Diagnosis and Treatment of 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.
There is a long standing World Health Organization system defining “normal” values for semen analysis.
- Semen volume: >1.5mL
- Sperm concentration: > 20 million/mL
- Motility (swimming ability): >50%
- Morphology (shape of sperm): >50% normal
There is another system for evaluation of sperm shape (morphology) called “strict morphology.” Our lab, (as do most IVF programs) uses this system. With the strict morphology system, normal is >9%. Men may fall between 4% and 9% in the so called “indeterminate zone.” Some men in this group will show normal fertility and some will be infertile-it is not possible to distinguish how these sperm will function. Men with morphology below 4% are clearly abnormal and concern exists that these sperm may not be able to fertilize an egg.
Sperm autoantibodies (antibodies the male produces against his own sperm) are present in about 5% of infertile men. Testing for sperm antibodies is not part of a routine semen analysis since the test is costly and the incidence of this condition is low. Recent extensive evaluation by Urology experts has revealed that perm auto-antibodies are not clinically useful in the evaluation and treatment of infertility. Therefore, we no longer perform this testing as it does not aid in the care of our patients.
There is also new information on what sperm numbers and motility are defined as “normal.” It is not as simple as suggested by the WHO standards. This new definition recognizes an “indeterminate” zone regarding these two parameters-as above with the shape parameter. Sperm numbers from 12 to 50 million and motility between 20 and 60% are broad “gray” areas (indeterminate). Men in these ranges may or may not be fertile. Many men fall into these ranges of number or motility.
Other tests have been devised to test sperm function-hampster test, acrosome reaction test, and zona assay. Unfortunately none of these are very useful.
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.
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: