Infertility has traditionally been thought of as a woman's problem. But as it turns out, we men don't get off that easily. About one out of every three cases of infertility is due to the man alone, and we're somehow involved in infertility about half the time.
A diagnosis of male infertility can be one of the hardest challenges a man can face. For some, it can be devastating. After all, the necessity of reproduction is one of the few things on which both Darwin and the Bible agree. Not being able to father a child can make a guy feel like he’s failing at one of his most primal responsibilities.
Unfortunately, some men have to cope with the reality that nothing can be done about their infertility. But for other men, advances in male infertility treatment offer real help.
Understanding male infertility: Sex Ed 101
To better understand infertility, here's a refresher course on the birds and the bees. (Anyone caught giggling will have to stay after class.)
Sperm are made in the testicles. They're then stored inside yards of “plumbing” called the epididymis, which lies on top of each testicle. Sperm are nourished by semen, which is made by glands along the way. When the magic moment arrives, about 150 million sperm are ejaculated in a half-teaspoon of semen through the penis.
This whole process hinges on there being proper levels of testosterone and other hormones as well as correct signaling from the nervous system.
Women ovulate — send an egg down into the uterus — once a month. This happens about 14 days after menstruation. Sex any time in the five days before ovulation can create a pregnancy. Sex any other time, even the next day after ovulation, will not result in conception.
“We generally advise couples to seek fertility evaluations if they are unable to conceive after 12 months of unprotected intercourse,” says Lawrence Ross, MD, president of the American Urological Association. About 85% of couples will have had a pregnancy by that point. “If they are over 30, they should seek evaluation after six months.”
Common causes of male infertility
The “male factor” contributes to infertility around half the time, and about one third of the time, it's the main cause of infertility. Most often, the problem lies in the process of either making or moving thesperm.
Any of the following can cause a man to have a low sperm count or abnormal sperm:
- Varicocele — an abnormal collection of bulging veins above the testicle; they’re the most common cause of correctable male infertility, accounting for 38% of cases
- Undescended testicle
- Infections in the testicle (orchitis), the prostate (prostatitis), or elsewhere in the body that causes a fever
- Chemotherapy for cancer
- Medicines such as anabolic steroids or anti-seizure medicines
- Genetic abnormalities
- Hormone problems
In some cases, these problems can be reversed, but other times they can’t. An evaluation by a physician is the only way to sort it out.
Sometimes, making sperm isn't the problem. The problem is getting the sperm where they need to go. Men with this type of male infertility have normal sperm in the testicles. But the sperm in the semen are either abnormal, very low in number, or not there at all. Causes of this kind of infertility include:
- Retrograde ejaculation. In this condition, semen ejaculates backwards into the bladder instead of out the penis. Usually previous surgery is the cause.
- Absence of the main sperm pipeline known as the vas deferens. This condition is a genetic problem.
- Obstruction. An obstruction can occur anywhere in the plumbing between the testicles and the penis.
- Anti-sperm antibodies. Antibodies can abnormally attack a man's own sperm on their way to the egg.
Up to 25% of infertile men have idiopathic infertility. That means they have abnormal or low sperm counts for no identifiable reason.
Male infertility tests: Going under the microscope
Identifying the cause of a man's infertility is as much an art as a science. “The first step is an evaluation by a physician specializing in male infertility,” says Stephen Shaban, MD, a urologist specializing in male reproductive medicine and microsurgery in Raleigh, North Carolina. Experts differ in their approach, but here are some of the tests you can expect:
Sperm and semen analysis. They provide a private room (and magazines). You provide a fresh sample of semen. Experts then assess your sperm count, their shape, movement, and other variables.
“Generally, a higher number of normal-shaped sperm means higher fertility,” says Shaban. But exceptions are common. Many men with low sperm counts or abnormal semen are still fertile. And about 15% of infertile men have normal semen and plenty of normal sperm.
Surprisingly, the complete absence of sperm in the semen (a condition known as azoospermia), can be a good thing. Ross says it might suggest a blockage in the “plumbing” that can be corrected with surgery.
- Physical examination. A thorough physical exam can detect varicocele and give clues to hormone problems. This should ideally be performed by a urologist.
- 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.
- 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. If abundant good sperm are found in the testicle, there's likely a blockage somewhere.
- Genetic testing. Genetic tests can identify specific obstacles to fertility and problems with sperm. Experts differ as to when genetic tests should be done.
Male infertility: New treatments, more pregnancies
The ultimate goal of male infertility treatment is to create a pregnancy. Ideally, the cause of the infertility is reversible and then conception can result from natural sex. Here are some common male infertility treatments.
- Varicoceles are repaired with surgery to block off the abnormal veins. This seems to result in a significant improvement in fertility, although some studies disagree.
- Hormonal abnormalities can sometimes be treated with medicine or surgery.
- Obstructions in the sperm transport plumbing can sometimes be surgically corrected.
In the past, if the above methods didn’t work, it often meant lifelong male infertility. Today, assisted reproductive techniques (ARTs) offer powerful new options.
These high-tech and expensive male infertility treatments give sperm an artificial boost to get into an egg. ARTs have made conception possible even for men with very low or abnormal sperm.
First, sperm are collected either from ejaculated semen or by a needle from the testicle. They are then processed and introduced to eggs by different methods.
- Intrauterine insemination (IUI.)At the time of ovulation, sperm are injected directly up into the uterus. Medicines are usually given to the woman first to increase the number of eggs she releases.
- In-vitro fertilization (IVF.)Sperm are mixed with multiple eggs collected from the woman in a “test tube” (actually just a plastic dish.). Fertilized eggs are then placed in the uterus. IVF requires at least some viable sperm.
- 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.
Shaban says that by using some combination of ARTs for several months, “most couples can expect a pregnancy between 40 to 50% of the time.”
Male infertility treatments to try at home
But are there things you can do on your own to maximize your fertility? Yes. For one, don’t do things to hurt your chances to have viable sperm — marijuana, cocaine, tobacco, and more than two alcoholic drinks a day harm sperm production, says Ross. Men should also avoid hot baths and whirlpools, he says, because the high temperatures slow down your sperm factory.
Taking testosterone, or any over-the-counter androgen like DHEA (for weight training), can harm fertility, says Shaban. “People have had unnecessary surgeries because they forgot to say they were on these medicines,” he warns.
Living with male infertility
When Steve S. of Joliet, Illinois was diagnosed with male infertility, he felt profound disappointment. An extensive work-up showed Steve was born without the vas deferens, the main sperm pipelines from the testicles. He and his wife underwent needle sperm extraction and in vitro fertilization, but it was unsuccessful.
“I feel bad mostly because my wife wants a baby so bad and it is the one thing I can't give her,” Steve says. “This has been a tough thing for the two of us.” They are currently looking into adoption.
For some men, no male infertility treatments seem to help. Finding out that you're infertile can be an unpleasant surprise, to say the least. “Many men feel emotional stress with a diagnosis of infertility,” says Ross.
Shaban says that often, there is embarrassment. “Guys confuse libido and potency with fertility. They get worried that they will be stereotyped.”
Ross reminds men that “most problems with [reproduction] do not affect their ability to produce male hormones, their sexual function, or their maleness.”
But even if things look bleak, the experts still have some hopeful advice: Keep trying. As many as 25 to 35% of “infertile” couples will go on to eventually have a child without any treatment.