Male Infertility

Roughly one couple in five will have difficulty conceiving. In the United States, that means that over 6 million couples are currently experiencing infertility. Approximately half of these cases are due to male factor infertility.

Strictly speaking, infertility is defined as the failure to conceive after a full year of unprotected intercourse. At that point, couples should seek professional assistance. And while the support of a fertility doctor may be crucial, there may also be steps that you can take on your own to help improve the chances of conception.

EVALUATING MALE FERTILITY: THE SEMEN ANALYSIS

When a couple is having trouble conceiving, they often seek the advice of either their family physician or the woman's gynecologist. Usually, as part of the initial evaluation, that physician will suggest that the man undergo a semen analysis.

  • How many specimens are needed?

    • Considerable variation in semen quality can occur from day to day or week to week. For that reason, it's usually best to do two separate specimens—at least two weeks apart.

    How should the specimen be collected?

    • Semen specimens should be obtained by masturbation, and collecting the specimen properly is very important. First, you should abstain from ejaculation for at least three days before each specimen. Second, be sure to use a sterile collection container—your doctor's office or the lab should provide this for you. Finally, it's best to produce the specimen at the lab so it can be tested immediately. If you must produce the specimen at home, be sure to get it to the lab within 30 minutes, and protect it from extreme heat or cold.

    What do they test for?

    • The three most important measurements taken are the sperm count, motility and morphology. The count simply means the number of sperm present. The motility means determining the percentage of the sperm seen which are actively moving. The morphology is reported as the percentage of the sperm which are shaped normally. Individual labs can have slightly different standards for “normal” for each of these measurements.

    What if the results are abnormal?

    • If the semen analyses are abnormal, the man should be evaluated by a physician, usually a urologist, who specializes in male infertility. That evaluation would start with a comprehensive history and physical examination, and then might include blood work, ultrasound testing, genetic testing or specialized tests on the semen.

    What if the results are normal?

    • A normal result on two semen analyses usually means that the man has normal fertility potential. However, there are certain situations (see “Oxidative Stress” below) in which a man's fertility may be low despite a normal semen analysis.

WHAT ARE THE CAUSES OF MALE INFERTILITY?

  • When the semen analyses are abnormal, the urologist's evaluation may reveal the source of the problem. The possible causes include:

    • Varicocele

      A varicocele (var-i-co-seal) is a condition in which the veins surrounding the testicle become swollen and dilated. It is fairly common, affecting about one in every seven men. Men with a varicocele have about a 50% chance of having an abnormal sperm count. Treating the varicocele, usually done with a minor surgical procedure, will often correct the problem.

      Infection

      Infections of the prostate or epididymis ( a duct behind the testicle) can have a major impact on a man's fertility. Such an infection would usually be diagnosed by the finding of numerous white blood cells in the semen. If infection is suspected, the urologist may request a semen culture, and being treatment with an antibiotic.

      Hormonal problems

      Sperm production is under the control of special hormones which come both from the pituitary gland (FSH, LH) and from the testicle (testosterone) . If the blood levels of those hormones are abnormal, sperm production may be very low, or even completely absent. This type of problem is diagnosed with simple blood tests, and, if present, may be correctable with medication.

      Genetic abnormalities

      We now realize that many cases of male infertility whose cause was unclear in the past are actually caused by genetic abnormalities. This includes problems in which whole chromosomes are broken or misshapen, where a whole chromosome is either missing or an extra one is present, and instances where individual genes on the Y- chromosome are damaged.

      Another type of genetic problem is known as sperm DNA fragmentation. In this condition, the DNA strands which contain the genetic information in the sperm head are filled with many breaks and nicks. This is believed to be due, in many instances, to oxidative stress (see below).

      Blockage of sperm flow

      Sperm are produced in the testicles. They then move out into the epididymis, a small duct behind the testicle, where they become fully mature. After several days in the epididymis, they swim up a tube called the vas deferens towards the ejaculatory duct. There are several conditions which can lead to a blockage of the path from testicle to ejaculatory duct. Such a blockage could cause the sperm count to be extremely low, or even create a condition known as azoospermia, in which no sperm are present in the ejaculate at all. Sometimes, a blockage can be repaired. And even if repair of the blockage is not possible, a pregnancy should be achievable through IVF.

      Medication and treatment side effects

      Certain medications or medical treatments can interfere with sperm production. Radiation treatment for cancer can impair testicular function. Many chemotherapy drugs will have a permanent effect on production. Some drugs, such as steroids and hormones, can have a temporary effect which should reverse when the medication is stopped. When taking a medical history, the urologist will ask about any medications or illnesses which have occurred in the past.

OXIDATIVE STRESS AND INFERTILITY

The process of sperm production is highly complex, and it takes almost 3 months for a fully mature sperm to form. During that time, the sperm are subject to damage from highly reactive oxidizing molecules known as “free radicals,” which are caused by the breakdown of oxygen as it passes through the cells in the body. Many infertile men have a higher concentration of free radicals in their semen when compared to fertile men. Free radicals can cause damage to sperm by attacking and destroying the membrane that surrounds sperm cells.

Antioxidants are substances that protect cells from damaging oxidative reactions. Certain vitamins, minerals, and other nutrients are natural antioxidants, which can fight against free radicals, and the damage they cause.

Oxidative stress is a term used when the level of reactive oxygen species (ROS) in the semen is greater than the amount of total antioxidants. Although low levels of ROS are needed for normal sperm function, high levels will impair fertility. A high level of oxidative stress is associated with decreased sperm production, loss of sperm motility (movement), and abnormal sperm morphology (shape). Some studies have shown that oxidative stress may be present even when a standard semen analysis appears normal. Although testing for levels of oxidative stress is not widely available for patients, research indicates that up to 50% of infertile men have elevated oxidative stress in the semen.

Nutrients and Male Infertility

There is a growing body of scientific evidence to suggest that the following nutrients promote male fertility. Read the journal references on this research.

  • Vitamins C and E- are essential antioxidants that protect the body's cells from damage from oxidative stress and free radicals. Vitamin C is the most abundant antioxidant in the semen of fertile men, and it contributes to the maintenance of healthy sperm by protecting the sperm's DNA from free radical damage. Vitamin E is a fat-soluble vitamin that helps protect the sperm's cell membrane from damage. Studies have shown that vitamin E improves sperm motility (movement) and morphology (size and shape). Vitamin C functions to regenerate vitamin E, thus these vitamins may work together to improve sperm function. Men with low fertilization rates who took vitamin E supplements for 3 months showed a significant improvement in fertilization rate. Vitamin E supplementation in infertile men resulted in increased pregnancy rates.

  • Selenium- is a mineral that functions as an antioxidant. Selenium supplements have been shown to increase sperm motility, and a combination of selenium and vitamin E has been shown to decrease damage from free radicals and improve sperm motility in infertile men.

  • Lycopene- is a potent antioxidant and carotenoid (plant pigment) that is abundant in tomatoes. This "phytonutrient" is found in high levels in the male testes, and research conducted in India has shown that lycopene supplementation improved sperm parameters in infertile men.

  • Zinc- is an essential trace mineral that plays a role in sperm formation, testosterone metabolism, and cell motility. Zinc supplementation increased testosterone levels and sperm count in a study of 22 men, which resulted in nine pregnancies.

  • Folic Acid- is a B-vitamin that is necessary for DNA synthesis. Low levels of folic acid have been associated with a decreased sperm count and decreased sperm motility. In a recent study, the combination of zinc and folic acid resulted in a 74% increase in total normal sperm count in subfertile men.

  • L-Carnitine- is an amino acid derivative produced by the body, which functions to transport fat so that it can be broken down for energy. L-carnitine provides energy for the sperm, and is important for optimal sperm motility.