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Male Infertility

1 November 2022 | 27 mins read | Male Infertility

A widely accepted definition of infertility is “the inability to achieve pregnancy after one year of frequent, unprotected intercourse”. At any given time, approximately 1 out of 8 couples trying to have a baby will find themselves in this situation. Around 20 % – 30% of cases are due to male infertility, and roughly another 30% are from factors affecting both the male and the female.   

Although infertility makes it more difficult for a couple to become pregnant, it is far from impossible.  There are numerous treatments available that will greatly increase one’s chances of having biological offspring. 

How is sperm produced & released? 

The areas of the body most involved in sperm production are the brain and the testes. 

In the brain, a hormone called GnRH (short for Gonadotropin Releasing Hormone) directs two other hormones to be released.  These two hormones, called FSH and LH,(short for Follicle Stimulating Hormone and Luteinizing Hormone) travel to the testes. 

In the testes, LH helps to produce testosterone and FSH helps produce sperm.   

In order to fertilize an egg, millions of sperm have to exit the testes and be propelled into the female reproductive tract. This happens during ejaculation. During ejaculation: 

  • Contractions push the sperm out of the epididymis into a tube called the vas deferens. 
  • In the vas deferens the sperm mix with fluids to form semen.  
  • The vas deferens connects with the urethra, which also connects to the bladder.  A sphincter closes off the ‘neck’ of the bladder during ejaculation so that urine and sperm do not mix.  


The urethra propels the semen to the end of the penis and, if pregnancy is desired, into the female’s vagina. However, most sperm die before they reach the egg.  This is due to: 
 

  • Loss as fluids flow out of the vagina. 
  • Getting stuck in cervical mucus. 
  • Death from acidity in the reproductive tract.  
  • Swimming too slowly and dying before they reach the egg.  
  • Being trapped in the folds lining the reproductive tract. 
  • Half of the sperm going into the wrong Fallopian tube. 


The rest of the sperm continue until they reach the egg.  Those sperm, of which there may only be dozens or a few hundred survivors, gather head-first all around the egg, whipping their tails and pushing their heads against it.  They release a substance that softens the exterior of the egg, called the zona pellucida.  Immediately after the first sperm penetrates through, the zona pellucida becomes impenetrable to the rest of the sperm. 
 

 

What are the most common conditions that cause male infertility? 

Any condition that affects the production or release of hormones that control sperm production, or any condition that affect the ability of the testes to produce, store, and release sperm can cause male infertility.  These conditions can be categorized as: 

Primary hypogonadism, directly affecting the testes and therefore sperm production.  The most common conditions causing male infertility are in this category.  They are categorized into chromosomal and non-chromosomal.  

  • Chromosomal (genetic; inherited) abnormalities can range from mild to severe.  If mild, the male might not know that his fertility is impaired until he starts trying to have a child.  The most common chromosomal cause of primary hypogonadism is Klinefelter syndrome.  
  • Non-chromosomal (acquired) abnormalities directly affect sperm production in the testes but are not inherited and would not be passed down. 


Common causes include:
 

  • Infection 
  • Injury 
  • Varicoceles.  A varicocele is a dilated vein in the scrotum.  Around 15% of males have a varicocele, but only some men are infertile as a result. For those men, surgery is often an effective treatment.   
  • Radiation treatment 
  • Testicular torsion 
  • Having had ‘mumps’ after puberty. 
  • Idiopathic (unknown) spermatogenic failure.  Having few or no sperm without an identifiable cause.   

 

Secondary hypogonadism, originating in the brain.
As with primary hypogonadism, these conditions are either chromosomal or acquired. 
 

  • Chromosomal abnormalities causing secondary hypogonadism are rare.  
  • Non-chromosomal conditions affect the parts of the brain that produce reproductive hormones.

Include: 

  • Tumor. 
  • Radiation. 
  • Structural abnormality. 
  • Steroid use, whether for medical or non-medical reasons. 
  • Exposure to environmental toxins such as lead. 
  • Testosterone use.   

