30% of fertility issues arise due to infertility in men. Treatment of infertility may be possible depending on the condition diagnosed by the fertility clinic.

Infertility In Men

Humza Khizer

Overview

Male infertility is an issue with the reproductive system in men that prevents them from impregnating a female<a href="#accordion">[5]</a>. Medical professionals usually define infertility as the inability of a couple to conceive after 12 months of unprotected sexual intercourse.&nbsp;&nbsp;

Unlike general assumption, male infertility is quite common, especially in the US where nearly 50% of the cases of infertility in couples are due to male infertility. It is the primary cause for approximately 20% of all infertility cases; it plays a significant role in another 30-40% of the cases<a href="#accordion">[1]</a>.

Infertility can either be primary or secondary<a href="#accordion">[6]</a>. Primary infertility means that the man is unable to conceive at all, while secondary infertility occurs when they have previously conceived, but are now unable to do so.

There are a variety of factors that influence natural male reproduction. For instance, they must be able to produce healthy sperm that&rsquo;s capable of fertilizing the egg, to have an erection, or to ejaculate.&nbsp;

Approximately, 90% of male infertility issues are due to sperm count. According to a meta-analysis, sperm density has reduced by nearly 50% globally over the last 50-60 years<a href="#accordion">[2]</a>. 
&nbsp;

Signs And Symptoms

The inability to conceive a baby is the most obvious symptom of male infertility, but apart from that, signs and symptoms of infertility in men can be unclear. They can easily be overlooked until the individual attempts to conceive.

However, in a few occurrences, an underlying issue, such as a genetic disorder, hormonal imbalance, dilated veins around the testicle, or a condition that blocks the passage of sperm, can trigger the following signs and symptoms<a href="#accordion">[7]</a>:&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Sexual Functioning</h5>
	</li>
</ul>

A man&#39;s fertility is affected by different aspects of sexual function e.g. decrease in sexual desire, reduced volume of fluid ejaculated, difficulties with ejaculation, erectile dysfunction, etc.&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Testicular Discomfort Or Swelling</h5>
	</li>
</ul>

Numerous conditions cause pain, discomfort or swelling in the testicles, most of which can lead to infertility. The testicles should also be checked for lumps.

&nbsp;

<ul>
	<li>
	<h5><a href="https://www.merisehat.pk/disease/erectile-dysfunction-90" target="_blank">Erectile Dysfunction</a></h5>
	</li>
</ul>

A man&#39;s inability to maintain an erection is known as erectile dysfunction. It is frequently related to low hormone levels.

&nbsp;

<ul>
	<li>
	<h5>Ejaculation Problems</h5>
	</li>
</ul>

A man&rsquo;s inability to ejaculate or being able to ejaculate only a small number of sperms is another sign.

&nbsp;

<ul>
	<li>
	<h5><a href="https://www.merisehat.pk/disease/gynecomastia" target="_blank">Gynecomastia</a></h5>
	</li>
</ul>

Abnormal breast growth in a man is also a sign of infertility<a href="#accordion">[8]</a>.

&nbsp;

<ul>
	<li>
	<h5>Small And&nbsp;Hard Testicles</h5>
	</li>
</ul>

Testicle health is critical to male fertility because the testes store a man&#39;s sperm. Small or hard testicles indicate potential problems that should be investigated by a medical professional.

&nbsp;

<ul>
	<li>
	<h5>Sperm Count&nbsp;</h5>
	</li>
</ul>

A low sperm count as indicated by less than 39 million/ejaculate OR less than 15 million sperm per milliliter of semen is indicative of fertility issues.&nbsp;&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Hormonal Or Chromosomal Abnormalities</h5>
	</li>
</ul>

Various signs of hormonal abnormalities e.g. decreased body or facial or other signs of a chromosomal abnormality could direct towards the cause for infertility.

