The Male Fertility Evaluation

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Perhaps because the woman carries the baby, we often consider infertility solely a female problem. In fact, up to 50 percent of all infertility cases involve the male partner. If male fertility issues are suspected based on the results of a semen analysis, we may refer him to a male fertility specialist or an andrologist, who specializes in male reproductive problems. Just as reproductive endocrinologists are gynecologists sub-specialized in treating female infertility, andrologists are urologists specially trained to treat male infertility.

As with female infertility, there are a number of treatments to successfully address various male infertility diagnoses. When recommending a given male fertility treatment option, we consider three important factors:

  1. Cause of infertility, if identifiable
  2. Severity of the sperm abnormality
  3. Age of the female partner

The male fertility evaluation will include a sperm count, and usually a panel of hormone blood tests, a physical and urogenital examination, and possibly genetic tests and/or sperm function testing.

Semen Evaluation

Most men will initially be diagnosed with a potential male factor problem based on the results of an ejaculated sperm specimen.

Normal values for the sperm analysis, as defined by the World Health Organization (WHO):

Semen Analysis-WHO Minimal Standards of Adequacy

Ejaculate volume———-1.5-5.0cc (milliliters)

Sperm Concentration—–>20 million sperm per cc

Motility———————>50%

Forward Progression——2 (scale 1-4)

Morphology—————-30% normal forms (WHO criteria)

Morphology—————->4% normal forms (Krueger criteria)

Total Motile Count. Sometimes only one sperm parameter is abnormal and sometimes several are abnormal. An indicator useful in determining overall fertility is called the total motile count. This number represents the total number of motile sperm in the ejaculate. The total motile count is calculated thus:

Ejaculate volume X Sperm Concentration X %Motility = TMC. If the TMC is 20 million sperm or less, there is likely to be a ‘significant’ male factor problem. Men with a TMC consistently less than 5 million are said to have ‘severe’ male factor infertility.

Morphology. Another important parameter in the semen analysis is the morphology, or shape of the sperm. The shape of the sperm is a reflection of proper sperm development in the testicle, or spermatogenesis. Men with a defect in sperm maturation tend to have problems with sperm morphology and may then be at risk for failure of their sperm to fertilize their partner’s eggs.

Fertility Treatment Options

Varicocele Surgery. Varicocele surgery is performed under local anesthesia and light (‘twilight’) sedation, usually taking a little over an hour. The patient will return home and may be advised to take it easy for a day.

Results. If the varicocele is of significant size (‘grade II or III’), about two thirds of men undergoing the infertility treatment surgery will see some improvement in the sperm quality, most typically seen as an improvement in motility. The reported pregnancy rates following surgery are in the range of 40%. However, it is important to note that most pregnancies occur 6-9 months following surgery, so age of the female partner needs to be considered before undergoing surgery.

Clomid therapy for unexplained low sperm count. If there is a mild decrease in the male partner’s sperm count or motility, a urologist may prescribe Clomid, an infertility pill commonly used to treat women who fail to ovulate. Clomid can stimulate the hormones responsible for sperm production. Sperm counts are re-analyzed 3-6 months after medication is started to evaluate any improvement in sperm production.

Anti-Oxidants and Micronutrients. Most cases of male factor infertility, even after full evaluation, will be labeled “idiopathic,” which means that we do not know why there is a low count, low motility, or poor sperm morphology (poorly formed, abnormally shaped sperm). It may be environmental (pollutants, toxins) or related to lifestyle (hot tub or hot bath use, smoking). When the causative factor can be found and changed, of course this will be advised. However, even men without known toxic exposures or lifestyle factors can have low sperm parameters. There are many dietary supplements that are known to improve sperm production and function (such as L-carnitine and zinc). A reproductive endocrinologist or andrologist may recommend beginning a vitamin and mineral supplement to help make the sperm as good as it can be.

IUI (intrauterine insemination cycle). When there is mild, unexplained low sperm count or motility, we may recommend an intrauterine insemination cycle (IUI). Sperm is processed and placed into the female partner’s uterus around the time of ovulation, giving sluggish sperm a big head start towards the egg or eggs.

What to expect from the IUI procedure. The male partner will be asked to provide a sperm sample through masturbation either at home or in our clinic. His sperm is then sent to our laboratory where it is prepared for transfer into the female partner’s uterus. The most active, motile (normal, forward moving) and healthy sperm are extracted and this optimal sperm sample placed into the uterus via a catheter.

Prior to the IUI procedure, the male partner will be asked to abstain from ejaculation for 1 to 3 days (however, abstaining for more than 5 days can result in decreased motility).

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