The medical infertility workup is usually able to diagnose the cause of a fertility problem in a man. Identifying the problem is the first step in recommending treatment. The most common causes for male infertility are problems with testicles, problems with sperm transport, hormonal problems, and ejaculatory problems. Each is described in detail below.Testicular Problem
The testicles are the manufacturing plants for sperm production (spermatogenesis). Normal sperm production requires hormonal orchestration as well as a sound and safe physical environment. Problems or injuries that affect the testicles can disrupt spermatogenesis. The following table reviews testicular problems.
Varicocele Explanation Varicoceles (a mass of varicose veins in the scrotum) are a leading cause of male infertility. A valve defect within the veins causes the blood to back up and pool, resulting in swollen veins. Varicoceles impair semen production. This problem usually only affects one testicle, often the left testicle.
Symptoms Large varicoceles produce a mass that visible through the scrotum. A physician can feel moderately sized varicoceles. Small ones are harder to detect. The testicle involved is often smaller than the unaffected testicle.
Treatment Surgery is performed under general anesthesia, and in most cases is successful in restoring fertility.
Mumps Contracted As An Adult Explanation
When mumps are contracted as an adult, the virus can invade one or both testicles, destroying the cells that are responsible for sperm production.
Symptoms Small testicles are usually noted, high levels of FSH, and low or no sperm production.
A mumps vaccine can prevent the disease and should be considered for men who did not contract mumps as a child. Low sperm production may respond to hormone therapy with fertility drugs or ART (Assisted Reproductive Technology) procedures. If no sperm are being produced, there is no treatment which can restore this ability.
Infections Affecting the Testicles Explanation
Sexually transmitted diseases (STD’s) are the most common type of infection that can lead damage of the reproductive tract and cause infertility.
Any illness that causes a high fever can temporarily reduce sperm counts. Dental abscesses have been implicated in low sperm counts.
STD’s may cause thick discharge, pain on urination, or difficulty urinating or ejaculating because of scar tissue. Some STD’s have no obvious symptoms.
Pain and swelling may accompany any infection that has reached the testicles.
In the case of STD’s, prevention is the best treatment. Condoms can help reduce the risk of infections. Many STD’s are treatable with antibiotics.
In the cases where STD’s are not the culprit, good oral hygiene can prevent oral bacteria from traveling through the bloodstream and invading the testicles. In terms of other illnesses and viruses, once treated, sperm production usually returns to normal.
Trauma Explanation Injuries to the testicles can damage the sperm making machinery. Sports injuries and torsion (when the testicle twists and cuts off it’s own blood supply) are traumas that can lead to infertility.
Symptoms Sports injuries and torsion cause obvious pain. Swelling may be noted.
Treatment Some injuries will require surgical treatment. Torsion is corrected with the help of a urologist who unwinds the testicle which restores normal blood flow.
Congenital Defects Explanation
Some defects are congenital, or present at birth. Klinefelter’s Syndrome is a chromosome abnormality where there is an extra X chromosome. (XXY). This syndrome prevents sperm production.
Sertoli’s Cell Only Syndrome results in an inability to produce sperm because the cells responsible for sperm production don’t develop during fetal development.
Undescended Testicles is another cause for sperm production failure. Testicles develop in the abdomen of the fetus and then descend into the scrotum after birth. If the testicles fail to descend, and go unnoticed, then the warmth of the body destroys the sperm manufacturing capabilities.
Klinefelter’s Syndrome often goes unnoticed until infertility is apparent. If symptoms are present they include; small testicles, and slightly enlarged breast tissue.
Sertoli’s Cell Only Syndrome is only detectable with infertility tests. Semen has all of the normal components except sperm.
Undescended Testicles can be detected by physical exam of the scrotal sac.
Klinefelter’s Syndrome and Sertoli’s Cell Only Syndrome cause untreatable sterility. However, some men who have Klinefelter’s have a partial defect where some cells carry the extra chromosome XXY, while other cells are normal XY. As long as some cells are normal, there may be some sperm production. ART procedures can be employed to increase the chances of conception.
For undescended testicles, HCG hormone can be given to male infants to stimulate the descent of the testicles. If that is not successful, microsurgery can be performed to move the testicles into the scrotum.
Other Factors Explanation High stress levels, excessive heat to the testicles, high altitudes, poor diet, exposure to toxic substances, use of certain drugs (including anabolic steroids) and alcohol can all decrease sperm production.
Symptoms Lab tests will show decreased sperm production or abnormal sperm cells.
Avoid the offending factor. Eat a balanced, healthy diet. Limit alcohol intake. Avoid street drugs and check with your doctor regarding the safety of any prescription drugs that you are taking. Reduce stress. Avoid exposure to toxic substances. Avoid extremely high altitudes because the lower oxygen content of the air can depress sperm production. Relocating from a lower altitude to a higher altitude temporarily reduces sperm counts. Once the body has adjusted by increasing it’s red blood cells, the sperm production will return to normal. Heat kills sperm. Avoid hot tubs, saunas and even tight briefs that hold the testicles too close to the body.
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Sperm Transport Problems
Sperm may be produced normally in the testicles, but the next feat involves moving the sperm from the testicles through the epididymis, vas deferens and out through the penis. Any obstruction in this pathway can prevent the sperm from reaching their target, the egg.
Sperm Transport Problems
Vas Deferens or Ejaculatory Ducts
Explanation Infections and sexually transmitted diseases (STD’s) can cause scarring that block the ducts. Tuberculosis (TB) can have a similar damaging affect. Surgeries done to correct other problems in the vicinity of the ducts could have bruised or severed the vas deferens. Trauma and birth defects can also render the transport system ineffective.