&nbsp;

<ul>
	<li>
	<h5>Respiratory Infections</h5>
	</li>
</ul>

Certain syndromes (e.g., Kartegner&rsquo;s syndrome and Young&#39;s syndrome) in men are characterized by frequent respiratory infections and infertility.&nbsp;

Note: Frequent respiratory disorders in all men are not necessarily indicative of infertility, but it definitely warrants seeking medical professional advice to check for underlying issues.&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Inability To Smell&nbsp;</h5>
	</li>
</ul>

This has been seen in cases of untreated Kallmann syndrome.&nbsp;&nbsp;

<div>&nbsp;</div>

Causes

A man&#39;s sperm count or sperm quality can be affected by any of the following factors<a href="#accordion">[8]</a>:

&nbsp;

<ul>
	<li>
	<h5>Medical Causes</h5>
	</li>
</ul>

A variety of health issues and medical treatments can contribute to male fertility issues:

&nbsp;

1. Sperm Disorders Affecting Semen Quality -&nbsp;The most common issues center on semen quality, including:&nbsp;

a. Azoospermia or no sperm in the ejaculate

b. Oligospermia or low sperm count

c. Sperms fail to move properly

d. Odd-shaped sperms&nbsp;

e. Sperm do not reach full growth

&nbsp;

2. Varicocele -&nbsp;A varicocele is defined as the swelling of the veins that drain the testicle. It is the most common cause of infertility in males that causes a reduction in both sperm quantity and quality. Although the precise cause of varicoceles remains unknown, it may be associated with abnormal blood flow.

&nbsp;

3. Infection -&nbsp;Some infections can disrupt the production and health of sperm OR cause scarring and obstruction of the sperm pathway. E.g. epididymitis (inflammation of the epididymis), orchitis (testicular inflammation due to STIs or in some cases mumps), and sexually transmitted infections (e.g., gonorrhea and HIV). Although these infections can induce long-term testicular damage, it is possible to retrieve healthy sperm.

&nbsp;

4. Retrograde Ejaculation -&nbsp;Retrograde ejaculation occurs when sperm moves backward in the body i.e. sperm passes to the bladder instead of outside the penis. This usually occurs because the nerves and muscles in the bladder fail to close during orgasm. Semen may contain normal sperm, but that semen is not ejaculated from the penis, and thus, is unable to reach the vagina.&nbsp;

Surgery (bladder, prostate, or urethral), medicines, diabetes, or spinal injuries can all induce retrograde ejaculation. It&rsquo;s easy to identify because it&rsquo;ll be a &lsquo;dry&rsquo; ejaculation, whereas the urine right after the orgasm will be cloudy due to the presence of semen<a href="#accordion">[9]</a>.

&nbsp;

5. Sperm-Attacking Antibodies -&nbsp;Occasionally, the body produces antibodies against sperm cells. They are called anti-sperm antibodies because they tend to mistake sperm for harmful invaders and, thus, destroy it.

&nbsp;

6. Tumors -&nbsp;Cancers and nonmalignant tumors affect the male reproductive organs either through unknown causes or directly through glands for e.g. pituitary gland which releases hormones linked to reproduction. Moreover, surgery, radiation, or chemotherapy to cure tumors can also have an impact on male fertility.

&nbsp;

7. Hormonal Imbalance -&nbsp;Decreased testosterone (male hypogonadism) and other hormonal issues can have a variety of underlying causes. For instance, it can be due to an issue with the testicles. Alternatively, it can be a problem with another hormonal system, such as the hypothalamus, pituitary, thyroid, or adrenal glands.&nbsp;

&nbsp;

8. Defects Of Sperm Transporting Tubules -&nbsp;Sperm is transported in a variety of tubes, which can become obstructed for various reasons, such as accidental injury from surgery, previous infections, or trauma. Abnormal development, as seen in patients of cystic fibrosis, can also cause obstruction.&nbsp;

Obstruction can occur at any level, including within the testicle, the testicular tubes, the vas deferens, the epididymis, the urethra, or close to the ejaculatory ducts.&nbsp;

&nbsp;

9. Chromosomal Defects -&nbsp;Genetic disorders, for example, Klinefelter&#39;s syndrome, occur when an individual comes into the world with 2 X-chromosomes and 1 Y-chromosome (rather than 1 X and 1 Y). This affects the development of the male reproductive organs. Cystic fibrosis and Kallmann&#39;s syndrome are other genetic syndromes linked to infertility.

