by Barrit Cowan, M.D., Urologist,
Why evaluate the male? It certainly requires both the male and female to make a baby, but what most people don’t realize is that it frequently takes both the male and female partner to lead to infertility. Infertility is not a female issue. It is not a male issue. It is a couple’s issue. Over the last decade, it has been estimated that there is a 50% increase in the number of couples seeking treatment for infertility. It is thought that this is due to several factors, including couples delaying having children due to “career first” strategies, willingness to have children in a second marriage and due to improvements in reproductive technology. It has been estimated that of the 15% of couples who experience difficulty with conception, 50% of the couples will have a male factor.
What are the goals in evaluating and treating males with infertility issues? Ultimately, the main goal is to facilitate the live birth of a healthy child, but how can this be achieved, and how, as a male infertility specialist, can we achieve this? The primary goal is to try to identify and correct any reversible cause for the individual’s abnormality. If it is not possible to fully correct the male partner’s infertility, then “upgrading” them to a lower level of intervention would be a worthwhile goal. For example, for a patient with azoospermia (no sperm present in the ejaculate) who was recommended that he adopt or use donor sperm insemination, it may be possible for them to conceive with in vitro fertilization (IVF). For a patient who has significant abnormalities in his semen analysis, it may be possible to improve the quality of his semen sample such that (IVF) will no longer be necessary, but intrauterine insemination (IUI) may be a reasonable option. Finally, with an individual with borderline quality and quantity of sperm, with intervention, it may be possible to upgrade him from IUI to natural conception. Although these interventions may take time, they may lower the cost and the degree of invasiveness of the method utilized for conception. Not only should we attempt to minimize the degree of invasiveness of the intervention required, but we need to ensure that our treatments are also the most cost effective. With healthcare costs escalating, we have a responsibility to be aware of the economic repercussions of our recommendations and treatment. This is especially true in treating couples with infertility issues, as frequently many charges may result in out-of-pocket costs, as health insurance may not cover the costs of diagnosis and/or treatment.
The challenges of male infertility Most frequently, the female partner initiates the infertility evaluation. Many men are reluctant to admit that they may be infertile. They may feel that such issues may question their manhood, and men are frequently reluctant to be evaluated. Rarely does a male present to the male infertility specialist on his own stating that he and his wife have not been able to conceive, and he would like to be evaluated to see if there is a male issue or not. Rather, the typical story is that the female partner goes to her gynecologist complaining of difficulty with conception. Commonly, it is at that point that the gynecologist recommends that her husband have a semen analysis while she is being evaluated.
How do we accomplish our goals? The first step in evaluating the male is to take a thorough medical, social, developmental, reproductive and sexual history . Although it is not primarily the urologist’s responsibility to evaluate the patient’s wife, it is absolutely necessary for him to have an understanding of the female partner’s reproductive status as well. Taking a complete medical history is imperative. There are many medical conditions which can effect one’s fertility. Prior inguinal or scrotal operations can obviously have an effect on one‘s fertility status, as can certain pelvic and retroperitoneal procedures. Several medications can affect one’s fertility status. One of the drugs which is most dangerous from a fertility perspective is testosterone when given as a supplement for a “low serum testosterone”, or in the form of a variety of anabolic steroids abused by athletes/bodybuilders. Common social factors which can influence sperm production include cigarette smoking and marijuana use. There are a multitude of toxic constituents in the inhaled smoke of both of these which can adversely affect sperm production. Universally, I will recommend a male infertility patient to discontinue either or both of these substances immediately.
The first step in assessing if there is a male fertility issue is through semen analysis. Although many laboratories perform semen analyses, specialized andrology labs should be used because they perform a high volume of these tests and have personnel specifically trained to evaluate the results. Other laboratory tests may be indicated, particularly if the sperm count is low. Assessing certain hormone levels can give us some understanding on whether the testicles are being adequately stimulated to make sperm or whether other abnormalities may be a cause.
What if the semen analysis is abnormal? Having an abnormal semen analysis does not mean that one cannot father a child. Once again, our goal is to identify reversible causes of the semen analysis and correct them so that the individual can conceive with the least amount of intervention and at the least cost possible. The treating urologist will fully evaluate the patient and make recommendations on how to improve the fertility status of the individual if possible.
What happens if the semen analysis cannot be improved? If the semen analysis cannot be improved, then some form of assisted reproductive technique will be necessary. If the semen analysis is only mild to moderately abnormal, then intra-uterine insemination (IUI) would be a reasonable option if it is felt that the female partner is a reasonable candidate. Because in vitro fertilization requires only a few sperm, IVF with ICSI can be extremely useful for the individual with a markedly abnormal semen analysis. IVF has allowed individuals who otherwise would not be able to father a child to now successfully have children that are biologically theirs.
What if there is no sperm in the ejaculate? Azoospermia means that no sperm are present in the ejaculate. Obviously, the presence of azoospermia makes natural conception impossible unless the situation is corrected. There are two types of azoospermia. One is due to problems with sperm production and the other is due to blockage of the normal reproductive tracts. In both instances, with intervention, it may be possible for these individuals to father children. There is nothing more fulfilling as a physician than helping an infertile couple conceive. Fortunately, with modern medical knowledge, technology and advanced surgical techniques, we are able to assist the vast majority our infertile male patients succeed in having children.