MALE INFERTILITY- TREATMENT AND MANAGEMENT

Infertility is defined as a couple’s inability to become pregnant after one year of unprotected intercourse.  In any given year, about 15% of couples in North America and Europe who are trying to conceive are infertile.

The fertility of a couple depends upon several factors in both the male and female partner.  Among all cases of infertility in developed countries, about  8% can be traced to male factors, 37% can be traced to female factors, 35% can be traced to factors in both the male and female partners, and 5% cannot be traced to obvious factors in either partner.

When infertility occurs, the male and female partners are evaluated to determine the cause and best treatment options.  In the past, men with infertility had few options because there was limited information about causes and even less information about successful treatment.  However, new tests have made it possible to determine the causes of male infertility and treatments, and assisted reproductive techniques (ART) offer hope to many couples.

Male infertility causes
Fertility in men requires normal functioning of the hypothalamus and pituitary gland (hormone-producing glands in the brain), and the testes. Therefore, a variety of conditions can lead to infertility.

● 30%-40% percent of cases are due to problems in the testes (of which about 15%-25% percent are due to genetic causes)
● 10%-20% are due to a blockage in the pathway that sperm use to exit the testes during ejaculation; this can be caused by prior infection.
● 1%-2% percent of cases are due to conditions of the pituitary gland or hypothalamus
● 40%-50% percent of cases have no identifiable cause, even after an evaluation

Male infertility evaluations
A separate article discusses the evaluation of infertility in men. The most important test for infertile men is a semen analysis (sperm evaluation). A normal result tells you that the male partner most likely does not have an infertility problem.

Male infertility treatment
The treatment of male infertility depends upon the underlying cause.  Several months to years of treatment are usually necessary to achieve fertility. The treatment often involves both male and female partners.

Blockage of the reproductive tract– Men who have a blockage in the ducts conveying the sperm from the testis until ejaculation (so that sperm cannot get out) can undergo surgery to correct the blockage.  If it is not successful, another option is assisted reproductive technologies using sperm retrieved from the testes.

Vasectomy (male sterilization) is a different type of blockage.  Vasectomies can be reversed in up to 85% cases; over 50% of couples can achieve pregnancy following vasectomy reversal.  However, the more time that has passed since the vasectomy, the less likely vasectomy reversal is to restore fertility.

Treatment of hypothalamic or pituitary deficiency– In a small percentage of cases (1% to 2%), male infertility is due to problems in the hypothalamus and pituitary gland (parts of the brain that regulate hormone production).  In this case, treatment with human chorionic gonadotropin (hCG), recombinant human follicle stimulating hormone (rhFSH), also called gonadotropin treatment, is often given.

Gonadotropin treatment– Gonadotropin treatment is started with injections of hCG three times per week (or sometimes every other day) for up to six months.  Blood tests are used to monitor blood testosterone levels and to adjust the dose if necessary.  If sperm cells do not appear in semen after six months of treatment, recombinant human follicle stimulating hormone (rhFSH) is added; this is also given by injection.  The success rate for this therapy is high as most men will eventually develop sperm in the ejaculate.  In many cases, a total of one to two years of treatment is needed to achieve normal fertility.

Varicocele– A varicocele is a dilation of a vein (like a varicose vein) in the scrotum.  Many men with varicocele have a low sperm count or abnormal sperm morphology (shape).  The reason a varicocele affects the sperm may be related to a higher than normal temperature in the testicles, poor oxygen supply, and poor blood flow in the testes.

Varicocele can be treated surgically by cutting the veins connected to the varicocele.  However, surgery does not always improve fertility and is not recommended for most men unless there is a large varicocele.  A varicocele that has been present for a long time can cause irreversible damage that cannot be surgically treated.

Other– Treatment is not currently available for most types of male infertility. For example, there is no known treatment when the sperm-producing structures of the testes have been severely damaged or are abnormal.  This happens in men with certain chromosomal abnormalities such as Klinefelter syndrome and small deletions in the Y (male specific) chromosome.

Assisted reproductive techniques
If the male partner’s semen contains few sperm, no sperm, abnormal sperm, or sperm with poor motility, assisted reproductive techniques can often help. These techniques offer hope to some infertile couples who could not achieve pregnancy without them.  However, the techniques are expensive, require a considerable commitment of time and energy, may pose certain health risks, and may have disappointingly low success rates. Couples should discuss the pros, cons, and success rates of these techniques with an infertility specialist.

When male infertility cannot be treated
Some treatments for male infertility fail, and some cases of male infertility simply cannot be treated at this time.  If this is this case, an infertility specialist can advise the couple of available alternatives. Each couple’s choice is a very personal one.  Men with irreversible infertility and testosterone deficiency may benefit from testosterone treatment. Although this treatment may not address a couple’s goal of having a child, it can improve the male partner’s sexual function and mood and help increase and maintain bone and muscle mass.