Infertility is usually defined as the inability of a couple to conceive even after one year of unprotected, frequent sexual intercourse. Male infertility is defined as the inability of a male to make a fertile female pregnant, also for a minimum of at least one year of unprotected intercourse. There are several reasons for male fertility to occur, including both reversible and irreversible conditions. Other factors that could influence each of the partners could be their age, medications, surgical history, exposure to environmental toxins, genetic problems, and systemic diseases. Male infertility can be caused by low sperm production, abnormal sperm function or blockages that prevent the delivery of sperm. Illnesses, injuries, chronic health problems, lifestyle choices and other factors may contribute to male infertility.

Causes

Making mature, healthy sperm that can travel depends on many things. Problems can stop cells from growing into sperm. Problems can keep the sperm from reaching the egg. Even the temperature of the scrotum may affect fertility. These are the main causes of male infertility:

Sperm Disorders:

The most common problems are with making and growing sperm. Sperm may not grow fully, be oddly shaped, not move the right way, be made in very low numbers (oligospermia) or not be made at all (azoospermia).

Varicoceles: A varicocele is a swelling of the veins that drain the testicle. It’s the most common reversible cause of male infertility. 

Retrograde Ejaculation: Retrograde ejaculation occurs when semen enters the bladder during orgasm instead of emerging out the tip of the penis.

Immunologic Infertility: Sometimes a man’s body makes antibodies that attack his own sperm.

Obstruction: Sometimes the tubes through which sperm travel can be blocked. Repeated infections, surgery (such as vasectomy), swelling or developmental defects can cause blockage.

Hormones: Hormones made by the pituitary gland tell the testicles to make sperm. Very low hormone levels cause poor sperm growth

Certain medications: Testosterone replacement therapy, long-term anabolic steroid use, cancer medications (chemotherapy), some ulcer drugs, some arthritis drugs and certain other medications can impair sperm production and decrease male fertility

Risk factors

Risk factors linked to male infertility include:

  • Smoking tobacco
  • Using alcohol
  • Using certain illicit drugs
  • Being overweight
  • Having certain past or present infections
  • Being exposed to toxins
  • Overheating the testicles
  • Having experienced trauma to the testicles
  • Having a prior vasectomy or major abdominal or pelvic surgery
  • Having a history of undescended testicles
  • Being born with a fertility disorder or having a blood relative with a fertility disorder
  • Having certain medical conditions, including tumors and chronic illnesses, such as sickle cell disease
  • Taking certain medications or undergoing medical treatments, such as surgery or radiation used for treating cancer

Symptoms

The main sign of male infertility is the inability to conceive a child. There may be no other obvious signs or symptoms.

In some cases, however, an underlying problem such as an inherited disorder, hormonal imbalance, dilated veins around the testicle or a condition that blocks the passage of sperm causes signs and symptoms. Like:

  • Problems with sexual function — for example, difficulty with ejaculation or small volumes of fluid ejaculated, reduced sexual desire, or difficulty maintaining an erection (erectile dysfunction)
  • Pain, swelling or a lump in the testicle area
  • Recurrent respiratory infections
  • Inability to smell
  • Abnormal breast growth (gynecomastia)
  • Decreased facial or body hair or other signs of a chromosomal or hormonal abnormality
  • A lower than normal sperm count (fewer than 15 million sperm per milliliter of semen or a total sperm count of less than 39 million per ejaculate)

When to see a doctor

See a doctor if you have been unable to conceive a child after a year of regular, unprotected intercourse or sooner if you have any of the following:

  • Erection or ejaculation problems, low sex drive, or other problems with sexual function
  • Pain, discomfort, a lump or swelling in the testicle area
  • A history of testicle, prostate or sexual problems
  • A groin, testicle, penis or scrotum surgery
  • A partner over age 35

Diagnosis

History and Physical Exam: The doctor will ask about childhood illnesses, current health problems, or medications that might harm sperm production. The physical exam will look for problems in the penis, epididymis, vas deferens, and testicles. Doctor will look for varicoceles. They can be found easily with a physical exam.

Hormone evaluation: Testosterone and multiple hormones made in the brain control sperm production. However, hormones are not the main problem in 97% of infertile men.

Sperm and semen analysis: In this  assess the sperm count, their shape, movement, and other variables.

Testicular biopsy: This is done for men with very low or no sperm in their semen. A needle biopsy of the testicle can show whether a man is making healthy sperm.

Genetic testing: Genetic tests can identify specific obstacles to fertility and problems with sperm. Experts differ as to when genetic tests should be done.

Post-ejaculation urinalysis: Sperm in the urine can indicate the sperm are traveling backward into the bladder instead of out of penis during ejaculation (retrograde ejaculation)

Scrotal ultrasound: This test uses high-frequency sound waves to produce images inside the body. A scrotal ultrasound can help doctor to see if there is a varicocele or other problems in the testicles and supporting structures.

Transrectal ultrasound: A small, lubricated wand is inserted into the rectum. It allows doctor to check  prostate and look for blockages of the tubes that carry semen.

Treatment

Surgical Therapy for Male Infertility

Varicocele Treatments: Varicoceles can be fixed with minor outpatient surgery called varicocelectomy. Fixing these swollen veins helps sperm movement, numbers, and structure.

Microsurgical Vasovasostomy: Vasovasostomy is used to undo a vasectomy. It uses microsurgery to join the 2 cut parts of the vas deferens in each testicle

Vasoepididymostomy: Vasoepididymostomy joins the upper end of the vas deferens to the epididymis. It’s the most common microsurgical method to treat epididymal blocks

Transurethral Resection of the Ejaculatory Duct (TURED):Ejaculatory duct blockage can be treated surgically. A cystoscope is passed into the urethra (the tube inside the penis) and a small incision is made in the ejaculatory duct. 

Treatment for Unknown Causes of Male Infertility

Assisted Reproductive Techniques

If infertility treatment fails or isn’t available, there are ways to get pregnant without sex. These methods are called assisted reproductive techniques (ARTs). Based on the specific type of infertility and the cause there will be:

Intrauterine Insemination (IUI). For IUI, the doctor places the sperm into the female partner’s uterus through a tube. IUI is often good for low sperm count and movement problems, retrograde ejaculation, and other causes of infertility.

In Vitro Fertilization (IVF). IVF is when the egg of a female partner or donor is joined with sperm in a lab Petri dish. For IVF, the ovaries must be  stimulated to produce multiple eggs (ova). This is often done with drugs given as daily injections. After 3 to 5 days of growth, the fertilized egg (embryo) is put back into the uterus. 

Intracytoplasmic sperm injection (ICSI.)A single sperm is injected through a tiny needle into an egg. The fertilized egg is then implanted in the uterus. ICSI can be performed when sperm counts are extremely low or abnormal.

Sperm Retrieval for ART. Many microsurgical methods can remove sperm blocked by obstructive azoospermia (no sperm). The goal is to get the best quality and number of cells. This is done while trying not to harm the reproductive tract. These methods include: Testicular Sperm Extraction (TESE), Testicular Fine Needle Aspiration (TFNA), Percutaneous Epididymal Sperm Aspiration (PESA), Microsurgical Epididymal Sperm Aspiration (MESA).

Alternative medicine

Supplements with studies showing possible benefits for improving sperm count or quality include: Coenzyme Q10, Folic acid and zinc combination, L-carnitine, Selenium, Vitamin C and Vitamin E.

Lifestyle and home remedies

There are a few steps you can take at home to increase your chances of achieving pregnancy:

  • Increase frequency of sex: Having sexual intercourse every day or every other day beginning at least five days before ovulation increases  chances of getting the partner pregnant.
  • Have sex when fertilization is possible: A woman is likely to become pregnant during ovulation — which occurs in the middle of the menstrual cycle, between periods. This will ensure that sperm, which can live several days, are present when conception is possible.
  • Avoid the use of lubricants: Products such as Astroglide or K-Y jelly, lotions, and saliva might impair sperm movement and function.
  • Live a healthy lifestyle: Eat a variety of healthy foods, maintain a healthy weight, get enough sleep, and exercise regularly.
  • Avoid things that damage your overall health: Stop or reduce the use of alcohol, quit smoking, and don’t use illicit drugs.

Coping and support

  • Set limits. Decide in advance how many and what kind of procedures are emotionally and financially acceptable for you and your partner and determine a final limit. Fertility treatments can be expensive and often aren’t covered by insurance.
  • Consider other options. Determine alternatives — adoption or donor sperm or egg — as early as possible in the fertility process. This can reduce anxiety during treatments and feelings of hopelessness if conception doesn’t occur.
  • Talk about the feelings. Locate support groups or counseling services for help before and after treatment to help endure the process and ease the grief if treatment fails.
  • Practice stress-reduction techniques. Examples include yoga, meditation and massage therapy.
  • Consider going to counseling. Counseling such as cognitive behavioral therapy, which uses methods that include relaxation training and stress management, might help relieve stress.
  • Express our self. Reach out to others rather than holding in feelings of guilt or anger.
  • Stay in touch with loved ones. Talking to the partner, family and friends can be helpful.

References

https://www.mayoclinic.org/            (MYOCLINIC)

https://www.urologyhealth.org/         (UROLOGY CARE FOUNDATION)

https://www.ncbi.nlm.nih.gov/            (NIH)

https://www.webmd.com/                  (WEBMED)