For decades, evaluation and treatment of the infertile couple centered on the female. The male was assumed to not be the origin of the problem if there were no problems in producing an ejaculate. Recent advances in the field of Andrology have shed new light on to the causes of male infertility. There are now many possible reasons why an infertile couple cannot conceive, which can be attributed to factors originating in the male. Of the more than 3 million infertile couples in the United States, approximately 40% have male factor infertility.
A simple way to understand the processes by which sperm are produced is to think of the process as an assembly line. The signals to begin sperm production originate in the hypothalamus and pituitary. The testes are like a factory, which should produce both healthy sperm and testosterone. The sperm produced will need to have an unobstructed route of passage into the female reproductive system. The male needs to have healthy ejaculatory mechanisms. The sperm will then need to be able to complete the task of fertilization once being exposed to the egg in ample quantities. A number of factors that could lead to male infertility are listed below.
- Genetic factors – genetic disorders such as cystic fibrosis or Klinefelter’s Syndrome are associated with decreased sperm count. Birth defects, such as undescended testes or congenital malformations may lead to a reduction in functional sperm count. Some infertile men may have a small deletion of genetic information from the Y chromosome. This can have a detrimental effect on the production of normal sperm.
- Hypogonadism – Hypothalamic or pituitary disorders may lead to inadequate spermatogenesis or insufficient production of testosterone. Typically, this is present at birth. It can also develop as a result of radiation therapy or brain tumors. The deficiency has a detrimental effect on both sperm production and sperm count.
- Trauma to the Testicles – Crush injuries, vascular compromise, and nerve damage all can affect male fertility.
- Infections – Sexually transmitted diseases, such as gonorrhea, chlamydia, and mycoplasma all may scar the delicate tubular structures of the testes (vas deferens). Mumps after puberty can lead to damage to the testicles. Infections such as chronic prostatitis may be asymptomatic. Once diagnosed, these can be treated with a course of antibiotics.
- Anti-sperm Antibodies – The immune system may produce antibodies which are directed against components of the sperm cell. Sperm antibodies can attack the head, neck or tail of the sperm. This may cause the sperm to clump or stick together and will result in decreased motility. Antibodies directed against the sperm head may coat the portion of the sperm, which is meant to come in contact with the egg, and thus prevent successful penetration. Anti-sperm antibodies may form following infection or surgery. Their formation may be diagnosed with a simple test. Your physician will order this test if it is indicated.
- Varicoceles – are enlarged or varicose veins present within the scrotum. An increased amount of blood will pool around the testes leading to an elevation in temperature. The long-term consequence of varicoceles is a detrimental effect on sperm count, motility or morphology.
- Drug Use – Chemotherapy, excessive use of alcohol or marijuana, anabolic steroids or female sex hormones all may reduce spermatogenesis and impair normal sperm function.
- Cancer Treatment – Medication side effects are known to reduce sperm function. Radiation and chemotherapy may have disastrous consequences on future fertility. Many males will undergo sperm banking prior to initiation of these treatments. Testicular cancer treatment may involve removal of one or both testicles.
- Medication Side Effects – Antihypertensives are well known for their beneficial effects on the cardiovascular system. One side effect is reduced ejaculatory function. Calcium channel blockers have an additional impairment on the metabolism of sperm. Selective Serotonin Reuptake Inhibitors (SSRI’s), which are widely used in the course of depression, can decrease libido or effect orgasm. Your physician will take an inventory of the medications you are on and evaluate the pros and cons of side effects such as these and how they impact your fertility.
- Retrograde Ejaculation – This is a condition where ejaculation may force sperm into a diverted course. Sperm may end up in the bladder after ejaculation. The sphincter muscles that normally control this process may not function properly as the result of nerve damage. This condition is seen often in spinal cord injury, diabetes, or multiple sclerosis. Your fertility specialist has special treatments that can help patients with this disorder.
- Environmental Exposures – Reproductive toxins, such as harsh chemicals, pesticides, cigarette smoke, and occupational exposures are known to decrease fertility.
- Vasectomy – Vasectomy is an intentional means by which the connection from the testes is interrupted, so that sperm are no longer present in the ejaculate. Patients who undergo reversal of a vasectomy may conceive in the future. In some instances the sperm that are produced following this surgery are impaired by antisperm antibodies. If the vasectomy cannot be reversed, in-vitro fertilization may still be an option. Ask your physician if an evaluation is appropriate. Also, you may want to consider sperm banking.
- Life-Style Considerations – Thermal injury may result from spending too much time in hot tubs, saunas, or steam baths. Stress has a role in infertility for both the male and female. The process of fertility therapy carries many factors that can serve to heighten the stress of the couple. They need to be aware of this and take steps to reduce stress when possible.