse every other day during this time may deposit sperm in higher concentrations in the vagina than daily intercourse deposits. Abstaining from intercourse for 4-5 days before your partner ovulates also helps increase the sperm density. Intercourse less often than 10-14 days may decrease sperm motility.

Heavy exertion such as training for a marathon or triathlon has been observed to decrease semen quality.

Medications Affecting Fertility in Men

There are a number of common medications that may interfere with hormone levels, be toxic to sperm, or interfere with fertilization. A partial list and their use are as follows:

  • Lubricants such as lotions, KY jelly, Astroglide, petroleum jelly, and saliva have been shown to kill sperm. These should be avoided.
  • Hypertension or high blood pressure is often treated with the following medications. (Please do not stop these medications without your primary doctor’s help in switching to a different medication.)
  • Calcium channel blockers like Calan (verapamil), Cardizem (diltiazem), Norvasc (amlodipine)
  • Beta blockers include most medications ending in “olol”. Atenolol is and example.
  • Alpha blockers may be used for hypertension or prostate issues. Flomax (tamsulosin) etc.
  • Thiazide diuretics are sued in hypertension control. Hydrochlorothiazide (HCTZ)
  • Spironolactone is a potassium sparing diuretic.
  • Reserpine
  • Estrogen: phytoestrogens in the diet and estrogens in prescription medications.
  • Progesterone
  • Ketoconazole is an antifungal medication that lowers testosterone.
  • Antiandrogens are most commonly used in the treatment of prostate cancer: Casodex (Bicalutamide) and Eulexin (Flutamide).
  • 5-alpha-reductase medications for benign prostatic hypertrophy may lower hormone levels in some patients; these include Proscar (Finasteride) and Avodart (Dutasteride).
  • Tagamet (cimetidine) lowers testosterone levels.
  • Antidepressants in many different classes may cause problems. These problems include both decreases in libido or sex drive and ejaculatory problems.
  • SSRI or Selective Serotonin Reuptake Inhibitors: Celexa (Citalopram), Lexapro (Escitalopram), Prozac (Fluoxetine), Paxil (Paroxetine), and Zoloft (Sertraline) have been associated with erectile dysfunction (ED), decreased sex drive (libido), and lack of orgasm or anorgasmia. Due to a side affect of difficulty ejaculating, these medications have been used with some effect on premature ejaculation.
  • Tricyclic antidepressants such as Elavil (Amitriptyline), Tofranil (Imipramine), Sinequan (Doxepin), and Pamelor (Nortiptyline) as are most frequently used in chronic pain or insomnia.
  • Antibiotics that affect sperm are Erythromycin and Tetracycline. These antibiotics are used in dermatology and urology while Nitrofurantoin is only used for urinary infections.
  • Minocycline may be toxic to sperm.
  • Methotrexate is used for arthritis, cancer, or psoriasis.
  • Chemotherapeutic agents are frequently toxic to sperm production. This is frequently permanent.
  • Allopurinol and Colchicine, commonly used for gout, may interfere with fertilization.
  • Cyclosporine and Sulfasalazine are used as immune system suppressants in chronic inflammation inducing diseases.

Medications affecting testosterone levels include:

Testosterone replacement therapy: topical gels (AndroGel, Axiron, Fortesta, and Testim), intramuscular injections (testosterone cypionate and ethanate), transdermal patches (Androderm), and buccal mucosal patches (Striant). Most oral medications are no longer used in the USA because they pose a risk of liver dysfunction and cancer.

History of Infections and Infertility

Infections of the testis are called orchitis. Epididymitis is the infection of the epididymal gland. Occasionally, this is referred to as epididymo-orchitis since both conditions frequently occur simultaneously. Bacterial infections are caused by the same bacterial organisms as prostatitis. E.coli is the most common organism. These infections may result in blockage of the vas deferens and epididymis.

STDs or sexually transmitted diseases such as gonorrhea (Neisseria gonorrhoeae) and nonspecific urethritis (Chlamydia or Mycoplasma) can lead to the inflammation and later obstruction of the vas deferens or the tubules within the epididymis. This obstruction can occur even in asymptomatic infections. It is important to tell your urologist if you ever had any of these infections.

