Infertility is a problem affecting up to 15% of couples. An estimated 4.6-7.3 million couples seek infertility care in the United States. About 50% of cases have a female factor, 20% have a male factor and 30% have combined factors. That means 50% of infertile couples will have an element of male-factor infertility. Diagnosis and treatment of male infertility can lead to lower intensity of infertility treatments possibly associated with improved success and decreased treatment costs.
What is male-factor infertility?
- The first and most important definition is the inability to achieve a pregnancy through natural means for a 1-year period. Sometimes this can be less than 1 year, especially if known problems already exist or the female partner is a little older. Both male and female partners should be evaluated as part of the workup.
- To most people, male infertility means an abnormality in the number of sperm or how they move. This is not the only definition. Sometimes it is how the sperm works (the function, such as DNA fragmentation) and the products in the fluid around the sperm that affect the sperm.
- Known urological and medical conditions that affect a man's reproductive ability include medications, cancer, surgeries, conditions from childhood, infections, vasectomy and more.
One in 100 men referred for infertility have been shown to have a previously unsuspected medical condition diagnosed on evaluation, including genetic disorders, endocrine diseases and malignancies. Importantly, semen analysis alone is unable to identify the men at highest risk for disease.
In a study, Kolettis and Sabanegh found that 6% of all men referred for infertility had other medical diseases that were only brought to the attention of the doctor because the couple was being seen for male-related infertility. We have also reported a number of cases of medical diseases have been found during the male evaluation at the time of infertility diagnosis. Research suggests male infertility is associated with a higher testicular and prostate cancer risk. Childless men may also have a higher risk of cardiovascular mortality later in life. Higher risk of shorter life expectancy in men with abnormal semen parameters has been reported. There are potentially later problems from low testosterone related bone health, cardiovascular and sexual issues. Our urologists care about the long-term consequences of a diagnosis of male infertility in the reproductive years.
Leading-edge research is ongoing under the guidance of Ajay Nangia, MD, to better understand the causes of male infertility. New treatment options are being investigated. Dr. Nangia specializes in the care of men in Kansas City, the Midwest and across the nation. He specializes in complex genetic and hormonal issues, ejaculation and erection problems, and the microsurgical correction of blockage problems (due to infections, vasectomy and other traumas/surgeries) that could potentially be corrected. Men will be guided to better health monitoring, hopefully improving quality of sperm if assisted reproductive technology is needed. Since women see gynecologists who specialize in their reproductive needs, shouldn't men be seeing a men's specialist? Dr. Nangia works closely with the female reproductive specialists in the Kansas City area that perform assisted reproductive techniques, i.e., intrauterine insemination (IUI) and in vitro fertilization (IVF). The overall joint care of the male and female partners as a couple is the key to succeeding in the joy of achieving a pregnancy and healthy baby.
Many causes of male infertility exist, ranging from hormonal, blockages, genetic, environmental/lifestyle or medications, to name a few. Certain potentially life-threatening medical conditions may present for the first time as the inability to achieve a pregnancy and lower sperm counts, such as testicular tumors and some brain tumors. They are uncommon, and the reason why male patients should be evaluated in couples who have infertility.
The evaluation should involve a thorough history and physical and evaluate some of the risk factors known to cause male infertility, e.g., some childhood disorders that do not become a concern until later in life, like undescended testicle(s); infections; smoking, alcohol and drug use; certain issues with heat (not boxers or briefs – a myth); cancer treatments; spinal cord injury; and other medical conditions. Blockages of the reproductive tract can sometimes be the cause. Reconstruction microsurgery can be performed to reverse blockages and avoid assisted reproduction techniques allowing the patient to have children naturally. Unfortunately, these blockages sometimes cannot be corrected and sperm retrieval techniques and sperm freezing are required for in vitro fertilization with intracytoplasmic injection – one sperm injected into an egg outside the body.
Low counts and/or motility can also be remedied with a manipulation of hormones and correction of certain conditions, such as:
Varicoceles: dilated veins in the scrotum that are thought to increase scrotal temperature and affect sperm production. Up to 40% of men who present with infertility have a varicocele upon exam. Treatment for this requires careful patient selection and can result in 40-70% improvement in sperm production and up to 40% improvement in pregnancy rates. Even some men with no sperm in their semen who have a varicocele may get return of sperm (approx 17%). It is important to know that the number of sperm is usually not enough for natural conception in these cases and would require assisted reproductive techniques with in vitro fertilization. Correction of the varicocele is an outpatient procedure that requires an operating microscope to tie off the veins accurately and completely without causing damage to the blood supply to the testicle. Embolization of the veins can also be performed.