&nbsp;

10.&nbsp;<a href="https://www.merisehat.pk/disease/celiac-disease" target="_blank">Celiac Disease</a>&nbsp;-&nbsp;Celiac disease is defined as a digestive disorder characterized by sensitivity to a protein (gluten) that is found in wheat. This condition may contribute to male infertility. However, following a gluten-free diet can help improve fertility.&nbsp;

&nbsp;

11. Specific&nbsp; Medications -&nbsp;Certain medications can damage sperm production, including<a href="#accordion">[10]</a>:

a. Sulfasalazine

b. Anabolic steroids&nbsp;

c. Chemotherapy medicines&nbsp;

d. Medicines to treat ulcers

e. Arthritis medications

f. Testosterone replacement therapy

g. Long-term use of anabolic steroids&nbsp;

h. Herbal remedies, such as root extracts of the Chinese herb Tripterygium wilfordii, affect sperm production or testicular size

i. Illegal drugs, such as marijuana and cocaine, also have an impact on sperm quality

&nbsp;

12. Previous Surgeries -&nbsp;Certain surgeries, such as vasectomy, scrotal or testicular surgery, prostate surgery, and extensive abdominal surgeries for testicular and rectal cancers, may cause infertility.

&nbsp;

<ul>
	<li>
	<h5>Environmental Causes</h5>
	</li>
</ul>

Heat, toxins, and chemicals, among other environmental elements, can decrease sperm production or function.&nbsp;

&nbsp;

1. Industrial Chemicals -&nbsp;Exposure to specific chemicals, such as pesticides, herbicides, organic solvents, and painting materials for an extended period can lead to reduced sperm count.

&nbsp;

2. Heavy Metal Exposure -&nbsp;Heavy metal exposure such as lead can result in infertility.

&nbsp;

3. X-rays And Heat -&nbsp;Radiation exposure can reduce sperm production, but it usually returns to normal after a while. However, high doses of radiation can permanently decrease sperm production.

Increased temperature of the scrotum has been linked to reduced semen quality, however, the utility of wearing loose-fitting underwear for improving fertility remains under research.

&nbsp;

<ul>
	<li>
	<h5>Health, Lifestyle, And&nbsp;Other Causes</h5>
	</li>
</ul>

Other reasons for male infertility include:

&nbsp;

1. Using Drugs -&nbsp;Anabolic steroids used to increase muscle strength and growth can shrink the testicles and reduce sperm production. Cocaine and marijuana, in particular, are known to temporarily decrease the quantity and quality of the sperm.

&nbsp;

2. Drinking Alcohol -&nbsp;Alcohol consumption can induce erectile dysfunction, and lower testosterone levels and sperm production.

&nbsp;

3. Smoking -&nbsp;Males who smoke tobacco may have reduced sperm counts as compared to nonsmokers.&nbsp;

&nbsp;

4. Gaining Excessive Weight -&nbsp;Obesity can impair fertility in various ways, such as inducing hormonal changes that affect sperm production.

<div>&nbsp;</div>

Diagnosis

The first step to deal with fertility issues is to consult a doctor, usually a urologist specializing in male infertility or a reproductive endocrinologist<a href="#accordion">[5]</a>. Male infertility is one of the most difficult challenges a man gets to experience. It can be overwhelming for some; it&rsquo;s not just physically exhausting, but also emotionally taxing not to say financially draining since infertility tests can be costly.

The following tests are used to detect male infertility:

&nbsp;

<ul>
	<li>
	<h5>Physical Examination And Medical History</h5>
	</li>
</ul>

A physical exam can detect varicocele and provide information about hormonal issues. Ideally, a urologist should perform this procedure &ndash; examining the genitals and inquiring about any genetic conditions, chronic health issues, illnesses, injuries, or surgeries that may affect fertility. They may also inquire about sexual development during puberty and their current sexual habits.

&nbsp;

<ul>
	<li>
	<h5>Semen Analysis</h5>
	</li>
</ul>

A doctor may order a semen sample to test for the following<a href="#accordion">[5]</a>:

<ol>
	<li>Sperm Volume: Sperm count per ejaculation&nbsp;</li>
	<li>pH: A measurement of acidity or basicity</li>
	<li>Sperm Concentration: The quantity of sperm per milliliter of semen</li>
	<li>Total Sperm Count: Total number of sperms in the entire semen sample</li>
	<li>Velocity: How quickly the sperm travels</li>
	<li>Linearity: How straight the sperm travels</li>
	<li>Morphology: The size and shape of the sperm</li>
	<li>Color: Semen is either&nbsp;white or light gray (normal)</li>
	<li>Viscosity: How speedily the semen liquefies</li>
	<li>Presence Of Blood Or infection<a href="#accordion">[6]</a></li>
</ol>

Note: Sperm counts fluctuate so multiple samples may be required.

