Evaluating & Treating Male Fertility Issues
You may be unaware that in 60% of cases a male factor contributes to infertility. That’s why it makes sense to evaluate the man as well as the woman when a couple is facing infertility. This post discusses the evaluation of male fertility as well as some of the physiological and lifestyle factors associated with it.
Sperm takes three months to produce and mature, so there can be a four to six month delay between when a man starts treatment and when he sees resulting changes in the sperm. Because his partner’s evaluation may also take several months, we recommend a comprehensive semen analysis be performed as soon as the woman starts treatment. If necessary, the male partner can also immediately begin treatment. When the treatment of both partners happens at the same time, there is no unnecessary, additional delay.
The most important first step in any man’s evaluation is the semen analysis; it allows us to identify problems to be addressed in order to maximize the quality of the man’s semen. This may reduce the need for more complicated interventions for the female partner. It also enables us to rule out significant medical problems that may contribute to poor analysis results. Based on our experience, concentration and progressive motility are the most important sperm parameters in predicting the likelihood of pregnancy via coitus or intrauterine insemination. For example, when sperm concentration is < 10 million/ml and/or progressive motility < 20%, the chance of pregnancy using conventional methods is very low. In vitro fertilization (IVF) would provide the best chance of pregnancy.
Semen is the fluid a man ejaculates. It is produced at several different sites in the body. The sperm within the semen are the cells that actually fertilize the egg. While it is most important to assess the sperm, they account for only 1% to 2% of the semen volume. Problems with the surrounding fluid may also interfere with the movement and function of the sperm. Therefore, both the sperm and the fluid must be tested.
There is no specific, magic number of sperm in the semen analysis of men whose partners will get pregnant. The partners of some men with a very poor semen analysis may conceive easily, while the partners of some men with an excellent semen analysis may experience difficulty. However, men with good semen analysis results will, as a group, conceive at significantly higher rates than those with poor results.
The semen analysis will help determine whether there is a male factor involved in the couple’s sub-fertility. In those cases, we will recommend an evaluation. There are certain findings of the semen analysis, which suggest specific potential problems. For example, an increased white blood cell count may indicate infection or inflammation. However, other abnormalities in many of the main parameters are non-specific. For example, there are a number of different causes for a decreased sperm count or diminished sperm movement. Some of these causes have other serious medical implications, others don’t. A thorough evaluation helps determine the cause of an abnormal semen analysis.
Standard Semen Analysis
In WHO 2010, the new normal values are based on data from men with proven fertility, men who were known to help their partners conceive in the previous 12 months. Following a large analysis of semen parameters from over 4000 men in 14 countries, a new set of 5th percentile parameters was recommended. The new WHO criteria are unique because, for the first time, a semen sample under evaluation can be compared to those of fertile men. We have found the new standards to be quite helpful in assessing the male fertility potential.
- Concentration (sometimes referred to as the count): This is a measurement of how many million sperm there are in each milliliter of fluid. There are various techniques for obtaining this number; some prove to be more accurate than others. Average sperm concentration is more than 60 million per milliliter (>60 million/cc). Counts of less than 15 million per milliliter (<15 million/cc) are considered sub-fertile.
- Motility (sometimes referred to as mobility): This describes the percentage of sperm that are moving. 40% or more of the sperm should be moving.
- Forward Progression: This describes how well the sperm that are moving are making progress. Only when the motility (percent moving) is combined with the forward progression is an accurate picture of sperm movement obtained. Unfortunately, this is often not tested by commercial laboratories. A man’s motility may be normal and the fact that the sperm are moving sluggishly or almost not at all will be overlooked if the forward progression is not recorded separately.
- Morphology: This describes the shape of the sperm. The sperm are examined under a microscope and must meet specific sets of criteria for several sperm characteristics in order to be considered normal. Most commercial laboratories will report WHO morphology (use World Health Organization criterion). 30% of the sperm should be normal by these criteria.
- Kruger Morphology: This is a more detailed evaluation of the morphology. Slides are specially stained and the sperm examined microscopically under high-power magnification. The sperm must meet a stringent set of criteria that evaluate the shape and size of the head, midpiece, and tail in order to be considered normal. A Kruger test helps determine which of the available advanced reproductive techniques may be most appropriate and successful.
- Volume: This is a measurement of the volume of the ejaculate. Normal is 1.5 milliliters or greater. The volume may be low if a man is anxious when producing a specimen, if the entire specimen is not caught in the collection container, or if there are hormonal abnormalities or ductal blockages.
- Total Motile Count: This is the number of moving sperm in the entire ejaculate. It is calculated by multiplying the volume (cc) by the concentration (million sperm/cc) by the motility (percent moving). There should be more than 40 million motile sperm in the ejaculate.
- Standard Semen Fluid Tests: Color, viscosity (how thick the semen is), and the time until the specimen liquefies should also be measured. Abnormalities in the seminal fluid may adversely affect the sperm. For example, if the semen is very thick, it may be difficult for the sperm to move through it and into the woman’s reproductive tract.
Lifestyle Factors That Affect Male Fertility
Smoking: Cigarette smoking significantly affects semen quality. A regular smoker has a 23% decrease in sperm density (concentration) and a 13% decrease in sperm motility (ability to move)2. To a lesser extent, smoking causes toxicity to the fluid ejaculated with the sperm (seminal plasma). And when sperm from non-smokers were placed in the seminal plasma (hormonal) of smokers, the sperm were adversely affected (had significantly decreased viability).
Smoking affects the hypothalamic-pituitary-gonadotropic axis, most commonly affecting levels of estrogens. Other problems are secretory dysfunction in the Leydig Cells, which are in the testes and produce testosterone. Most worrisome is that evidence suggests paternal smoking may also be associated with congenital abnormalities and childhood cancer, though the relative risk in most studies is less than two.
· Marijuana: Marijuana often causes a decreased average sperm count, a change in the movement of the sperm (motility), and compromised size and shape (normal morphology). It affects the hormonal axis (HPG), causing decreased plasma testosterone. It may also have a direct negative effect on the Leydig Cells.
· Cocaine: Even infrequent cocaine use causes decreased sperm count, motility, and normal morphology. These effects can be found in men who have used cocaine in the two years preceding their initial semen analysis. Cocaine also decreases the ability of sperm to penetrate the cervical mucous, making it difficult for them to enter the uterus.
· Anabolic Steroids (male hormones): The use of anabolic androgenic steroids has reached almost epidemic proportions. Nearly 7% of 12th-grade males use or have used them to build muscle mass and improve athletic performance. These male hormones suppress normal testosterone production. This decreases the intratesticular testosterone level and may cause severely diminished spermatogenesis or complete absence of sperm (azoospermia). These steroids cause a persistent depression of the hypothalamus and pituitary, which may be irreversible even when the steroids are stopped.
· Alcohol: Moderate alcohol use does not affect male fertility. However, excessive alcohol use affects the hormonal axis and negatively affects the gonads. It may cause associated liver dysfunction and nutritional deficiencies, which are also detrimental for sperm production.
Most vaginal lubricants, including K-Y Jelly, Surgilube, and Lubifax, are toxic to sperm. Couples should avoid their use when trying to achieve a pregnancy. There are lubricants specifically formulated for use when trying to conceive.
If you’re having trouble conceiving and suspect male infertility call us at 1 203.373.1200 or 1 855.CFABABY (Toll Free) to schedule an appointment. We can perform an evaluation, pinpoint any issues, and help you determine the best way to grow your family.