Male infertility accounts for 15% of infertility cases. Also male infertility may contribute to 30-40% of all infertility instances. Because of this, couples who cannot get pregnant should apply to the clinic together.
Male Infertility Reasons
When evaluating for infertility, semen analysis is the first test that must be done. In order to standardize the results, 2-4 days sexual abstinence is recommended.
In the event that the results of the semen analysis are sub-normal, the test must be repeated one month later. If the second test also shows sub normal results, then a physical exam and blood tests will be required.
The doctor will examine the penis, opening of the urethra, testes, epidydimis, and prostate. The patient’s body type, hair growth, genitalia will be examined in detail. Sexual functions, erection – ejaculation and other habits that might result in infertility will also be evaluated. Items below are also shown to cause infertility.
Hormone tests are required if semen analysis is sub normal or if the patient has other endocrinological disorders such as diabetes. FSH and Testosterone are the most commonly tested hormones. More detailed tests will be done if necessary.
FSH may appear to be normal in some patients with abnormal spermatogenesis. But an increased level of FSH in the serum is a sign of abnormal spermatogenesis.
Some patients may have their urine checked for the presence of sperm right after ejaculation. Ultrasonography, the antisperm antibody test, cervical mucous interaction test are some of the more detailed tests they may be done on semen and sperm.
When looking at semen under a microscope, leukocytes and immature germ cells are difficult to tell apart. These cells are labeled round cells. Many laboratories evaluate all the round cells as leukocytes and report them as such.
Azoospermia is the condition describing a complete lack of sperm cells in the ejaculate. There is a 1% incidence in all men and 10-15% incidence in infertile men. Azoospermia is divided into three categories: pre-testicular, testicular and post testicular.
Pre and post testicular abnormalities are treatable. Testicular failure is irreversible. Varicocele is excluded from this group however.
Another way of categorizing azoospermia is by dividing up groups based on whether or not the ducts are blocked.
TESA: TEsticular Sperm Aspiration
Normal semen analysis values
The veins surrounding the testicles expand and result in an increased temperature which is believed to negatively affect sperm production. Surgery may be required to correct the condition.
Men who have varicocele are not infertile but 1/3 of infertile men have varicocele.
Normally varicocele is seen in 15% of the general population whereas 40% of infertile men have varicocele. The doctor will examine the patient both in an upright position and while the patient is lying down. Palpation done when the patient standing will feel like a sack of worms but this feeling will decrease or disappear when the patient is lying down.
Varicocele can only be treated surgically.
Indications for varicocele surgery:
If sperm parameters are normal then surgery is performed if it causes discomfort or for cosmetic reasons (if it is large).
Young men should have yearly examinations even if their sperm parameters are normal to monitor any changes and operate before the problem progresses.
When children are diagnosed with varicocele:
When the male partner is infertile then his female partner’s age gains importance. If the woman’s age is close to 40 then the couple may not have time to wait for the results of varicocele surgery. If the varicocele is not painful, artificial reproductive technology might be a quicker solution.
Young infertile patients may also benefit from varicocele surgery.
If the female partner is also infertile then the couple will need treatment for infertility which obviates the need for varicocele surgery except for cosmetic reasons.
Some of the possible complications of varicocele correction surgery are: infection, hydrocele, varicocele persistance and recurrance.
Semen analysis must be done every three months after varicocele correction surgery for one full year minimum or until the couple achieves pregnancy.
There are a varieties of procedures for varicocele treatment. Retroperitoneal, inguinal (an incision is made in the groin area), microsurgical, making sub inguinal cut near the scrotum, laparoscopic ligation or blocking the veins with radiation (embolization) are some of the methods. The ultimate goal is to perform the treatment that best fits varicocele type and has the least chance of reccurrence. Ligating veins near the scrotum with the aid of a microscope (microsurgical varicocelectomy) appears to be the most successfull treatment. This method also has less post operative pain.
Varicocele and Azoospermia:
Some studies suggest that azoospermic men with clinical type varicocele might benefit from varicocele surgery. According to research results 50% of patients show resumption of spermatogenesis and 20% report spontaneous pregnancy. Testicular biopsy done before or during surgery will give the doctors an idea of the sucess of the procedure. Men who have immature sperm cells may start sperm production but patients who had no spermatogenesis, previously, do not start producing sperm after varicocele treatment. Consequently azoospermic patients with varicocele who have begun infertility treatment, and have sperm cells found in testicular biopsy, should be treated for varicocele even if they get pregnant through IVF.