Symptoms Low or no sperm count.
Microsurgical repair is sometimes possible. Some untreated infections or STD’s can cause permanent sterility.
A vasectomy is a form of permanent sterilization. The vas deferens are cut or tied off to prevent sperm from exiting the testicles. If a man later decides he wants to father a child, the vasectomy becomes a barrier to fertilization.
Some men who have had vasectomies will form antibodies to the sperm that remain in the testicles. Once a man produces antibodies to his own sperm, the antibodies continue to attack the sperm even if the vasectomy is reversed.
Symptoms Sterility after the vasectomy.
Microsurgery to reverse the vasectomy requires reconnecting the minute tubes. Success rates vary, but reversal often restores fertility.
Antibody problems are addressed by ejaculating into a buffer solution. The sperm can then be washed and used in ART procedures. Cortisone is a drug that suppresses the immune system and is used to treat the problem of sperm antibody formation.
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FSH and LH are hormones, messengers from the brain, that are responsible for directing sperm production. Low hormone levels can indicate a problem with the brain’s control of sperm production. High hormone levels usually mean the message to produce sperm has been sent, but the testicles are unable to manufacture the sperm. High levels of FSH and LH may indicate a problem that does not currently have good treatment options. Low levels of FSH and LH can often be corrected with hormone replacement therapy.
Kallman’s Syndrome Explanation
This congenital problem (present at birth) effects the hypothalamus, which is the region of the brain that starts the hormone relay that directs sperm production. Men with Kallman’s Syndrome have no sperm in their ejaculate.
Symptoms Besides infertility, men with this syndrome tend to be tall and thin, and have soft, small testicles. The men may be color blind or deaf, and have no sense of smell. Testosterone is not produced, and all other hormone levels are low.
Fertility drugs are used to treat this disorder. Providing hMG (a combination of FSH and LH) can stimulate the testicles to produce testosterone so that male sexual characteristics develop. HCG and LH-RH are other hormones that can stimulate the testicles into normal sperm production.
Damage to the Hypothalamus or Pituitary Explanation The hypothalamus and the pituitary gland are instrumental in initiating the hormonal flow that directs sperm production. Any injury to the brain or directly to the hypothalamus or pituitary can shut down the hormonal control center and lead to infertility. Brain tumors, infections, encephalitis (brain infection) and certain drugs can be the cause of the problem.
Symptoms No or low sperm count. Low hormone levels of FSH, LH and testosterone. High levels of prolactin hormone. Possibly small, soft testicles, enlarged breast tissue and impotence. Blurred vision may accompany large pituitary tumors.
Hormonal replacement of FSH and LH may direct the testicles to produce sperm. CAT scans can detect pituitary tumors and then the tumor can be removed surgically. Some forms of damage are irreparable. Your physician will be able to direct you towards any treatment possibilities.
Faulty Adrenal Gland Explanation The adrenal glands, located on the kidneys, produce some testosterone. (Most testosterone is produced by the testicles). Although rare, if the adrenal gland produces too much testosterone, the message to the brain is to stop sending FSH and LH. This interferes with normal sperm production.
Symptoms If adrenal problems occur in young boys, they will experience accelerated sexual maturation. If the problem occurs after puberty, the result is low sperm count. Hormone tests will detect low levels of FSH and LH and high levels of testosterone.
Treatment Cortisol treatment (a steroid) will correct the problem and slow down the testosterone production.
Faulty Thyroid Gland Explanation The thyroid gland directs cell metabolism. (Metabolism is the rate at which cellular functions occur). Sperm production can be may be affected by changes in metabolism.
Symptoms Hyperthyroidism (too much thyroid hormone) has symptoms that include agitation, restlessness, insomnia, muscle fatigue, shakiness, jumpy reflexes and irritability.
Hypothyroidism (too little thyroid hormone) has symptoms that include sleepiness, poor reflexes, hair loss, slurred speech, and constipation.
Treatment Hyperthyroidism is treated with drugs that reduce thyroid hormone production, or the thyroid gland may be radiated. Hypothyroidism is treated by thyroid replacement therapy.
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The process of ejaculation propels the sperm out of the man’s body, making the sperm available for fertilizing the egg. Problems related to ejaculation can interfere with the process of conception.
Impotence Explanation Impotence may have physical or psychological causes. Illicit drugs, alcohol and some prescription drugs can cause impotence. Stress and emotional upset may be the cause. Certain disease states can cause impotence; for example poorly controlled diabetes can lead to high blood sugar levels which damage blood vessels and nerves. Spinal cord injuries may also cause impotence.
Symptoms Inability to achieve or maintain an erection.
A medical workup must be done to distinguish between medical or psychological causes. Counseling and resolution of emotional conflict may correct the impotence. Abstain from alcohol and drugs that result in impotence. Blood sugar control in men with diabetes is crucial in preventing all diabetes related complications, including impotence. Men with spinal cord injuries can use a medical electrical device designed to induce ejaculation. The collected sperm can be used with ART to fertilize an egg.
Retrograde Ejaculation Explanation
The valve that separates the urethra from the bladder is supposed to close during an orgasm to force the semen out of the penis. A faulty valve won’t close. Instead of the ejaculate leaving the body through the penis, it travels backwards into the bladder and is expelled later with urination. Causes include uncontrolled diabetes, certain drugs (including some high blood pressure medications), or injury to the area.
Symptoms An orgasm that doesn’t produce any semen. Urine that is milky white after an orgasm.
Injury may require surgical repair. Blood sugar control in men with diabetes is crucial in preventing all diabetes related complications, including retrograde ejaculation. Lastly, medical technology allows collection of the sperm from the voided urine. The collected sperm may then be used with ART to fertilize an egg.