Genital Examination in Infertility

Your urologist will need to examine you for physical causes of infertility. The penis will be examined for the position of the urinary meatus. The meatus is the opening on the tip of the penis. Hypospadias is the birth defect where the meatus is under the head of the penis and is not on the tip. Hypospadias may interfere with proper deposition of semen deep enough into the vagina. Deposition of the semen outside or just barely inside the vagina may not be adequate for conception.

The testicular exam is to evaluate the testes for normal testicular size. About half the volume of each testis is from the cells producing the sperm and the other half is from cells producing testosterone. Small testicular size may be due to inadequate production of either sperm cells or testosterone. Small size may be from inadequate development in the womb, trauma damaging a testicle, or from prior surgery as a child. Having a mumps orchitis infection as a child may cause enough swelling within the testicle to kill some of the cells inside that testicle. Trauma and rarely infection can have similar results.

Examination of the spermatic cord structures refers to the evaluation of the muscle, blood vessels, and vas deferens above the testicle up to its disappearance into the abdomen.

Varicocele is the medical term for varicose veins of the spermatic cord. The non-medical description of this is that the scrotum feels and sometimes looks like a “bag of worms”. This condition is more common on the left side but may be bilateral. Usually, there is an 80/20 ratio of left to right varicoceles. It may or may not cause pain after lifting or with long-term standing. It is occasionally associated with a decrease in the size of the testicle on the affected side. The veins are most prominent when standing and almost immediately flatten upon lying down. Repair consists of dividing (cutting) all these veins into. The best approach to these veins is where the veins exit the abdomen (internal inguinal ring) but before they reach the scrotum (external inguinal ring). Division of these veins usually increases sperm count and motility.

The vas deferentia are the tubes from the testes that carry the sperm up to the prostate. Your semen is a combination of the fluids produced in the prostate, seminal vesicles, and testicles. Ejaculation is the discharge of semen at orgasm. The scrotal examination will evaluate the vas deferens. The vas deferens or vas may be congenitally absent in families that carry the gene for cystic fibrosis. The vas can be damaged in childhood surgeries for hernia, hydrocele, and undescended testis. In the condition of undescended testis, the testicle is up in the groin and must be surgically placed into the scrotum. The most common damage is a crush injury that scars the vas closed. However, just the fact that the testis is undescended has an affect on the fertility of that testicle. Often, these testicles have a long, looped vas deferens with an abnormal insertion into the epididymis. Usually, the epididymis is abnormally attached to the testis.

The epididymis is the gland behind the testicle in the scrotum. The epididymis is adherent to the testicle. This gland is soft enough that most men do not know it even exists. The epididymis is the gland in which the sperm mature before traveling up the vas deferens. Enlargement may be an indication that the vas is obstructed. Cysts occasionally form in the epididymis as well. These are defined as simple cysts if they contain clear fluid. Those cysts containing sperm are called spermatoceles.

The prostate examination is a digital rectal examination (DRE). The urologist will check for signs of enlargement or infection of the prostate. Infected prostate glands are often soft or boggy feeling. Normally, little fluid can be expressed from the prostate. If a moderate or large amount of fluid is produced upon massaging the prostate, this fluid is then placed on a microscope slide for visual inspection for white blood cells (WBCs). WBCs secrete chemicals in their attempt to fight an infection. These chemicals may harm the sperm resulting in death or decreased motility. Clearing of the infection may resolve some infertility issues. The urologist usually cannot feel the seminal vesicles unless they are markedly abnormal. Occasionally, people that carry the cystic fibrosis gene do not develop seminal vesicles and vas deferens, and there is no way for the testis to add sperm to the semen.

Tests for Infertility

Blood tests and semen analyses are used to look for causes of infertility. The blood tests are to check for hormonal abnormalities. If the semen analysis has more than 10 million sperm, these tests are usually not necessary. The usual hormones evaluated are testosterone, total and free testosterone, and sex hormone binding globulin levels. These levels look for testosterone production from the testis. The Pituitary hormones involved are follicular stimulating hormone or FSH and luteinizing hormone or LH. FSH stimulates sperm production, and LH is involved in testosterone production.

If the testosterone level is low, additional tests for prolactin levels and thyroid hormones may be needed.

Measurement of blood sugar or blood glucose and hemoglobin A1C may be needed to check for diabetes or to check one’s level of diabetes control.

Semen analysis is the direct microscopic evaluation of the ejaculated semen. This looks at multiple different parameters.