Other conditions that cause male infertility are:
Up to 10% of male infertility may have a hormonal association. Determining how important that is requires expertise in the field of male infertility. Many of these hormonal issues arise from childhood, but a recent trend on the rise is the overuse of testosterone for "low T" in men still in their reproductive years. Dr. Nangia specializes in the management of these men, many of whom have male infertility. Male patients who want children should not be placed on testosterone. This will shut down sperm production. Correction of the testosterone level has limited success for male fertility but is becoming more and more recognized as a potential health concern for later heart disease, insulin resistance and diabetes. To correct the testosterone in such men, non-testosterone methods/medications are an option. Dr. Nangia has a special interest and expertise in this field and will be able to share how it relates to male reproductive and post reproductive health.
Obesity can cause hormonal abnormalities that need to be corrected. Of course, weight loss is the best way for many reasons. Life-threatening conditions, such as prolactinoma of the pituitary gland, can show up for the first time during a couple’s difficulty getting pregnant. This condition requires urgent care and, in the early stages, can be managed with medication alone.
When semen goes backwards into the bladder and not outwards. Retrograde ejaculation can be caused by previous surgery such as prostate; medications such as alpha-blockers; or diseases affecting the nervous system, such as diabetes and spinal cord injuries. Sometimes this occurs in men with no known medical conditions. It may be corrected with the use of medications.
When a blockage of the sperm system occurs from the back of the testicle (epididymis) to the sperm duct (vas deferens) and the prostate. Sometimes this happens because of injury or infection. Most times it is due to a vasectomy. These blockages can be corrected with microsurgery and can lead to pregnancy without the need of assisted reproduction such as in vitro fertilization. Dr. Nangia specializes in such cases. It is sometimes necessary to perform a biopsy of the testicle to prove that sperm are present. Sometimes reconstruction is not possible and consideration for freezing sperm/tissue from the testicle needs to be considered at the same time as the diagnostic biopsy.
Medications, lifestyle and environmental
Certain medications and environmental toxins are known to cause male infertility and affect sperm function, including pesticides and petroleum products. Lifestyle issues such as smoking, chewing tobacco, excessive alcohol use and drug use (including anabolic steroids) are known to cause infertility. Obesity is a known cause for male infertility. The use of laptops and cell phones has recently been popular in the press as possible causes of male infertility.
Some causes of male infertility, such as no sperm (azoospermia) or very low counts, can be due to a production problem. About 5-25% of these cases can be due to an abnormal number of X and Y chromosomes or a missing piece of a Y chromosome. Other conditions, such as Klinefelter syndrome and congenital bilateral absence of the vas deferens, are genetic conditions that cause male infertility.
A large number of male infertility cases are unfortunately still unexplained. This is called idiopathic. For this, there are a number of methods that can be tried to improve the situation and hopefully achieve natural conception or improve the effectiveness of any assisted reproductive techniques used.
Sporting injuries and male infertility
Have you ever winced when an athlete takes a hit in the groin? You should. It hurts and has some serious potential consequences. Not only does it cause the player to double over in pain, it can cause a rupture of the testicle and injury to the reproductive and urinary system. All of these issues can lead to problems with erections and cause infertility.
An injury can be tragic to the hopes and aspirations of a couple and cause serious social, psychological and economical distress in a relationship. Because of this, many specialists believe educating boys at the time of sports physicals is essential. From testicular self-exams to detect testicular cancer early; education about contraception; STD prevention; and injury prevention. This is also important because most males who engage in sports are in their reproductive years; in an age group with the highest risk of risky/dangerous and carefree behavior; as well as the age group most likely to develop testicular cancer.
Routine male genitourinary examination during the preparticipation physical evaluation, including testicular and hernia evaluation, is recommended by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Sports Medicine, the American Medical Society for Sports Medicine, the American Orthopedic Society for Sports Medicine and the American Osteopathic Academy of Sports Medicine. This is somewhat concerning because, in 2008, the U.S. Preventive Services Task Force, or USPSTF, made a recommendation against routine screening for testicular cancer in asymptomatic adolescents and adults based on the lack of written evidence that it helps. The USPSTF consensus has been that screening does not provide any benefit over current case-finding practices, i.e., when a young man may feel a lump in his testicle and/or have pain. The problem is that Dr. Congeni and colleagues from Akron, Ohio, showed in 2005 that no more than 15% of athletes correctly differentiated the urgency of seeking medical treatment of painless versus painful testicular swelling. 34% still reported they would delay seeking medical care for painful testicular swelling. Only 38% knew that young men had the highest risk of testicular cancer. The majority believed older men have the highest risk.
This highlights the problem and stresses the need for improved education in junior high schools and upwards, as well as in sports teams and government and recreational health policy groups. This is very concerning because self-exams are free and testicular cancer is very treatable if detected early. In the face of poor evidence, we strongly encourage adolescents and young men to continue to perform self-exams until the issue has strong evidence to support that screening is not needed. Lance Armstrong is a classic example of someone who waited too long to seek a medical intervention. His testicular cancer spread to his belly, lungs and even brain. He was lucky he survived. Now he promotes “Livestrong,” We also promote “Live Smart.” With testicular cancer, the later the diagnosis, the more aggressive the treatment, with not only removal of the testicle but also abdominal, lung and brain surgery, and chemotherapy possible. All have an increased risk of effecting later fertility. The more aggressive the treatment beyond removal of a testicle, the more risk of damaging later fertility permanently. Genital injuries during sports have been described mostly in case studies. However, The National Electronic Injury Surveillance System, or NEISS, showed that between 1990 and 2000, 883 sports-related genital injuries occurred in males less than 26 years old requiring emergency evaluation. Blunt trauma (such as being hit by a bat, ball or hockey puck in the genitals without breaking though the skin) accounts for approximately 85% of injuries, and penetrating trauma (punctures the skin and underlying organs) accounts for 15%.