&nbsp;

<ul>
	<li>
	<h5>Hormonal Profile</h5>
	</li>
</ul>

The lab test will check the levels of testosterone and other hormones<a href="#accordion">[6]</a>. The pituitary gland, hypothalamus, and testicles all produce hormones that are important for sexual development and sperm formation. Any irregularity can cause infertility.

&nbsp;

<ul>
	<li>
	<h5>Chlamydia Test</h5>
	</li>
</ul>

A urine sample is required to check for chlamydia, which can interfere with fertility<a href="#accordion">[6]</a>.

&nbsp;

<ul>
	<li>
	<h5>Testicular Biopsy</h5>
	</li>
</ul>

Testicular biopsy is for men who have very little or no sperm in their semen. A needle biopsy of the testicle can reveal whether or not a man is producing healthy sperm<a href="#accordion">[11]</a>. If good sperm are abundant in the testicle but are not released or ejaculated, then there is most likely an obstruction somewhere.

&nbsp;

<ul>
	<li>
	<h5>Genetic Testing</h5>
	</li>
</ul>

Genetic tests can also point out specific underlying barriers to fertility and sperm issues that the man has inherited<a href="#accordion">[11]</a>.&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Scrotal Ultrasound</h5>
	</li>
</ul>

This test generates images of the body by means of high-frequency sound waves. A scrotal ultrasound helps the doctor determine whether the testicles and supporting structures are working inefficiently due to a varicocele or some other issues.

&nbsp;

<ul>
	<li>
	<h5>Transrectal Ultrasound</h5>
	</li>
</ul>

A tiny, lubricated wand, placed inside the rectum, enables the doctor to examine the prostate and look for obstruction in the tubes that transport sperm.

&nbsp;

<ul>
	<li>
	<h5>Post-Ejaculation Urinalysis&nbsp;</h5>
	</li>
</ul>

The presence of sperm in urine can help specify retrograde ejaculation.

&nbsp;

<ul>
	<li>
	<h5>Specialized Sperm Function Tests</h5>
	</li>
</ul>

A doctor can use a variety of tests to determine how well a sperm will penetrate an egg and whether or not it will attach to the egg in the first place. These tests are rarely used as they do not have a significant impact on treatment recommendations.

<h4>&nbsp;</h4>

<h5>Fertility Clinics</h5>

There are numerous fertility clinics for men to schedule an appointment and get a checkup. Here, they can discuss their concerns with the doctor, who will assist them as needed. In case of infertility, the doctor will examine the genital area. They will measure the size of the testicles and check to see if the rest of the male genital anatomy is normal. This will also include examining the vas deferens (the tubes that transport sperm away from the testicles).

<div>&nbsp;</div>

Treatment

The number of treatment options for male infertility has increased with advancements in technology. Treatment for infertility is determined primarily based on the cause.

Some of the common fertility treatments are mentioned below:

&nbsp;

<ul>
	<li>
	<h5>Hormone Treatments And Medications&nbsp;</h5>
	</li>
</ul>

Hormone therapy is done to improve the amount of sperm. Medications are recommended when the cause of infertility is either elevated or reduced levels of specific hormones or there are issues with how the body is utilizing those hormones<a href="#accordion">[3]</a>.

&nbsp;

<ul>
	<li>
	<h5>Surgical Procedures</h5>
	</li>
</ul>

Surgeries are also recommended to treat male infertility. These include<a href="#accordion">[5]</a>:

<ol>
	<li>
	Vasectomy Reversal&nbsp;- This is performed as an outpatient procedure. The surgeon reconnects the vas deferens, which is the scrotal tube through which the sperm travels.&nbsp;
	</li>
	<li>
	Vasoepididymostomy -&nbsp;A technique similar to vasectomy, this is used to repair vas deferens obstructions. During this procedure, vas deferens are surgically divided, the obstruction is removed, and then the tube ends are connected again.&nbsp;
	</li>
</ol>

&nbsp;

<ul>
	<li>
	<h5>Treating Infections</h5>
	</li>
</ul>

Although antibiotics can cure a reproductive tract infection, they do not always restore fertility.

&nbsp;

<ul>
	<li>
	<h5>Treatments For Sexual Intercourse Issues</h5>
	</li>
</ul>

In cases of erectile dysfunction or premature ejaculation, medication and even counseling can help improve fertility.