 

Disorders of sperm transport
Sperm may be healthy and plentiful but are unable to get where they need to go.  Causes include: 

  • Retrograde ejaculation, in which the sphincter at the neck of the bladder fails to close during ejaculation.  Semen is propelled toward the bladder, and therefore not toward the female. 
  • Anatomic abnormalities  
  • Obstructions or scar tissue  
  • Premature ejaculation 
  • Vasectomy 

 

Miscellaneous or idiopathic (unknown) 

  • Lack of knowledge about the type or timing of sexual activity needed for conception. 
  • Sexual dysfunction. 
  • Having risk factors which may impact fertility.

Risk factors include:

  • Heavy alcohol use. 
  • Smoking. 
  • Use of street drugs. 
  • Complications of diabetes and certain systemic diseases. 
  • Excessive exposure of the testes to heat. 
  • Emotional stress. 
  • Use of lubricants that are toxic to sperm.   
  • Recovering from fever. Fever can temporarily suppress release of GnRH, resulting in a decrease in ejaculated sperm several weeks later. 

 

How do doctors determine the cause of male infertility? 

The doctors will follow a step-by-step process consisting of: 

  • A detailed medical history.   
  • A physical exam. 
  • Evaluation of a semen analysis.   The analysis must be considered in context of the history, physical, and other tests.

The semen analysis looks for: 

  • Viscosity: After ejaculation semen should liquify so that sperm can move through faster. 
  • Quantity of semen: Minimum of 1.5 mls. 
  • Sperm concentration: At least 15 million sperm per milliliter of semen.  
  • Sperm count: A minimum of 39 million sperm per ejaculate.  
  • Motility:  The percentage, speed, and direction of sperm that are moving. 
  • Morphology: Size, shape, and appearance. 
  • Ph: Semen that is too acidic might be obstructed or contacting urine before ejaculation.  Semen that is too alkaline could indicate an infection.  
  • White Blood Cells: Too many WBCs could indicate an infection. 
  • Clumping: Randomly clumped sperm could indicate infection; organized clumping could indicate the presence of antisperm antibodies.  

 

The results of the semen analysis may be diagnostic or may provide a guide for additional tests. 


  • Follow up tests as needed. These can include:  
  • Hormonal testing. 
  • Genetic testing 
  • Imaging – such as ultrasound of the testes or prostate; MRI of the brain. 
  • Testicular biopsy  

 

What are the treatments for male infertility?  

The treatment for male infertility depends on the cause.  Often fertility is restored once the underlying condition is treated.   

If the male has a low sperm count but is otherwise healthy, he may be treated with Clomiphene Citrate. Clomiphene Citrate is a medication used (off-label in the U.S.) to increase GnRH levels.  

 

How can an infertile male have a biological child? 

If the male is producing at least some sperm, doctors may recommend one of several physician-assisted methods. For each, the male either provides a sample of semen through ejaculation or, if the male has a blockage or extremely low sperm count, the doctor retrieves the sperm directly from the anesthetized testes. The egg is then fertilized by:   

  • Intrauterine insemination (IUI):  

In IUI, the doctor puts a sample of the male’s sperm into a narrow catheter.  The doctor threads the catheter through the female’s vagina and directly into the uterus, releasing the sperm as close as possible to the fallopian tubes where the egg awaits. 

  • In Vitro Fertilization (IVF):  

In IVF, the sperm fertilizes the egg outside of the female’s body, in a laboratory.  

In IVF the female’s ovaries are hormonally stimulated to produce eggs that the doctor retrieves directly from the ovarian follicle.  Around the same time, the male provides a sample of semen, either through ejaculation or sperm retrieval.  The sperm are sorted out and are released next to the eggs with the hope that at least one egg will be fertilized and form an embryo.  Three to five days later the embryo is placed in the female’s uterus. 

For more information on IVF, see Halza’s article HERE 

  • Intra Cytoplasmic Sperm Injection (ICSI) with IVF: 

As with IVF, fertilization of the egg takes place in the laboratory.  The technician injects a single sperm directly into the egg.   

 

For 10-20% of men who don’t impregnate a woman within 12 months of frequent, unprotected intercourse, the results of fertility tests are negative (normal).  However, assuming that the female partner is fertile, many of those couples will find themselves pregnant at some point within the following 12 months without any medical assistance.  In fact, the majority of couples who are “infertile” by the common definition can go on to conceive a child, either with or without medical assistance.  

 

How can Halza help? 

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