Blunt testicular injuries can be managed with either observation or immediate surgery, depending on the situation. Early surgical intervention for blunt trauma is associated with testicles more likely to be saved. Most blunt trauma to the testicles is minor and usually requires only conservative therapy. However, the injury can be underestimated and up to nearly half of patients presenting with blunt scrotal trauma in one study underwent surgery and were found to have rupture of the testicle. The NEISS showed that serious injuries to the genital area were most commonly seen with baseball, followed by basketball and football. Approximately 20% of emergency visits for sports-related genital trauma had a risk of permanent injury, and up to 7% resulted in staying in the hospital overnight or transfer to a more comprehensive trauma center. Football had the highest risk of resulting in hospitalization or transfer to a trauma center for genital injury.
The risk of genital injury in baseball was 1 in 383, versus 1 in 669 in football and 1 in 799 in basketball. When it comes to protection against injury, a study in 2005 showed that 47% of males playing sports did not wear genital protection. Overall, only 33% of football players wore a cup, versus 78% of baseball players. There are no clear statements or recommendations by any medical organizations on the issue. Protection is recommended, and common sense prevails on the degree of contact involved and protection needed. Certain sports are high risk (e.g. football, ice hockey and baseball), as well as certain positions, such as goalie and catcher. Overall, cups are often not worn by players due to the relative uncomfortable nature of the device during fast motion sports. This is an important focus of public awareness in this discussion, and coaches, local recreational committees, as well as college and professional leagues need to educate players on these simple means to prevent injuries by wearing their cups.
Other sports or fitness activities like bicycle riding or spinning may result in testicular pain. Repeated and/or prolonged bike riding without coming off the seat and remaining in a forward leaning aerodynamic position may cause numbness of the groin and in some cases affect the ability to get and maintain an erection. All these issues can potentially compromise male reproductive health, especially with repeated trauma. Extreme sports like skateboarding to BMX and motor cross have been associated with urological injuries, especially straddle injuries and damage to the male urethra, which can result in strictures (narrowing) that make urinating and ejaculation difficult. Even recreational sports such as paintball have resulted in testicular fractures and hospitalization.
Excess exercise may represent a physical stress that challenges the body at several levels. The beneficial effects of exercise are well known, but there is evidence of exercise-related short- and long-term consequences concerning male reproductive function – such as hormonal disturbances or effects directly on the testicles. Sperm and erectile function can be affected. Training intensity, duration and type of exercise, as well as level of fitness will influence these effects. Current research has not been conclusive. It is important that physicians and the general public pay attention to exercise as a possible cause of male infertility and be precautionary until future research has thoroughly elucidated this relationship.
Other injuries such as neck/spinal cord injuries and concussions from high-contact sports like football are not rare and associated with a number of health issues, with some of the most extreme being inability to move arms and/or walk (paraplegia and quadriplegia). All these issues can affect fertility, ejaculation and erections. This brings up the issue of neck supports and helmets, which has been discussed more recently in connection with concussion risk/injuries. This is another extension of the same issue. All these issues do not take into account other effects of sports on male reproduction, such as the abuse of anabolic steroids. This is the focus of a separate topic in this series.
Overall, sporting activities highlight the need to discuss men’s health issues at preparticipation physicals at all levels but also in schools from an early age. Sports also highlight the need to reiterate education and enforce protection of the male genitals. At present, there is a lack of adequate information provided to young men and also inadequate technology to make such protection comfortable to wear. More work is needed to educate sports equipment companies and sporting leagues of the importance of this issue. Great advances have been made with bike seats through better knowledge and health promotion, now it is time to improve other genital protection. We urge boys and men who participate in sports on a regular basis to help and educate themselves to ensure a successful reproductive life and good long-term men’s health.
Ajay Nangia, MD, along with a large group of scientists at the University of Kansas Medical Center, is advancing the treatment of men with male infertility, especially unexplained cases with better insight into the reasons for the infertility problem. The Center for Idiopathic Male Infertility has been developed at the University of Kansas Medical Center. Dr. Nangia is a leading member in the field of male infertility on a regional and national level and will be able to advise couples on all the latest information in the field of male infertility and best advise couples on options and alternatives. He recently was a member of the Best Practice Statement in Male Infertility, prepared by the American Urological Association, and will be happy to discuss current standards of care in the field of male reproduction and infertility, along with new testing techniques and their limitations. Treatment options need to be determined after thorough evaluation of history and careful examination.