The results of a physical examination and tests help determine the type of male infertility condition exists.The main conditions of male infertility are:
Deficiency of the two hormones from the pituitary gland which control testicular function; luteinizing hormone (LH) and follicle stimulating hormone (FSH), can be treated by injections of hormone preparations. Usually the testes increase in size and produce testosterone in normal amounts. Sperm may appear in the semen after several months of treatment. At least 50% of the partners of such men conceive during treatment, but the treatment often needs to be given for many months. Also it must be repeated for each pregnancy unless adequate sperm can be collected during the first course of treatment and stored frozen for later use. This hormone deficiency affects less than 1% of infertile men. Other treatable hormone deficiencies are even rarer.
Approximately 6% of infertile men have blockages in the genital tract that prevent the passage of sperm between the testes to the penis and result in absence of sperm in the semen.
There are three major groups of causes of male genital tract blockages:
(1) Disorders of development of the epididymis, vas and seminal vesicles,
(2) Scarring from inflammation (especially gonorrhoea)
Rarely other blockages may occur in the vas and ejaculatory ducts.
Some patients can be treated with bypass surgery, joining the tube in the epididymis above the blockage to the vas deferens. The results depend on the level of the blockage, being poor with blockages close to the testis. This is partly because the sperm are immature, having not passed through parts of the epididymis in which maturation usually occurs. With blocks in the tail of the epididymis or vas, sperm appear in the semen of up to 80% of men after surgery, although only about half of these produce pregnancies within one year.
It is possible to obtain sperm by a surgical operation from the tubes above the obstruction, by sucking liquid out of the epididymis or epididymal cysts through a needle or from a testicular biopsy. These sperm can be used for intracytoplasmic sperm injection (ICSI) with in vitro fertilisation (IVF) . This approach is particularly useful for: absence of the vasa deferentia, high epididymal obstructions for which the results of surgery are predicted to be poor, and failures of vasectomy reversal or other operations.
About 15% of infertile men have no sperm in their semen (azoospermia), because the sperm producing cells in the testes either did not develop or have been irreversibly destroyed (Primary Seminiferous Tubal Failure). This may be caused by chromosomal or genetic disorders, inflammation of the testes or treatment with certain drugs. It may also be associated with failure of the testes to descend into the scrotum during childhood. For couples in this category who wish to have a family, an attempt to retrieve sperm by testicular biopsy is a reasonable primary approach. If sperm can be retrieved, it can be used for intracytoplasmic sperm injection (ICSI) with in vitro fertilisation (IVF).
Failing that, the use of donor insemination or adoption are probably the only options of couples in this category to achieve their own family.
Antibodies are normally produced in response to introduction of foreign material, such as bacteria, into the body and are protective. However, antibodies to sperm develop in many men after vasectomy and may interfere with fertility after vasectomy reversal operations. Antibodies are also found in about 6% of other infertile men, some of who have had injuries to the genital tract that may have caused the immunisation against sperm. However in most, the reason why the sperm antibodies develop is not obvious. The sperm antibodies are often present in the blood as well as in the semen and coating the sperm.
The antibodies may reduce fertility at several levels: such as interference in the sperm production and reducing sperm numbers in the semen, causing clumping together of sperm, reducing sperm motility, preventing sperm from swimming through the liquid in the female genital tract including cervical mucus, and interfering with the process of fertilisation. Men with sperm antibodies and sperm which will not penetrate normal midcycle cervical mucus, are severely infertile and rarely produce pregnancies without treatment. In these cases IVF- ICSI is the usual treatment approach.
Most (65%) men investigated for infertility have sperm present in the semen, but lower numbers than normal – low sperm count oligozoospermia (35%); or adequate numbers, but with reduced motility (asthenozoospermia), abnormal morphology (teratozoospermia) or acombination of both (25%).
A few (5%) have normal semen tests (normozoospermia) but there are other abnormalities which impair the fertilising ability of the sperm.
At the present, very little is known about the mechanisms by which sperm production and function are reduced either in men with an obvious cause such as previous undescended testes or inflammation of the testes, or in men who have no apparent cause for the problem. There are also men in general community with poor sperm test results who have no major problems producing pregnancies.
Sometimes there are obvious factors contributing to the poor results of sperm tests: incorrect sperm collection techniques, such as too short or too long an interval since previous ejaculation, recent illness, such as influenza, inflammation in the genital tract such as epididymitis or prostatitis, heavy alcohol or social drug consumption, obesity, frequent hot spa baths or saunas, use of anabolic steroids and certain medical treatments. Removing the cause can result in improvement of semen quality within a few months. Patients undergoing IVF treatment should be aware of the possibility that a minor illness particularly with a fever could result in a serious reduction in sperm output over the next 3-4 months. The Fertility Specialist should be informed if such an illness occurs.
Dilated veins in the scrotum (varicoceles) are often present in men (20-40%). Also not uncommon are: previous testicular injuries, minor hormone disorders, surgery for torsion (twisting) of the testis, failure of descent of testes, and past episodes of inflammation of the testes, epididymis, prostate or urethra that may have been sexually transmitted. These conditions may cause or contribute to the poor semen quality, but it has not been proved that treatments improve the semen test results and increase fertility.
Factors often suspected as being significant such as tobacco smoking, moderate alcohol intake, quality of diet, exercise, mental stress and anxiety, exposure to environmental toxins and exposure to heat as a result of wearing tight underpants are of uncertain relevance as causes of disorders or sperm production or function. Changing lifestyle may be important for good health in the long term, but there is usually no consistent marked change in the semen test results. Smoking has significant negative effects on female fertility and during pregnancy.
There are some genetic causes of male infertility that may need investigation and genetic counselling about the risks of having children with similar infertility or other health problems, for example cystic fibrosis with bilateral congenital absence of the vas. Genetic disorders, such as microdeletions on the long arm of the male determining Y chromosome and other yet to be discovered mutations, are responsible for some of the more severe disorders of sperm production or function and these may be transmitted directly to sons or to future generations. There may be some increase in the risk of chromosomal disorders such as Klinefelter syndrome in the offspring of men with severely reduced sperm production