Straight Talk About Male Infertility

By: Dr. Eugene M. Stoelk, MD

Infertility is extremely common with at least 15% of American couples unable to conceive even after one year of unprotected intercourse. Statistics further show at least 40% of infertility cases involve a problem with male infertility or a combination of both male and female factors. These numbers often times surprise people as it seems that “everyone is pregnant”. However, if you yourself have difficulty in conceiving and are at all open about it, it is immediately apparent that there is a large group of similar couples.

Evaluation of the reasons for infertility most often are performed through a medical physician, sometimes beginning with the woman’s gynecologist, but often times through specialists called Reproductive Endocrinologists. Men are sometimes evaluated first through a urologist, but could also appropriately be seen by a Reproductive Endocrinologist (who are located in fertility centers). Finding the underlying reasons for infertility always begins with a thorough medical history, sometimes associated with a physical exam. An intelligent game plan for testing needs to be set up depending on the most likely issues. The great majority of couples can and do achieve successful pregnancies. Often times this is with simple treatments such as ovulation medications, inseminations, or fairly simple surgeries such as diagnostic laparoscopy to remove endometriosis from the woman’s pelvis. Other couples need to advance to more involved treatment using medications designed to produce several eggs at one time. Finally, advanced reproductive technologies (ART) have been ever increasing frequently used to achieve successful “test tube babies”.

MALE INFERTILITY TESTS

The rest of this article will be largely focused on male infertility, some of the more common reasons, and brief discussion of treatments. Testing, of course, begins with the infamous “little room” where semen specimen is collected and then a thorough semen analysis is performed. This includes the count which normally ranges from 20million to 100 million per milliliter. The average ejaculate ranges from 2ml to 5ml (5ml= 1tsp). So no, even the suddliest guy does not “and cannot” fill up the cup! The sperm are also evaluated for motility, which is the percentage of moving sperm, and the degree to which they are vigorous. Finally, strict criteria are used for evaluating the shapes of the sperm (morphology). All of these factors are collectively evaluated for normalcy.

More advanced testing includes the immunobead assay (I.B.T.) that looks for the presence of immunological problems, called sperm antibodies. Basically the man develops an immune allergy response to his own sperm. This is quite commonly seen in men who have had vasectomies and subsequent vasectomy reversals. I’ll address this once again later in the article. Other advanced testing includes a crazy sounding test, the hamster sperm penetration assay. While this test is not universally used by reproductive physicians, and would never be a routine sperm test, it can be helpful in identifying situations where the man has relatively normal sperm perameters, but still there is some functional problem that the sperm cannot successfully fertilize eggs. One final new test that I am using ever more frequently is called the Sperm Chromatin Structure Assay (SCSA). This looks at the sperm DNA for fractured chromosomes (the mans complete DNA complement is encoded on 23 strands of DNA called chromosomes). All men have a small percentage of sperm cells that have some fractured chromosomes. However it is now apparent that certain men have a much higher percentage of sperm cells with fractured chromosomes. This correlates with a much lower pregnancy rate and a much higher miscarriage rate such that the delivered babies are few and far between. The causes for the high rate of abnormal DNA are varied and most often no specific reason can be found. There is some evidence that certain treatments can partially reverse this.

VARICOCELE

One cause for decreased male fertility is the presence of a varicocele. A varicocele is varicose veins that exist in the scrotal sac above the testis. Because of anatomically differences between the right and the left side, a man who has a varicocele always will have it on the left side and some will also have it present on the right side. The treatment for varicoceles has always been somewhat unclear. The classic treatment is a varicocele repair done surgically with the veins being identified and ligated to obstruct and eliminate them. Results are highly variable with some men getting very significant improvements in sperm count perameters and pregnancies. The full improvement in the sperm might take at least 6 months if not a full year. Besides surgery, the couple may also begin doing intrauterine inseminations (IUI) in the fertility center. This takes all of the sperm in a single specimen, rinses the semen fluid away and then the concentrated specimen is placed way up inside the women’s uterus.

Many other cases of a varicocele problem do not show any significant improvement following the varicocele surgery. While this is hard to predict exactly who will benefit and who will not, the more abnormal the sperm count is to begin with, the less likely improvement will be enough. Of course, the sperm factor is only part of the couples whole situation when seen in a reproductive endocrinology fertility clinic. The age of the wife is also very critical to deciding which treatment to use. Women who are younger, can afford more time to see if the surgery and inseminations will work. Women who are 35 and older probably should have their husband not go through surgery and proceed quickly on to assisted reproductive technology with in vitro fertilization.

VASECTOMY REVERSAL

A very common situation these days is couples where the man has had a vasectomy, usually during a previous marriage. A vasectomy reversal done with microscopic techniques to cut out the obstructed tubing and bring the open ends back together is performed by a urologist (preferably a urologist who does many of these every year). Unfortunately, I also see many couples where the vasectomy reversal has failed and the reversal maybe wasn’t even the best treatment for them right from the start.

Sperm are unique in many ways but one is that they are “immune privileged”. This means that the sperm cells themselves are not in direct contact with the mans blood. When a vasectomy is performed and the tubing is blocked, frequently there will be microscopic ruptures through the tubing such that the sperm now come in contact with the mans blood for the very first time. Therefore his immune system will consider the sperm as foreign particles and produce an immune reaction called sperm antibodies. These antibody proteins attach to the sperm cells. When a vasectomy reversal is performed, even when a good result occurs and there is now ample sperm in the ejaculate again, the sperm antibodies can block fertilization. Basically, when the couple has natural intercourse (and even inseminations), the sperm cells with the antibodies attached signal the women’s immune cells to destroy the sperm. Therefore very few of the sperm ever get close to the egg to fertilize it.

There is no good way to know if the man has developed sperm antibodies until after the vasectomy reversal has been performed. Now the semen specimen can be checked through the immunobead assay (I.B.T.) to determine if sperm antibodies are present. Obviously this is problematic because those who do have the antibodies will have a much harder time achieving a pregnancy. A good rule of thumb has been in place for many years which suggests that if the vasectomy has been performed less than 5 years before a potential reversal, that the chances of sperm antibodies being present is fairly low. However, if the vasectomy has been present for more than 5 years, antibodies are very commonly seen and pregnancy rates disappointing low. Therefore, I think it is very important for couples to be counseled about this and for most of them to choose high tech means of achieving a pregnancy through IVF, rather going through a surgery that may have low chances. Sperm are obtained through a very minor procedure called testicular biopsy. The sperm cells are then placed directly into the eggs using super microscopic glass needle without damaging the egg. Success rates are quite good, although certainly dependent on the age of the woman.

Finally, even if the man has had the vasectomy for less than 5 years, if his wife is 35 or older, certainly if 38 or older, then avoiding surgery and going directly to testicular biopsy and IVF would be suggested.


Dr. Eugene M. Stoelk, MD is a Reproductive Endocrinologist practicing through the Northwest Fertility Center in Portland Oregon. After completing medical school and then residency in obstetrics and gynecology, he then completed a 2-year fertility fellowship at the University of Louisville. Dr. Stoelk has been in private practice in Portland since 1986. His practice focuses on all aspects of fertility treatment for both women and men. He is a member of the American Society of Reproductive Medicine, the Society for Assisted Reproductive Technology (SART), the Association of American Physicians and Surgeons, and the Oregon Medical Association. You can visit his website for more information at drstoelkdelivers.com.

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