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FERTILITY EVALUATION

MALE INFERTILITY

Male factor infertility is solely responsible for about 20% of infertile couples and is contributory in another 30 to 40%.   Therefore, it is critical that both partners are evaluated.  Additionally, it is important to understand that a normal result of a semen analysis does not rule out all male factors that may be causing or contributing to the infertility.  In nearly all cases there is no way to predict the fertility of a man without having a semen analysis performed.  Because day-to-day sperm production can be quite variable, if the first semen analysis returns abnormal it is usually recommended that a second semen analysis be performed.  Male fertility gradually decreases with increasing age, however unlike the female, with a limited supply of eggs, the male continues to make sperm throughout his life.  Medical studies suggest that men older than age 45 take significantly longer to successfully father of pregnancy even with a younger partner.

There is a long standing World Health Organization system defining “normal” values for semen analysis.

  • Semen volume:  >1.5mL
  • Semen volume:  >1.5mL
  • Sperm concentration: > 15 million/mL
  • Motility (swimming ability):  >40%
  • Morphology (shape of sperm): ≥4% normal

Based on current medical information, the evaluation of male fertility is not so simple.  There is new information regarding what sperm numbers and motility are associated with normal fertility.  In this system, men with sperm counts above 48 million/cc, show “HIGH” fertility- in other words they are normal.  The new system recognizes a large indeterminate or gray area when sperm numbers are between 13 million and 48 million/cc.  Many men fall into this category.  We choose to call this the “FAIR” fertility zone.  Some men with these sperm numbers will father a pregnancy and some will not-- it is impossible to precisely predict.  Men with less than 13 million /cc almost all show “LOW” fertility-- and are probably infertile.

The sperm analysis information applies to movement and sperm shape as well.  With regard to movement or motility, men with more than 63% of sperm moving have “HIGH” fertility potential; men with movement of 32-63% have “FAIR” fertility potential; men with movement of less than 32% have “LOW” fertility potential.  The new semen analysis system uses an entirely different way to evaluate sperm shape called strict morphology.  The same 3 areas as above are observed.  Men with more than 9% of sperm with a perfect shape have “HIGH” fertility; men with sperm shape 4-9% have “FAIR” fertility; men with sperm shape less than 4% have “LOW” fertility.

There are effective treatments to be applied to all of the above categories of sperm quality to assist with conception.

Vasectomy Reveral

 
Vasectomy Reversal

Some men choose to have a vasectomy for birth control. Sometimes life situations change, such as remarriage, and he may want to father a child. Dr. Bateman discusses treatment options for men who had a vasectomy.

Other Tests

Other tests have been devised to test sperm function including: the acrosome reaction test; the zona assay; the hamster test.  None of these tests have effectively translated into useful medical information and therefore we do not use them.

Sperm antibodies (autoantibodies), in other words antibodies that a man makes against his own sperm are present in about 5% of infertile men.  The contemporary view of male fertility specialists is that sperm antibodies do not cause infertility and therefore we do not test for them.

Genetic Testing

Men with low sperm counts are offered testing to evaluate whether they carry a genetic abnormality that could be transmitted to the offspring.  This is because some causes of low sperm counts are genetic so a couple is at risk for having a male baby who will have similar problems as his father.  A karyotype is a genetic test that looks at the chromosomes, in general, for any abnormalities.  There is also more focused testing, such as microdeletion testing that look for genetic pieces that are missing.  These missing pieces of certain genetic information on the Y-chromosome are known to cause male factor infertility.  In men with no sperm (azospermia) karyotypes are abnormal 10-15% of the time and Y-microdeletion testing is positive in approximately 15%.  In men with sperm concentrations less than 2 million/mL a karyotype will be abnormal 5% of the time and Y-microdeletion testing is positive for an abnormality in about 10% of cases.  Meeting with a genetic counselor is also available for couples.  All genetic causes of male infertility are not known or testable so a normal result to genetic testing does not rule out the possibility that male infertility might be inherited.  Frequently, genetic testing in infertility is not covered by insurance.

Forty percent of men with no sperm in the analyzed semen have an obstruction (blockage) that prevents the sperm from being ejaculated.  This can result from infection in the reproductive tract, from failure of a surgical procedure to reverse a vasectomy, or by a malformation in the tract known as congenital bilateral absence of the vas deferens (CBAVD).  CBAVD is frequently associated with the gene complex responsible for Cystic Fibrosis.  Genetic testing for Cystic Fibrosis is recommended in these cases. 

Treatment

Abnormal results of a semen analysis may lead your physician to suggest a consultation with a urologist. Testing by the urologist may reveal a hormonal or anatomic problem that can be corrected thereby improving the sperm quality. 

In situations where the urologist concludes that the quality or quantity of the sperm cannot be significantly improved, specific treatments can be offered such as intrauterine insemination of the partner’s sperm (IUI), donor insemination or in vitro fertilization (IVF).

About Vitamins, Antioxidants for the male

There is some evidence that male fertility may be improved by taking over the counter medications-vitamins and antioxidants.  The research on this issue is inconclusive.  A combination of these over-the-counter drugs, that does no harm, and may improve male fertility includes:  a multivitamin with zinc (without iron), Vitamin C 500 mg, L-Carnitine 1000 mgm daily, and Coenzyme Q10 200 mgm daily.  Even men with “normal” sperm counts may benefit.  This treatment is inexpensive-a few dollars a month and can easily be purchased at nutrition stores. 

There are 4 commercial products that are formulations of some of the above vitamins and antioxidants with additional ingredients that are purported to be of value in promoting improved male infertility. In our opinion, none of these products are really proven to be superior to the simple over-the-counter combination outlined above. For your information we list these products and their web sites below: