When evaluating couples who are having difficulty conceiving, it is not uncommon to find that the male partner may have an abnormal semen analysis. In fact, 40% of the causes of infertility are due to the male.
It is very important to take a medical history from the man in the intial appointment.
Life Style Choices that Affect Male Infertility
Steroids, Illict Drugs and Smoking
Some men use anabolic steroids for body building and/or recreational drugs, such as marijuana. Steroids suppress the hypothalamic pituitary area lowering the stimulation of the testicle. As a consequence, sperm production can drop dramatically. This is similar to a woman using an oral contraceptive agent (birth control pill).
Marijuana lowers the production of testosterone and increases the production of estrogen, a compounding negative effect on sperm production.
Likewise, smoking has a detrimental effect on sperm function.
If the man is overweight, his excess fat increases the conversion of the male’s testosterone to estrogen, again changing that ratio to an unfavorable situation. Fortunately, these adverse effects are usually reversible. Therefore, changing these social habits and improving the man’s general health can lead to an improvement in sperm production.
Physical Examination of the Male Partner
When the evaluation of the semen is abnormal, it is appropriate for the man to be referred to an urologist for an evaluation. Usually the urologist will perform a “pelvic exam” which consists of examination of the testicles (which are responsible for the production of sperm) and a rectal exam to evaluate the prostate gland.
The Prostate Gland
The prostate produces approximately 1/3 of the semen (the liquid portion of the ejaculate). Inflammation of the prostate gland can result in the production of inflammatory white cells. These white cells can result in the development of reaction oxygen species (ROS) in the semen. ROS can interfere with sperm function, even when the numbers of sperm are adequate.
One of the common findings from the examination by the urologist is a varicocele. This is a swelling of the testicular vein in the scrotum, more commonly found on the left. Occasionally, the urologist may recommend that the varicocele be repaired. Results of the procedure have been mixed with some men showing an improvement of the sperm motility and morphology. However, some men show no change and some may experience a decline in the sperm numbers.
Hormone Evaluation and Low-T
Also, it is important for the evaluation of the male to include a hormonal evaluation. A serum FSH and a serum testosterone are critical to ensure that the testicles are functioning properly.
If a man is found to have a low serum testosterone with either a low or normal serum FSH, he is a candidate for clomiphene therapy. Most couples have assumed that clomiphene is a fertility drug for women only. However, in certain clinical situations, men can use clomiphene.
Clomiphene acts on the hypothalamic-pituitary area of the brain to stimulate the release of FSH and LH. These hormones stimulate the ovary in women and the testicle in men. Therefore, in the appropriate clinical setting, this medication can be helpful for men.
Clomid Use in Men with Low Sperm Counts
A few years ago, our group evaluated men who were candidates for clomiphene therapy and found that the medication caused a significant increase in their serum FSH, LH, and testosterone levels. More importantly, there was a significant increase in the numbers and motility of their sperm. However, there was no increase in the number of normal sperm (morphology).
The starting dose of clomiphene for men is 25 mg on a daily basis. The medication is manufactured as a 50 mg pill. Therefore, it is necessary for the pill to be cut in half so that the man can take 25 mg. In six weeks, a serum testosterone and FSH are drawn to determine if the testicle is responding. If the hormonal response is inadequate, the medication is increased to 50 mg on a daily basis.
On the other hand, if there is a response at either level, the medication is continued until conception is obtained. The sperm cycle is 70 to 90 days for men. An improvement in spermatogenesis may not be seen for at least three to four months. After six months, usually no further improvement is noted. If there is no response to the higher dose of clomiphene, it may be that this therapy is not going to be beneficial.
Other Fertility Options for Men with Low Sperm Counts
An elevated serum FSH suggests that the man has testicular failure as the cause of his poor sperm production. Usually the cause of a low sperm count with an elevated serum FSH is genetic. In this situation, it is uncommon that any surgical procedure or hormonal therapy will improve sperm production.
Therefore, these guys are not very good candidates for Clomid.
If the quantity of sperm is not too low, these couples may benefit from intrauterine insemination (IUI). However, there needs to be at least 10 million moving sperm following the preparation of sperm for IUI. If the numbers are below that level, then it is best for the couple to undergo in vitro fertilization (IVF).
IVF, In vitro Fertilization & Male Infertility
IVF is very successful even with very low numbers of sperm. When the numbers of sperm are very low, it is common for these couples to need to utilize intracytoplasmic sperm injection (ICSI) during the IVF procedure. ICSI involves injecting sperm directly into the egg in the IVF laboratory utilizing an operating microscope.
If the abnormality is so severe that there are no sperm seen in the ejaculate (referred to as azoospermia), some men are candidates for surgical extraction of the sperm directly from the testicle. When sperm are surgically retrieved, the couple needs to undergo IVF/ICSI to achieve pregnancy because sperm obtained surgically are immature and cannot fertilize an egg on their own, even with insemination.
A complete evaluation of the male is important when working with a couple struggling to become pregnant. Occasionally, improving general health and avoiding recreational drugs may be all that is necessary to significantly increase sperm production. Also, there are many available treatment options for couples, even when the male has a very low sperm count.