Male Infertility as Factor
30-40 % Of All Infertility
Of the many tests performed on the infertile man, there are really only two that are truly meaningful – the semen analysis and the post-coital test. Our lack of understanding as to what causes male infertility is obviously the reason why we still don’t have more and/or better tests. With rare exceptions, we still do not understand what affects a man’s ability to produce normal semen. Once we know the cause, there will be accurate tests and also, hopefully, effective therapies.
Other tests that have been used such as the Hamster Egg Penetration Test, Immuno-Bead testing looking for immune problems, and the Hypo-Osmotic Swelling Test may be of value in selected situations but are too unreliable to be used routinely. Also, these tests are expensive and are not usually covered by insurances. Furthermore, treatment options are limited. Therefore, I feel there is little reason to waste a couples’ money since the tests mentioned in this paragraph are not covered by insurance and treatment will usually be the same regardless of the results. Immunobead testing for antibodies may be of benefit in selected cases but the test must be done properly.
Because we do not understand the causes of male infertility, there is (with occasional exceptions) no therapy for the infertile man that has ever been proven to be effective. I am well aware that many men undergo numerous therapies in an attempt to improve their sperm count. Unfortunately, when these studies are done in a very scientific fashion, it is difficult, if not impossible, to prove that any of these therapies are more effective than no treatment at all. There is some recent evidence that treating men who have very low sperm counts with high doses of FSH may improve their count. However, it requires giving the FSH every other day for 6 months to know whether the therapy will work. Tamoxifen, an anti estrogen similar to Clomiphene may also work is a few isolated instances.
It has often been said that the best way to discover an infertile man is to marry him to an infertile woman.
It is also true that the best way to treat male infertility is to evaluate and treat his partner. If you study men requesting vasectomy, 25% of them will have sperm counts that are “subfertile”, yet they have been able to father children. These men have been able to achieve fatherhood because their wives had no problems compromising their fertility.
This means that a man with a fertility problem can often father children if the woman herself has no significant problems. If an infertile man tries to impregnate a woman who herself has compromised fertility, that couple will not achieve a pregnancy.
Since there is usually little that can be done for the infertile man, better success can be obtained by properly diagnosing and treating the woman. In this way, pregnancies can often be achieved.
Even though there is little that can be done to treat the man himself and improve the quality of the semen he produces, newer treatments that allow us to bypass the natural reproductive processes are helping many men to achieve fatherhood. A full discussion of these techniques is beyond the scope of this pamphlet. However, I would like to mention them here so that you are aware of what is happening.
Artificial insemination was previously a common therapy for male infertility. However, to simply put a man’s semen into the woman’s cervical mucus is, with rare exceptions, a totally useless procedure. It has virtually no place in modern infertility therapy. However, after “enhancing” the man’s semen by washing it and then carrying out a “swim up”, placing that semen into the uterus (Intra-Uterine Insemination or IUI) may be an effective therapy for male infertility. However, despite many reports as to the effectiveness of intrauterine insemination, there are also some reports that cannot demonstrate any advantage and no improvement in the pregnancy rates. Nonetheless, it is often done on the theory that it cannot hurt and may help.
In-Vitro Fertilization has emerged as the “last resort” treatment for male infertility. You need far fewer sperm to fertilize an egg “in vitro” than you do naturally and it is possible to extract a few normal sperm from an infertile man for IVF. However, as with any infertility therapy, the success rate in those couples with a significant male fertility factor will be less than for couples where the husband’s semen quality is normal.
There are men whose ability to produce normal sperm is so impaired that it is impossible for them to achieve a pregnancy even with IVF. It is now possible to successfully artificially fertilize an egg by taking these very abnormal sperm and literally injecting them into the egg where fertilization can then occur. This technique is call Intra-Cytoplasmic Sperm Injection (ICSI) and is the treatment of choice for male infertility when nothing else has worked.
Because of ICSI, there is no such thing as an infertile male (with very rare exceptions). Sperm can even be removed directly from the testicle and used for ICSI. This is called MESA, or Micro-Epididymal Sperm Aspiration. Unfortunately, ICSI must be done in conjunction with IVF. The cost is $10,000 or more a try which puts it beyond the reach of many couples who would benefit from it.
There are other techniques which have been used with some degree of success, but not as good as ICSI. You may still read about them in various articles. These techniques go by several names and you need to be aware of them. They are called either Subzonal Insemination (SZI or SUZI), or Zona Drilling.
I have put the whole discussion of varicocele in its own separate section because it is such a common problem and because it is still a very controversial one.
As I have indicated, a varicocele is a varicosity of the spermatic veins. Ten to fifteen percent of all men have varicoceles. Twenty-five to forty percent of all infertile men have varicoceles.
It has been known for many years that there is an association between a varicocele and male infertility. Whether it is a cause and effect or simply an association is unknown.
Because it is so commonly found in infertile men, it did not take very long for people to decide that perhaps treating the varicocele might improve the man’s semen quality. Indeed, the initial reports were very glowing and very quickly, many men with varicoceles underwent surgical correction. The surgery itself is very similar to having a hernia repaired.
Unfortunately, as was true of most infertility studies, the early reports on the success of varicoceles were not done with control groups. Without a control group, an infertility study is meaningless. Therefore, many people felt that the success claimed for varicocele ligation was vastly overstated and the surgery began to fall into disrepute. I freely admit that for many years, I discouraged patients from undergoing this surgery because I did not believe that there was any evidence that it worked.
In the mid 1980’s, a large study was published in the British Medical Journal from Melbourne, Australia. At one of the major hospitals in Melbourne, they had a large male infertility clinic and virtually all the infertile men in the Melbourne area were seen and treated at this one facility.
This infertility clinic in Melbourne accumulated a large number of men whom had undergone varicocele ligations and an equally large number of men who, for whatever reason, did not undergo this surgery. It was impossible to scientifically categorize all the problems that these men and their wives might have had. None-the-less, the results quite clearly showed that the pregnancy rates in the two groups were the same. The study could not demonstrate that there was any benefit to ligating a varicocele.
None-the-less, there were men who did show improvement in their semen quality after having undergone a ligation of their varicocele. The question really became one of how to select those men who might benefit.
The only type of medical study that really proves anything is a “prospective one.” In other words, you must set up your research criteria and then go forward from that time. Looking back at data that has already been accumulated is very risky because people’s memories tend to fade with time.
Finally, a prospective study looking at varicocele ligation has been done and has been published. In addition, this study was randomized. In other words, some men were initially assigned to have their varicoceles ligated immediately. The other men in the study group were not treated for a period of one year. Following that year’s period of observation, if their wives had not become pregnant, they too underwent ligation of their varicoceles.
The study quite clearly shows that if a man has a varicocele and his semen quality is only mild to moderately impaired, there will be a substantial improvement in his ability to impregnate his wife. This study only included men whose sperm counts were between five and twenty million. This is in keeping with all the evidence that clearly shows that if a man’s sperm count is less than five million, there is probably no therapy that is going to improve it, even if he has a varicocele.
There is another reason for ligating a varicocele even if the man’s semen quality is not that much impaired. It has become evident that men with varicoceles suffer a progressive decrease in their semen quality as they age. Therefore, if a man has a varicocele, there is justification in ligating it to prevent his semen quality from getting any worse. Therefore, even though he might be able to get his wife pregnant now, if his varicocele were not treated, he might not be as fertile several years hence when they might hope for another child.
Another controversy that has arisen which must be clearly understood by any man who is infertile is how to diagnose a varicocele. Initially, all the studies and all the treatments were offered to men with clinically apparent varicoceles, i.e., those varicoceles that could either be seen or felt on routine scrotal examination.
Studies began to emerge over the past ten years or so looking at men who were subfertile who did not have an obvious varicocele. These men were then subjected to ultrasound evaluations of the spermatic veins. Men who were found to have a small varicocele detected only by ultrasound but not by physical exam were termed “subclinical varicocele.” Many men with these subclinical varicoceles also underwent ligation. This further muddied the waters and made it more difficult to assess whether or not varicocele ligation has a role to play in the treatment of the subfertile man.
Most infertility specialists now feel that in order to justify the surgery necessary to correct a varicocele, it must be detectable on routine physical exam. Varicoceles that can only be detected by ultrasound do not justify therapy.