Semen Collection for Analysis

Masturbation is the most accepted form of collection. This normally produces the most complete specimen. Specimens from condoms are much less useful. These contain many skin cells lost from the skin surface during intercourse. Unless a special condom without spermicide is used, the spermicide will kill the sperm. Collection condoms are made of silicone or polyurethane since latex is toxic to sperm. There is no way to determine if the sperm died from spermicide exposure or if the sperm were dead at the time of ejaculation. If coitus interruptus is used and even a small amount of the ejaculate is lost, the test results will be artificially abnormal. The use of any lubricants or saliva will also kill the sperm.

Transportation of the specimen is best done at body temperature. Placing it in a shirt pocket or between the thighs is the easiest way to achieve this temperature. Sperm begin to die within an hour of ejaculation. If the specimen is brought to the laboratory within 20-25 minutes, the appropriate tests can begin before that hour has elapsed. Sperm begin to die, in a specimen cup, at a rate of about 10% per hour after ejaculation.

Terminology of Semen Analysis

  • Oligospermia refers to a decreased number of sperm.
  • Aspermia is the total lack of semen.
  • Hypospermia is low sperm volume.
  • Azoospermia is the absence of sperm in the semen.
  • Teratospermiais an increase in sperm but they are morphologically abnormal.
  • Asthenospermia is reduced sperm motility or ability to swim.
  • Motility refers to the ability to swim.
  • Morphology refers to the normal or abnormal appearance of the sperm.
  • Vitality refers to the sperm being alive at the time of ejaculation.
  • Liquefaction measures the time it takes the semen to go from a gelatinous state to a liquid state.
  • Fructose is a type of sugar in the semen. It is chemically the same sugar found in fruit.
  • 106 is scientific notation for 1 million.
  • Volume is the amount of semen produced measured in cubic centimeters or ccs.
  • Sperm Concentration is the number of sperm per cc or milliliter (ml).
  • Sperm count is the total number of sperm per ejaculation.
  • Motility is expressed as a percentage of how many of the sperm are moving.
  • Morphology evaluates the shape of the sperm.
  • Liquefaction looks at the time it takes semen to turn from a gel to a liquid.
  • Progression evaluates forward movement of motile sperm.
  • Vitality measures the percentage of sperm alive in the fresh specimen.
  • White Blood Cell Counts look for infection that may be affecting semen quality.
  • Agglutination is the clumping together of sperm.
  • Fructose should be present in the semen, and when fructose is absent, blockage is frequently present.
  • Inhibin B may be measured and low levels may indicate blockage.
  • Alpha-glucosidase levels, if found to be low, may also indicate blockage.
  • A post-ejaculatory urinalysis can be used to look for retrograde ejaculation. This is the medical condition where the semen goes back into the bladder rather than out the penis at the time of ejaculation. It occurs with diabetes, spinal injury, and some medications.

Interpretation of Semen Analysis

Your doctor doesn’t just read the numbers off of your semen analysis report; he must instead interpret the results. What the semen analysis shows is what is normal. This is different than what is adequate for conception.

An example of the difference in normal and adequate is that it is normal to have two kidneys, but one is adequate for a normal life. It is normal to have 10 fingers, but many people get along adequately after the loss of multiple fingers.

Normal Semen Parameters

Semem Volume >2.0 ml; range 1.5-3.5ml
Semem pH 7.2-8.0
Semem Concentration >20 million/ml
Semem Total Sperm Count 40-150 million
Semem Motility >50%
Semem WBC Count < 1 million/ml
Liquifaction 20-25 min; range 20-60 min
Sperm Viability > 65-75% of the sperm are alive

Download Understanding Semen Analysis

Due to a wide daily variation in semen analysis values, 2-3 specimens may be required to determine if a man is infertile.

Semen volume may be low if intercourse is too frequent, such as daily ejaculation.

Low volume may indicate obstruction, retrograde ejaculation or incomplete collection. In retrograde ejaculation, the sperm may be seen on a post-ejaculatory urinalysis.

A pH that is >8.0 may indicate a prostate infection. Low pH <7.2 may indicate blockage of the seminal vesicles. If fructose is also absent, the seminal vesicles are blocked.

Please note that in “normal” individuals’ normal-looking sperm or normal morphology is present at a level of only 30%. Alternately, 70% of the sperm in a normal specimen are abnormally formed and not able to fertilize an egg.

White Blood Cell (WBC) counts that are elevated have been found in up to 10-20% of men tested for infertility. WBCs are designed to kill bacteria. When present in semen, these WBCs can kill sperm as well. Immature sperm cells must be differentiated from WBCs as they look very similar. WBC counts also increase in men with sub-clinical prostatitis.

Motility may be low due to not ejaculating at least every 10-14 days or due to heat exposure: environmental or fever.

Fertility comes down to a game of numbers. All of the parameters in a semen analysis do not have to be normal for an individual man to be fertile.

Contrary to popular belief, one sperm and one egg do not usually result in fertilization. Under normal circumstances, it takes multiple sperm to break down the zona pellucida or outer coating of the human egg (ovum) before one sperm finally penetrates and fertilizes that egg.

Let’s start with an example of the numbers needed for successful intrauterine insemination.

What is said to be adequate for insemination is a semen specimen of 1 ml, containing 20 million sperm with 20% (0.20) normal motility and 20% (0.20) normal morphology.

This then equals 1 x 20 million x 0.20 motility x 0.20 morphology= 800,000 normal sperm.

So, if an individual has, for example, a specimen of 1.5 ml, a count of 18 million sperm/ml, an abnormal motility of 30% (0.30), and a low morphology of 20% (0.20), this appears to be quite abnormal. The math however is quite different.

This equals1.5 ml x 18 million x 0.30 motility x 0.20 morphology=1.6 million normal sperm. So while on the surface this specimen has multiple abnormal values, it is still possible to achieve pregnancy through insemination but not through intercourse. The increase in volume and motility, in this case, make up for the lower sperm count.

Using the lowest normal semen parameters of 20 million/ml x1.5 ml x 0.50 motility and 0.30 morphology=4.5 million normal sperm. While pregnancy is achievable at these semen analysis levels, conception will likely take timing of intercourse and up to 12 months or more to achieve pregnancy.

Pregnancies have been achieved at lower counts, but as the sperm count decreases, so does the chance of conception. It is rare that a man can achieve conception at sperm counts less than 10 million/ml even with all other parameters being normal. Unfortunately, most of the time, low sperm counts are associated with low motility as well. Even at mid range numbers such as 3 ml x 10 million/ml x 0.50 motility x 0.50 morphology=7.5 million normal sperm, this would be barely adequate for conception through intercourse.

Some studies suggest that sperm motility is more important than sperm concentration and sperm morphology. The lowest semen parameters that are adequate for readily achievable pregnancy through intercourse may be 10-12 million viable sperm.

Mid range normal values of a volume 2.5ml x 20 million/ml x 0.40 motility and 0.50 morphology =10 million normal sperm.

At counts around 15 million/ml, it is a little easier to reach adequate numbers of normal sperm; therefore, 15 million/ml x 3 ml x 0.50 motility x 0.50 morphology=11.25 million normal sperm.

Ultrasonic Evaluations for Infertility

Scrotal ultrasound is an examination using ultrasound that can look for testicular and epididymal abnormalities that might suggest blockage or abnormal fetal development of these structures. This is the same type of ultrasound used in pregnancy to monitor fetal development. Doppler ultrasound also checks for arterial blood flow to the testicle. Venous blood flow or varicocele presence is assessed at the same time.

Transrectal ultrasound uses the insertion of an ultrasound probe, about the size of your index finger, into the man’s rectum to look at the prostate and seminal vesicles. Enlarged or cystic seminal vesicles may be found if there is obstruction of the ejaculatory ducts.

Surgery for Male Infertility

Varicocele surgery is the ligation (tying and cutting into) of the enlarged veins to the involved testis. Some studies have shown a 70% increase in semen parameters after varicocele surgery and a 40-50% conception rate. This may not be permanent, and there is a 10-15% recurrence rate after open surgical repair and a 1-3% recurrence of the varicocele after microsurgical correction. Alternatively, this can be done intra -abdominally using the laparoscope to apply surgical titanium clips to the veins before the veins enter the inguinal canal on their way to the testicle. The interventional radiologist sometimes can block the veins by injecting small metal coils into these same veins. This technique is called embolization.

Vaso-vasostomy or epididymo-vasostomy is used to bypass blockage in the vas deferens or epididymis. There is usually a 50-75% success rate with up to a 50% fertility rate after these procedures.