&nbsp;

<ul>
	<li>
	<h5>Assisted Reproductive Technology (ART)</h5>
	</li>
</ul>

ART helps increase the probability of fertilization by bringing the spermatozoa closer to (or even within) the oocyte(s)

<div>&nbsp;</div>

Male infertility may result in the following:

<ul>
	<li>Stress and relationship difficulties&nbsp;</li>
	<li>Monetary and time-related issues due to treatment</li>
	<li>Increased chance of colon cancer, melanoma, <a href="https://www.merisehat.pk/disease/prostate-cancer" target="_blank">prostate cancer</a>, and testicular cancer</li>
</ul>

<div>&nbsp;</div>

Infertility in men may be more probable in people with:

<ul>
	<li>Smoking&nbsp;</li>
	<li>Alcohol consumption</li>
	<li>Use of illicit drugs&nbsp;</li>
	<li>Overweight/ Obesity</li>
	<li>Previous genital infections or prostate inflammation</li>
	<li>Exposure to toxins</li>
	<li>Trauma to the testicles&nbsp;</li>
	<li>Delayed or early puberty</li>
	<li>Exposure of the genitalia to extreme heat</li>
	<li>Major abdominal/ pelvic surgeries including vasectomy&nbsp;</li>
	<li>Undescended testicles</li>
	<li>Medical conditions (e.g. tumor) and certain medications (radiation for cancer treatment)</li>
	<li>Born with a fertility disorder</li>
	<li>Genetic predisposition for a fertility disorder 
	&nbsp;</li>
</ul>

Additionally, particular prescription medications can lead to<a href="#accordion">[13]</a>:

<ul>
	<li>High blood pressure</li>
	<li>Psoriasis</li>
	<li>Depression</li>
	<li>Ulcers</li>
</ul>

<div>&nbsp;</div>

Sometimes, male infertility cannot be avoided. However, there are some contributing factors that can be minimized or avoided completely in order to prevent the condition. For instance:

<ul>
	<li>Quit smoking.</li>
	<li>Quit drinking alcohol.</li>
	<li>Quit using illegal drugs.</li>
	<li>Maintain a healthy weight.</li>
	<li>Avoid having a vasectomy.</li>
	<li>Avoid activities that cause testicles to be exposed to heat.</li>
	<li>Avoid stressful activities.</li>
	<li>Avoid exposure to pollutants such as pesticides and heavy metals. 
	&nbsp;</li>
</ul>

The conventional serum hormones used to assess male infertility include testosterone, FSH, LH, and estradiol.&nbsp;

In a recent study, researchers demonstrated how 17-hydroxyprogesterone (17-OHP) is able to function as an intermediate to convert cholesterol into testosterone during the steroidal process. They also presented 5 case scenarios of male infertility in this study where the use of 17-OHP improved management and enabled the doctor to provide a more tailored care approach.

Serum 17-OHP could be a helpful supplement to the standard hormonal fertility workup when combined with a semen analysis. Despite the fact that the research is new, it can help clinicians make decisions that will lead to more individualized care<a href="#accordion">[4]</a>.

&nbsp;

Key Points

<ul><li>Male infertility is the inability of a male to conceive a child with a woman.</li><li>The causes of male infertility may vary. A man, for instance, may not be able to produce sufficient or healthy sperm, or they may suffer from a hereditary condition, such as<a href="https://www.merisehat.pk/disease/cystic-fibrosis" target="_blank"> cystic fibrosis</a>, or their genital tract may be blocked.</li><li>If the individual has experienced genital infections, testicular injuries, or early or late puberty, they may be more prone to experience male infertility.</li><li>The cause of infertility may determine the course of treatment.&nbsp;</li></ul><div> </div>

[1] Leslie SW, Siref LE, Soon-Sutton TL, Khan MAB. Male Infertility. In Treasure Island (FL); 2022.

[2] Kumar N, Singh AK. Trends of male factor infertility, an important cause of infertility: A review of literature. J Hum Reprod Sci. 2015;8(4):191.

[3] Valenti D, Vignera S La, Condorelli RA, Rago R, Barone N, Vicari E, et al. Follicle-stimulating hormone treatment in normogonadotropic infertile men. Nat Rev Urol. 2013;10(1):55–62.

[4] Reddy R, Mason M, Patel M, Ramasamy R. Clinical utility of serum 17-hydroxyprogesterone as a marker for medical therapy for male infertility: recommendations based on clinical scenarios. Int J Impot Res. 2022;1–3.