Medical Treatment of the Subfertile Male

Clomid or clomiphene citrate is an estrogenic treatment first used in women to stimulate ovulation. It has been used in men with mixed results. The addition of Vitamin E 400IU per day may help the Clomid to work better than by itself. Most studies show a modest improvement in semen quality in about one third of patients treated with 25 to 50 milligrams per day for up to one year. While women cycle monthly, men can only be cycled every 3 months.

Human gonadotropin has been used as an injectable medication alone and in combination with testosterone with mixed results.

Retrograde ejaculation results in the backward flow of semen into the bladder at the time of ejaculation. Retrograde ejaculation is most common in diabetics and patients with certain spinal cord injuries or that have had surgery in the retroperitoneum. The retroperitoneum is the area in the abdomen behind all the organs. The nerves that control ejaculation are found here. Cancer surgery for testicular cancer may damage these nerves.

Medications that close the bladder neck may stop retrograde ejaculation and restore normal or antegrade ejaculation. An older antidepressant, Imipramine, at doses of 25mg twice a day may help. This has resulted in success about 38% of the time. An older antihistamine (Brompheniramine) may be used with Sudafed (Pseudoephedrine) to stimulate closure of the bladder neck and restore antegrade ejaculation. Success has been reported about 60% of the time with this combination.

Supplements suggested to assist with infertility are: Vitamin C, Vitamin E, Vitamin B12, folic acid, beta carotene, L-Carnitine, selenium, and zinc. While all have been proposed to benefit semen quality, there has not been much rigorous testing to confirm this. Some of these such as selenium have proven to be toxic in high doses.

Infertility Clinic Specialty Treatments

The following treatments are out of the normal scope of your urologist, and you will most likely be referred to the infertility clinic.

Intrauterine insemination (IUI) is the introduction of washed sperm directly into the uterus. A small catheter is inserted into the uterine cavity. This bypasses the cervical mucus and places the sperm close to the opening of the fallopian tubes. This is successful in people with low sperm counts, sperm motility problems, and retrograde ejaculation.

In Vitro Fertilization (IVF) is the fertilization of the egg outside the body in a glass (Petri) dish. After incubating the sperm and eggs for 48-72 hours, the fertilized eggs can then be inserted into the uterus, and a normal pregnancy should follow. This technique can be used in women with obstruction of the fallopian tubes due to infection, scarring, or endometriosis. It may also be used for men with low sperm counts or oligospermia. Many times, the ovaries have been stimulated to allow for the retrieval of multiple eggs at one time.

Intracytoplasmic Sperm Injection (ICSI) is the variation of in vitro fertilization that involves the injection of a single sperm directly into an egg using a microscopic needle. This technique allows even men with very poor semen quality to conceive. If azospermia is present, no sperm are in the semen, sperm may be extracted from the epididymis or testicle for use in this procedure.

Karyotyping is the medical testing of the chromosomes to look for genetic defects.

Sperm retrieval from the urine, usually associated with retrograde ejaculation, may be used as a source of sperm for these procedures.

MESA or Microsurgical Sperm Aspiration is done through a small incision with microscopic guidance of a needle into the epididymis.

PESA or Percutaneous Sperm Aspiration inserts a needle through the skin under local anesthesia to retrieve sperm. This technique does not always obtain sperm.

FNA or Fine Needle Aspiration inserts the needle directly into the testicle to obtain sperm. Frequently, there are low numbers of sperm retrieved.

Testicular Biopsy/TESA or open biopsy is occasionally utilized in the evaluation of infertility. The covering to the testicle is opened, and a small portion of the seminiferous tubules is removed. The sperm may then be isolated from this piece of tissue.

Cervical mucus testing evaluates the sperm’s ability to swim up the cervical canal into the uterus. In some instances, this mucus adversely affects the sperm, preventing progression into the uterus, often called hostile mucus.

Anti-sperm antibody testing looks for factors that kill sperm, immobilize sperm, or agglutinate sperm. Agglutination is the condition where the sperm stick together or clump together.

Hamster egg penetration testing is used to see if the viable, appearing sperm are able to fertilize an egg.

Inhibin B can be measured. If the levels are low, this may indicate blockage.

Alpha-glucosidase levels may be measured. If levels are found to be low, blockage may be present.

Chemical analysis for fructose, citrate, and zinc may be obtained.


Male factor infertility is a complex problem. Feel free to discuss this with your urologist. He will likely be able to counsel you about ways to improve fertility and at least begin an evaluation. If you need referral to an infertility clinic, he will be able to supply the clinic with the basic test results up to that point of your evaluation.